NATIONAL LIBRARY OF MEDICINE NLI1 DD5blfllE fl NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Serrice NLM005618128 /i^ THE PRINCIPLES AND PRACTICE SURGERY. BY \f JOHN A£HHURST, Jr., M.D., barton professor of surgery and professor of clinical surgery in the university of Pennsylvania; surgeon to the Pennsylvania hospital; senior surgeon to the university hospital and to the children's hospital ; consulting surgeon to the woman's hospital, to st. christopher's hospital, etc. SIXTH EDITION ENLARGED AND THOROUGHLY REVISED. WITH A COLORED PLATE AND SIX HUNDRED AND FIFTY-SIX ILLUSTRATIONS IN THE TEXT. StHL1 r/ 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 cupped. 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 VirchowT, the first manifestations of the inflammatory process are to be traced. The parenchymatous tissues become swollen, the swelling being, accord- ing to Virchow, due to the fact that the cells of the part become enlarged, through the absorption of new material; this power of taking up an 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. According to Metchnikoff, the effect of an irritant, either microbic or toxic, is to attract lymphoid cells derived from the mesoderm (ohemotaxis) which cells then destroy the irritant (phagocytosis), inflammation bein^ thus the "phagocytic reaction of the organism to an irritant." The ner- vous and vascular changes are regarded as only secondary, and the kind of inflammation depends upon the chemotaxis and the varietv of phagocyte which is attracted. " ° J 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, corresponds to what will be hereafter spoken of as the first stage of inflammation. FORMATIVE CHANGES. 37 Fig. 1.—Corpuscles and filaments in recent lymph. (Bennett.) Formative Changes : Lymph and pus.—The third series of changes to be noticed as due to inflammation are the formative, consisting in the formation of the substances known to surgeons as lymph and pus. A mi- croscopic examination of inflamed tissue, made at a period varying from a few to twenty-four hours after the commencement of the inflammation, shows the part to be filled with a large number of cells, about ^Vtfth. of an inch in diameter, spherical or nearly so, pellucid, and colorless or grayish- white. The origin of these cells, which are commonly called lymph cells or corpuscles, and which form the corpuscular element of what is known as inflammatory lymph, cannot be said to be positively 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 aban- doned ; and the three theories which at pres- ent chiefly divide the suffrages of pathologists are, (1) Yirchow's, which looks upon the new cellular elements as the result of proliferation1 of pre-existing cells ;^(2) Cohnheim's, which regards the cells of inflammatory lymph as identical with the white blood-corpuscles and cells found in the lymphatic vessels: as iden- tical, 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 existing cells, thus taking a share in the new production.3 Inflammatory lymph, as ordinarily observed by the surgeon, is a yellowish or grayish- white, semi-solid substance, which is somewhat elastic and semi-trans- parent, resembling a good deal the buffy coat of an inflammatory clot. 1 It would appear from the observations of Virchow and others that new, may origi- nate from previously existing cells, by one of two processes, viz. : (1) division, and (2) endogenous growth, or the formation of new cells within the cavity of the old. The first process, or that of simple division, is much the more common, and is that to which the term proliferation is habitually applied. The first thing observed in this process is the enlargement of the nucleolus, which subsequently becomes constricted in the middle, and finally divides into two. Afterwards the nucleus, and finally the cell 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 (Kblliker), and the thymus gland (Virchow) ; and has, according to Paget, been met with in certain encephaloid and epitheliomatous tumors. 2 Tnes'e cells, in common with many others, possess a power of spontaneous move- ment which, from its resembling that of the amasba, has been called amoeboid or amoeba- 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 again and re-enter the circulation. According to Julius Cohnheim. however, the leucocytes have no power of spontaneous movement, but are mechanically filtered through the walls of the vessels. 3 According to Strieker, the theory of the migration of cells is based on an illusion : the supposeof "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 Encyclopedia of Surgery, vol. i. p. 35.) 38 INFLAMMATION. Chemically, it consists of fibrin with an admixture of oily and saline matters,1 while when examined microscopically it is found to contain fibrils2 and corpuscles (which have already been referred to) in varying proportion. The fibrinous, or, as Paget calls it, fibrinous element of lymph, is, accord- ing to that author, probably exuded from the capillary bloodvessels in a fluid state, and subsequently coagulated; that there is in inflammation an exudation from the capillaries into the surrounding tissue is, as we have already seen, in accordance with the doctrines of Billroth and 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 con- sidered as established that this exudation takes any direct part in the formation of lymph. According to Billroth, during the active cell-wander- ing which has been described as taking place in an inflamed part, the filamentary intercellular substance of the connective-tissue itself gradually changes to a homogeneous, gelatinous substance.3 Hence it would appear not improbable that both elements of inflammatory lymph may originate in pre-existing structures, the corpuscular from an increase in the number of wandering cells, from proliferation of the ordinary connective-tissue cells, or from both sources, as well as from a return of basis-substance to an embryonic condition, and the fibrinous element also from a transforma- tion of the intercellular substance. Lymph is said to be absorbed, to be developed into new tissue, or to undergo various forms of degeneration. In some cases where absorption of lymph is supposed to have taken place, it is probable that the true 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 / y, can be no doubt, however, that lymph can ./^ JJ /f/( „•:;•?■•' d / actually disappear by a process which may / &i^lC^$$0^ J &? be properly called absorption, as is not un- f„ ""' 0\"° ; ' frequently seen in cases of iritis When L'i. - ' ' *•..- /fj.' ' ■- lymph is absorbed, the lymph corpuscles |£Xx v ''' £/ may be gradually utilized in the normal ^lk','5;4i^^^--^'™S|?J?' ,.,f nutrition of the part, being converted into ^T.-.y.. ,-' habits and re-enter the circulation. In the fig.2.-Fibro-Piastic and fusiform ceils development of Ivmph into new tissue it from recent lymph on the pericardium. „„„„„„\u„„„„u 4-u j?i i> 7 ^"^i »" Simi.ar cells are found in granulations. PasSe« through thefibro-celhtlar Condition, (Bennett.) beyond which, indeed, it frequently does not advance. It is this material which con- stitutes the adhesions, bands, etc., which are so frequently met with after the inflammatory process has subsided. Lvmph that undergoes development becomes vascular; new vessels appear in it, apparently originating from those in the surrounding tissues, and form a capillary network through 1 According to Hoppe-Seyler, the lymph corpuscle contains glycogen while its r,ow^r of movement continues, but upon becoming rigid (transformation into nus ceinin^ its glycogen and contains sugar. * ' luoes 2 Paget speaks of fibrinous and corpuscular lymph, this division corresponding ^trv closely to that of Williams and others into plastic and aplastic, and to that of Roli tansky intofibrinous and croupous lymph. Inflammatory lymph is, however essential J the same under all circumstances, though the relative proportion of its const!tl„. may vary in different cases. eiua s Virchow also refers to this liquefaction (as he calls it) of the intercellular sulwtanp*. of connective tissue, as accompanying proliferation. Strieker, as already remark maintains that, in inflammation, the entire tissue returns to an embryonic conditio FORMATIVE CHANGES. 39 which the circulation is carried on. It is somewhat doubtful as vet whether any production of nerve-fibres takes place in lvmph 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. (see Fig. 2). Lymph may undergo various forms of degeneration, as the calcareous, fatty, or granular (the degenerated lymph cells forming the so-called granule or granular cells, inflammatory globules, etc.); it may become the^ seat of pigmentary deposits, or, when exposed to the air, may form shrivelled and horny masses of effete material. Finally (a frequent change), lymph may be transformed directlv into pus; the second stage of inflammation, that of lymph formation (lymph i- zation, lymphogenesis), then passing into the third stage, or that of'pus formation (suppuration, pyogenesis). Pus is a creamy, whitish-yellow fluid, sometimes having a greenish tinge, thick, opaque, smooth, and slightly glutinous to the touch, with a fa?nt odor and slightly sweetish taste. It is of variable gravity, ranging from 1.021 to 1.042, and is neutral or slightly alkaline in its reaction. This description is to be understood as applying to what is called healthy or laudable pus, derived from an ordinary suppurating wound in a person of good constitution. Beside this form, sur- geons speak of saniov.s pus (mixed or tinjred with blood), ichorous pus (when it is thin and acrid), and curdy pus (when it contains fig. 3.—Pus corpuscles, a. From a Cheesy-looking flakes). MuCO-pilS and SerO- healthily granulating wound. 6. PUS are Of Course pUS mixed respectively From an abscess in the areolar tissue. v, n * ~, ... J c. The same treated with dilute acetic with mucus and serum. Chemically, pus acid. A From a sinus ln bone (ne_ contains water, albumen, pyine (which ap- crosis). e. Migratory pus corpuscles. pears to be almost identical with fibrin), (Rindfleisch.) 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 Dr. Gibb, of Canada, ten cases in which pus presented a blue1 color from containing the cyanuret of iron. Orange- colored pus has been observed by Delore, Broca, Yerneuil, and other sur- geons, and red pus by Ferchmin, of Charkow.2 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 piiris, and may also be found in the serum of the blood) has been isolated in a crystalline form by Fados, who calls it pyocyanine; it is believed by Roucher and Jacquin to be of vegetable origin. 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 cyuno- 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 C14HUNM, 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 pysemic cases, and is believed by Verneuil to indicate the existence of some grave constitutional 40 INFLAMMATION. Under the microscope, pus is found 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 j^th to 3^th of an inch- Th(>y usually contain several nuclei, which become apparent upon the addition of acetic acid. With these pus corpuscles there are commonty found granular matter, shreds of fibrin, and disintegrated lymph corpuscles. The above description applies to what must be called" dead pus cells,1 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 seem to originate directly from the latter by a simple liquefaction of the gelatinous intercellular substance of lymph (p. 38); but in other instances the pus cell appears to have a different source. Virchow and other observers believe that pus corpuscles originate from rapid proliferation (luxuriation) of connective-tissue and other nucleated cells, while Cohnheim,2 on the other hand, maintains that the sole origin of the pus corpuscle is the migration by amoeboid movement of the white blood- corpuscles through the vascular walls.3 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 t\>*ne-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 believed by modern pathologists that the formation of pus is al- ways due to the presence of special organisms or microbes, a description of the more important of which will be found in the chapter on Surgical Bacteriology. Destructive Changes Due to Inflammation__We have now traced inflammation through its nutritive and formative changes, consider- ing in succession the temporary hypertrophy from cellular enlargement, and the development of lymph and of pus, both forms of new material derived from pre-existing elements in the part inflamed. We have next to 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. The color of red pus is due to the presence of a bacillus which appears to be innocuous in the human subject. i The absence of glycogen may, according to Hoppe-Seyler, serve to distinguish the pus cell from the lymph corpuscle. (See note 1, p. 38.) 2 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. Prov. Med. and Surg. Assoc, vol. xi. pp. 247-253.) Dr. Augustus Waller, also, in 184b', described the passage of white blood- corpuscles through the walls of the capillaries. 3 Dr. Richard Caton, however, concludes, from observations on the fro°- fish and tadpole, that (1) the migration of white corpuscles is due not to amcebaform move- that the whole theory of migration is based upon an optical illusion CAUSES. ■41 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 isthrownoff 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 process ; they are indeed often regarded as terminations or effects of inflammation rather than as themselves parts of the process in question. Pathological Summary__Let us now, before entering upon the clinical study of inflammation, briefly recapitulate what has been said as to its pathological phenomena. The inflammatory process, according to the degree of irritation present, modifies the phenomena of natural textural life as regards function, nutrition, and formation ; in each case the modifica- tion is primarily in the direction of excess. As regards function, there is first increased activity, followed by perversion, and eventually, perhaps, by diminution, or even total abolition. The nutritive changes are shown in an altered state of the vascular system of the part (hyperemia, deter- mination) ; in an altered state of the blood itself; in an altered condition of the parenchyma (temporary hypertrophy) ; and in a change as regards the neurotic condition, which doubtless reacts upon both vessels and paren- chyma. The formative changes consist in the production of lymph and of pus. There may also be a destruction of existing tissue, resulting in its being thrown off as effete material by the process of ulceration or by that of gangrene. Clinical View of Inflammation. In the clinical study of inflammation, there are to be considered succes- sively its causes, its symptoms, its course, its terminations, and its treat- ment in its various stages and conditions. Causes.—The causes of inflammation may be divided into the predis- posing, and the exciting or determining causes. The predisposing causes may be said, in general terms, to be any circumstances which impair the general health of an individual, or which render his tissues less capable of resisting the injurious influences to which they may be subjected. Thus the various conditions of a person's life, the nature and amount of food which he consumes, the thermometric and other meteoric conditions to which he is subjected, the nature of his occupation, his having been affected with various diseases at previous periods of life, even his age, tempera- ment, etc., may all be considered at times as causes predisposing to the development of the inflammatory process. The exciting or determining causes are usually said to be either local or constitutional, arising either from without or from within. I think, however, that it is more correct to look upon the determining causes of inflammation as always local or external, those which are commonly considered as acting constitutionally bein"- really either predisposing causes or else properly to be termed local, though acting from within the body, and therefore, in that sense of the word, internal. 42 INFLAMMATION. The determining causes of inflammation are either mechanical or chemi- cal. Among the mechanical causes are to be enumerated the results of external violence, blows, cuts, wounds of all kiuds, fractures and disloca- tions (in these cases acting from within the body), the presence of foreign bodies, whether introduced from without or originating internally (as a renal calculus), distention of parts, as in the cutaneous inflammation which often accompanies dropsy of the lower extremities, and compression, whether from without or from within. Among the chemical causes may be classed heat and cold, the application of acids or alkalies, poisoning of the blood by septic matters, various forms of contagion, as of gonorrhoea or chancre, etc. Certain forms of nerve-lesion may probably be considered determining causes of inflammation. It has long been known that injuries or diseases of nerves may act as predisposing causes, by diminishing the natural power of the tissues to resist the external influences to which they are constantly and unavoidably subjected; thus, after spinal injuries, sloughing of the paralyzed parts may be produced by circumstances which would have no perceptible influence in a state of health, and carbuncle and spontaneous gangrene, diseases in the progress of which inflammation plays a prominent part, appear to be often associated with diabetes, which there are strong reasons for believing to be, in some cases, an affection of the nervous system. Some experiments, made by Dr. Meissner, would appear to show further that certain nerve-fibres exercise a peculiar "trophic" function, and that a lesion of such fibres may be the immediate and determining cause of an inflammatory condition of the parts supplied.1 It is sometimes said that certain abnormal properties of the circulating blood are to be considered as determining causes of inflammation ; but from what has gone before, I think it will appear that this is incorrect. Either a plethoric or an anaemic condition of the blood may indeed act a- a predisposing cause, by impairing the general health ; or the blood may carry in its course through the system septic or other morbid elements derived either from within or from without, but in this case its function is ministerial merely, and those morbid elements themselves are to be looked upon as the determining causes of the inflammatory process, not the blood, which is simply their vehicle of transmission. The influence of certain micro-organisms, such as the staphylococcus pyogenes aureus, the micrococcus pyogenes tenuis, the bacillus pyogenes foetid us, the strepto- coccus pyogenes, etc., in causing suppurative inflammation has already been referred to. Symptoms—We have next to consider the symptoms'1 of inflamma- tion. These may be distinguished into the local, and the constitutional or general symptoms. The latter will be treated of on a subsequent page, under the heading of symptomatic or inflammatory fever. The local symptoms of inflammation may be classified under six heads, viz. : (1) alteration of color, (2) alteration of size, (3) alteration of temperature, (4) modification of sensation, (5) modification of function, and (6) modi- fication of nutrition. One or more of these symptoms may exist in a part 1 See upon this point Holmes's Syst. of Surgery, 3d edit., vol. i. pp. 20-22 and Paget's Surgical Pathology, 3d edit., p. 36. A clinical observation of Dr. Geo. C.'Har- lan's is confirmatory of the same view (P/ula. Med. Times, Dec. 13, 1873). 2 Inflammation limited to its first stage (temporary hypertrophy), as is' seen in the repair of trivial injuries by immediate union, may be attended with sucli slight dis- turbance as to present no recognizable symptoms. Hence immediate union of wounds is said by Paget to be accomplished without inflammation. Clinically speaking this may be accepted as correct, but if the pathological views given above be true the inflammatory process must exist, though unattended by definite symptoms. SYMPTOMS. 43 without that part being inflamed, and it is only when they are present in combination that the diagnosis of the inflammatory process can properly be made. The phenomena of the erectile tissues furnish a familiar example. Again, certain nervous lesions give rise to a combination of these symp- toms so striking as to have been considered by many excellent observers to indicate a true inflammatory condition (the so-called neuro-paralytical inflammation), and, indeed, this state is one which can be converted into true inflammation by the action of very slight external causes. The degree in which any one of these symptoms is manifested depends, in a great measure, upon the nature of the tissue in which the inflammatory process is going on. Thus in the case of the skin or of mucous membranes, a change of color is the most prominent symptom. Inflammation of the connective or areolar tissue is particularly distinguished by the swelling by which it is attended. In the fibrous tissues, pain is the best marked symptom. Conjunctivitis or a superficial burn, inflammation of the sub- cutaneous fascia, and periostitis may be taken as illustrations of these propositions. Again, modification of function is more prominent in an inflammation involving the eye than in one affecting a much larger area of the skin or of the alimentary canal, while in some tissues, cartilage for instance, almost the only change that can be recognized after a long dura- tion of the inflammatory process is an alteration in the nutrition of the part involved. Redness, the first of the symptoms made classical by the description of Celsus,1 is perhaps the most noteworthy of all the signs of inflammation. It varies from a bright scarlet, as in the skin, to a deep crimson, or even a dusky, almost purple hue, as in some mucous membranes. In some tissues other forms of discoloration take the place of redness; thus the inflamed iris becomes gray or brown. The redness of an inflamed part is undoubtedly due to its being in a hyperaemic condition, tne capillaries being dilated so as to contain more blood than in the natural state, and the red corpuscles of the blood entering into vessels which, in their normal condition, were too narrow to admit them. In some depressed states of the system there is an absolute oozing of the coloring-matter of the blood through the walls of the capillaries, thus adding a new source of discolor- ation, while, when the inflammatory process has gone on to the formative stage, the new tissue developed from the inflammatory lymph, being very vascular, causes a more or less permanent redness, which, as is well known, may persist in a scar or in a part that has been inflamed for a con- siderable period. The next symptom that demands our attention is swelling. This is of course due in some measure to the hypersemia of the part, the increased amount of blood in the vessels naturally adding to the common bulk. It is, however, probable that the principal cause of inflammatory swelling, in the first stage, is the increased absorption of nutritive material, this stage of inflammation being indeed, as remarked by Virchow, almost indistin- guishable from a true hypertrophy. The swelling may be further increased, if the inflammation continue, by the presence of what are ordinarily called the products of inflammation, viz., by the formation of lymph or pus, or by the exudation of the watery constituents of the blood, or even, in certain cases, of the blood itself. The amount of swelling varies greatly, accord- ing to the looseness or closeness of texture of the part affected. Thus the eyelid, when inflamed, swells so rapidly as often completely to close the 1 " Notse vero inflammationis sunt quatuor, rubor, & tumor, cum calore, & dolore" (Celsus, de re medicd, Lib. III., c. 10. Opera, ed. L. Targse, Lugd.-Bat., 1785, p. 109). 44 INFLAMMATION. eye, while inflammation involving the cancellous structure of bone may give rise to the most excruciating suffering, and even run on to suppura- tion, with almost no swelling in the whole course of the affection. Ihe increase of size of an inflamed part may be evanescent, or may remain as a kind of hvpertrophy, as is often seen after the healing of old ulcers of the leg, or, "still more markedly, in the case of bone after long duration of osteitis. On the other hand, "from certain nutritive changes to which we shall have occasion to refer again, a part which has been inflamed may become permanently smaller than it was in the natural condition. The third symptom to be considered is alteration of temperature, in- creased heat. The illustrious John Hunter entertained the view that the increased temperature of an inflamed part was directly and solely due to the fact of its receiving an additional quantity of blood, and hence it is fre- quently said that the temperature of an inflamed part cannot possibly ex- ceed that of the left ventricle of the heart. The experiments upon this point of Mr. Simon and of Dr. Edmund Montgomery would appear to establish the incorrectness of Hunter's view. Their observations, which were made with the aid of a very delicate thermo-electric apparatus, are detailed in Mr. Simon's able article on inflammation in Holmes's System of Surgery (3d edit., vol. i. p. 10), and their conclusions are as follows:— " First, that the arterial blood supplied to an inflamed limb is less warm than the focus of inflammation itself; " Secondly, that the venous blood returning from an inflamed limb, though less warm than the focus of inflammation, is warmer than the arterial blood supplied to the limb; and "Thirdly, that the venous blood returning from an inflamed limb is warmer than the corresponding current on the opposite side of the body. "Unquestionably, therefore, the inflammatory process involves a local production of heat." Later experiments by Dr. Burdon Sanderson, however, tend to show that the temperature of an inflamed part is not higher than that of the heart, and never higher than that of the rectum. That there is thus a relative increase of heat due to the inflammatory process may be considered as proved, but whether there is an absolute increase over the temperature of the central organs is still uncertaiu. The sensations of the patient are of course unreliable in determining the amount of increased heat, and, it must be confessed, the impression con- veyed to the hand of the surgeon cannot be implicitly trusted. Prof. S. D. Gross, however, by actual observation, repeatedly found the tempera- ture of inflamed parts to be above 100° Fahr., and in some instances saw the mercury 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. SYMPTOMS. 45 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 coucerned 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 swelling and 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 already been 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 disturb- ances 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 in- variably 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, stimu- lates the function of secretion. In absolute inflammation it is temporarily suspended, and when restored the nature of the secreted material is usu- ally markedly altered. The power of using an inflamed organ is much impaired or altogether 46 INFLAMMATION. 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. Theirs/ 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, 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 process is going on, rather than on anv 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 oedematous 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 GRANULATION AND CICATRIZATION. 47 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 portion may desquamate. If the part which is about to suppurate be of sufficient size, the presence of fluid beneath the skin may be detected by the touch recognizing fluctuation or undulation. Under other circum- stances, 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 ulceration, 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 edges of the ulcer are more or less sharply cut, and often have a jagged or eroded appearance. The destructive action may affect the subcutaneous tissue more than the skin itself, so that the latter may be undermined for a con- siderable 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 papillae which have been spoken of above are called granulations, and an ulcer is said to heal by granulation and cicatrization. Granulations appear to consist of lymph which has become organized into new tissue, and their 48 INFLAMMATION. 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 aJid 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 surface, 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 margin 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 GANGRENE. 49 the lymph or granulation cells into fibrils, which occupy less space, and therefore occasion the shrinking which is characteristic of all cicatricial tissues. In some instances contraction 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 some- times 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 maybe bluish if deeply congested ; in the course of time its color fades, so that an old scar is commonly of a dead white color. Cicatrices gradually assume the appearances of the surrounding textures, and at the same time their deep attachments become stretched and loose, so that the mobility of the part is after a time measur- ably restored. A scar, however, never 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 Adams that cicatrices formed in childhood grow with the part in which they are placed. Gangrene.—As abrasion (see page 41) 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 vitalitv that mortification, gangrene, or sphacelus is said to have occurred. The term sphacelus 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, while the part affected is spoken of as sloughing. Gangrene may occur at a late stage of the in- flammatory process, or it may be primary from the intensity with which the original irritant has 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 burning, 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 be- comes colder than the surrounding tissue; and a peculiar odor is emitted, due to gaseous ex- halations from the gangrenous mass. This description is to be understood as apply- ing 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 mummi- 4 Fig. 5.—Complete sphacelus of foot and ankle. The sloping line of separation well shown ; studded with granulations. (Miller.) 50 INFLAMMATION. fication or dry gangrene is applied; this presents somewhat different cha- racters, and will be considered in its proper place.1 When the spread of gangrene has been arrested, whether from the irri- tant 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 mortified 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 remarked 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 gangrene is immediately succeeded by the reparative process of granula- tion. 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 symptoms 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 independent of traumatic causes. Surgical fever would be a good name but for the confusion which might arise from the term having been applied (by Sir J. Y. Simpson) to an entirely different affection, viz., pyaemia.2 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 inflammatory process. Mr. Pick 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, » If a part dies quickly, wbile full of blood and otber fluid matters, the gangrene which ensues is of the moist variety ; when the death is slower, the gangrene is dru. Th<- occurrence of moist gangrene is chiefly determined by the existence of venous congestion. 2 According to Kocher and Ogston, however, pyaemia and simple acute inflammation are identical affections, differing only in intensity. INFLAMMATORY FEVER. 51 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 high as 102.5°-103° Fahr. bv Dr. Montgomerv, 104° by Mr. Croft, 104.6° by Mr. Pick, and 104 5°-i05.5° by Prof. Bill- roth. The face is flushed, the eyes injected, and there may be distressing headache, together with muscular pains and general uneasiness. The patient is apt to be delirious at night. In favorable cases, as the local phenomena of inflammation decline, the violence of the symptomatic fever likewise passes away. The beginning of convalescence may be marked by profuse, acid sweating, by diarrhoea, by profuse diuresis, or even by hemorrhage from the mucous membranes, constituting what the older writers called critical discharaes. This is the course of an ordinary attack of inflammatory fever, as seen in healthy persons in connection with traumatic or other inflammations, unattended with special causes of depression Under other circumstances there may be fever of an asthenic or typhoid type, resembling a good deal the ordinary forms of enteric fever. In these cases the tongue is covered with a dark-brown fur, and is apt to be dry; sordes accumulate about the lips and teeth; the countenance presents a dusky hue; the pulse is un- usual]}' feeble; the patient seems dull and soporose, and the delirium assumes a muttering character. This form of inflammatory fever is often attended with pneumonia of a low type. Convalescence from it is slow and inter- 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 ordinary, 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- 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 52 INFLAMMATION. 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 usuallv 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- rhaia, 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 by continuity or by contiguity of structure. A n 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- mation may spread by means of the lymphatics, as inadenitis of theaxillarv 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 theoccurrence of the inflammatory process ;' but any more direct agency of the nervous system is still a matter of doubt (see p. 42). Terminations of Inflammation—What I have called the stages of inflammation are often spoken of as terminations of the inflammatorv 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 reallv an instance of resolution. The other so-called terminations do not end the process, but are mere events in its course. HYGIENIC TREATMENT. 53 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 ereneral condition of his patient. 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- 54 TREATMENT OF INFLAMMATION. 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 held. p]very 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 diet1'' 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 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 the results met with in practice, it of course becomes any one sur- geon to speak with great modesty and hesitation ; I can. however, honestlv 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 that a patient suddenly attacked with inflammation may subsist for a short time__ 1 See, in relation to this point, Rev. Dr. Haupditon's "Address on the Relation of Food to Work done by the Body," etc. (Brit. Med. Journ., Aug. 1868.) LOCAL TREATMENT. 55 perhaps a day or two—upon barley-wTater or water-arrowroot, and prob- ably 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 (fgiv) 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 dif- ferent forms of strong broth may be appropriately made to alternate with milk in the patient's diet. As a general 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 advan- tageously 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 patient inhabits should be well ventilated, and well warmed in winter. The patient's skin should be 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 56 TREATMENT OF INFLAMMATION. Fig. 6. -Mediate irrigation : coil prepared for use. (After Petitgand.) 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 inflammatory affections not de- pendent on traumatic causes. It may be applied in the form of dry cold, or in connection with moisture. The use of dry cold has been especially recommended by Esmarch, and is particularly useful where the skin is unbroken and where it is desir- able to avoid the maceration and other discomforts unavoidable with wet applications. Ice may be ap- plied in India-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 inter- posing a folded towel or handker- chief between the bag or box and the skin. This is an admirable 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 ice melt, and the application be no longer a cold one. A safer and an equally efficient method of applying dry cold is that described by M. Petit- gand 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 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 any temperature that may be de- sired, and by testing the temperature of the water as it leaves the tube, the surgeon can easily ascertain to what degree he has succeeded in reducing the temperature of the inflamed part itself. The application of cold to the head, by this method, is recom- mended by Sir Spencer Wells in all cases of traumatic 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 bein»- that the tubes are made of flexible metal. In cases where there is an open wound, the relaxing properties of with cold, and here the Fig. 7.—Coil applied to head. (After Petti gand.) cases moisture are often is an advantageously combined LOCAL TREATMENT. 57 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 later 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 should 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 macera- tion and desquama- tion of the cuticle, and hence the application, when repeated seve- ral times, becomes ex- tremely painful; to obviate this, I am in the habit of using warm olive oil instead of hot water, a sub- stitution which does not impair the effici- ency of the remedy, while it renders it much more agreeable to the patient. Moist- ure may, in some cases, be advantage- ously employed by the process Of Steaming ; Fiq g_Mec1iate irrigation : a. Supply-tube acting as a siphon; b. this may be done 0)T C()il appiieci to lower extremity ; c. Waste pipe with stop-cock. (After means of an ordinary petitgand.) funnel, inverted over the hot liquid and directed towards the affected part, or by means of the 58 TREATMENT OF INFLAMMATION. atomizer, as used in affections of the throat and air-passages; in employ- ing the latter apparatus, the temperature of the vapor can readily be regu- lated by varying the distance of the instrument 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- meal or bread poultices must be made about half an inch thick, and may be 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 evaporation. It is well for the surgeon to give his personal 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 attendant. The fermenting poultice, which is an excellent appli- cation to sloughing sores, may 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 moist- ure, in whatever form used, are especially to be recommended in the second stage of inflammation, and when suppuration is impending. When the discharge of pus is fully established, poultices are, as a rule, not desirable, while in the gangrenous 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 may 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 con- 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. Fig. 9.—Irrigating apparatus. (Erichsf.n.') LOCAL TREATMENT. 59 nection 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 mem- branes, conjunctivitis, gonorrhoea, etc. 6. 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 the latter of which into common use is undoubtedly due to Sir Joseph Lister, 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. 1. 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. Counter-irritants are sometimes advantageously employed in the local treatment of inflammation. This is denied by some modern writers of high authority, but, for my own part, I cannot doubt that great benefit is occasionally derived from the practice. I have seen a bubo disappear without suppuration under the application of blisters or of tincture of iodine (applied, 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, likewise seem to me unquestionable. The principal counter-irritants em- ployed by surgeons are blisters, issues, setons, and moxa. 9. Cauterization is a remedy which iray prove serviceable in certain cases of inflammation. The actual cautery may be advantageously applied to serpiginous chancroids, while caustic in some form is frequently em- ployed by the surgeon in the treatment of ordinary ulceration. 10. Local bleeding, by cupping or leeching, is now much less often re- sorted to than formerly. The general question of the abstraction of blood in inflammation will be considered under the head of constitutional treat- ment, but I may say here that I cannot doubt that local bleeding is some- times of use, and may prevent fatal disorganization in an important organ ; I firmly believe that it may save life in cases of traumatic peritonitis. 11. Incisions, to relieve tension, are often of great use in cases of in- flammation ; after incising the tunica albuginea in cases of swelled testicle, the pain disappears almost instantly, and the duration of the affection is 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 60 TREATMENT OF INFLAMMATION. revived, to treat or to attempt to prevent inflammation of joints by ligating the main artery of the limb above the part affected. If inflammation 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 re- laxed (as in indolent ulcers), that pressure is of service, though it is occa- sionally useful at a much earlier period. I know of no better treatment for carbuncle than methodical pressure by the concentric application of strips of adhesive plaster. 14. Finally, friction, the use of which has been systematized under the name of massage, is frequently a valuable remedy in cases of inflammation. 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 employed in cases of sprain ; in the later stages of inflammation, again, friction 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, being asked what was the most important remedy in the treatment of inflammation, would have answered unhesitatingly that it was bleed- ing; and the expression was constantly used that venesection was the surgeon's "sheet-anchor" in dealing with inflammatory affections. Now I suppose that there is no fact better established in the whole circle of therapeutic observation than that certain of the symptoms of inflamma- tion (especially pain) can be relieved by the abstraction of blood; and hence, when the prevailing doctrines of pathology taught that the essence of inflammation was an altered action of the vessels, accompanied by 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, how- ever, now shown that, in the words of Mr. Simon, already 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, it must be con- fessed, has been more enlightened than that of surgeons. Few would, in- deed, at the present day, bleed for the inflammation attending a compound fracture, but it is still held by many surgeons 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 origin, and hence that venesection should not be resorted to in the treatment of surgical affections, except for its imme- diate 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 CONSTITUTIONAL TREATMENT. 61 the darkly congested face, turgid lips, distended veins, and laboring pulse give warning that the brain is oppressed, 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 con- ditions. 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 thirty-three years of hospital prac- tice, I have never had occasion to employ venesection, 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 opening in a large vein, generally the median-cephalic. Arterial sedative* 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 in cases of traumatic peritonitis from the Vera- trum viride, 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 manage- ment of inflammation. They are best adapted to the first stage, and seem to have a decided effect in preventing the further progress of the inflam- matory process. This property of antimony has been called the "anti- cipatory anaplastic" 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 any form, antimony is a remedy which should be used with great caution and watchfulness. It should never be given for a trivial inflam- mation, and should be avoided in cases of children or old persons, or in patients of feeble constitution. Purgatives have been much emplo}red 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 pill, 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. 62 TREATMENT OF INFLAMMATION. 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. : phvsiological 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 :— $.. Morphia? acetatis gr. j ; Spirit, setheris nitrosi fjij ; Sacchari albi 5'j ! -Aquae camphorae fgiijss ; Liq. atnmonii acetatis fgiv. M. ^ $.. Morphias acetatis gr. j ; Spirit, aetheris nitrosi t"5ij ; Syrupi acaciae f0vj ; Aquae aurantii riorum f3iij ; Mist, potassii citratis i'giv. 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 bloodletting 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 Potassium is a valuable remedy in certain forms of inflamma- 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,2 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- 1 The action of opium in inflammation is physiologically explained by its property of arresting osmosis and cell-hypertrophy. 2 The muriated tincture of iron may be conveniently combined with the solution of acetate of ammonium, and in this form may sometimes be given with advantage even in the earliest stages of inflammation. MORPHOLOGY AND PHYSIOLOGY OF MICRO-ORGANISMS. 63 lable but nutritious, and must in some cases pour in alcoholic stimulus besides, even at the very time when he is applying leeches and adminis- tering purges. Finally, in many chronic inflammatory conditions, the surgeon must give up treating the disease, and devote himself to improv- ing 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. SURGICAL BACTERIOLOGY. By CHARLES B. NANCREDE, A.M., M.D., PROFESSOR OF SURGERY IN THE UNIVERSITY OF MICHIGAN. The terms bacteria, microbes, or, in a generic sense, micro-organisms, are applied to certain minute vegetable cells. The fully developed organ- isms, consisting of cell-walls enclosing protoplasm, so often assume the form of rods that the name Bacteria (Greek ^axtr^ioi) is loosely applied to all pathogenic germs. General Morphology and Physiology.—The cell-wall, usually invisible, consists of cellulose. Iodine, by contracting the protoplasmic contents, renders the cell-wall visible. The protoplasm yields mycoprotein, is either homogeneous or granular, and can be stained by the aniline dyes ; the power of fixing stains varies in the different species, indicating chemical or vital differences in the protoplasm. Some organisms are chromogenic, the pigment in most instances being external to the cell, although it may be partly within and partly without, as in Bacillus pyocyaneus. A gelati- nous envelope characterizes certain species, and has been viewed as either (1) the result of an actual secretion from the cell, or (2) due to swelling of the outer layer of the cell-wall from imbibition of moisture; a good illustration, where a capsule is formed, is Micrococcus tetragonus. From its solubility in water the capsule is often hard to demonstrate, while in some instances it disappears during cultivation. When this gelatinous material forms masses containing numerous imprisoned bacteria, the irregular aggregations are called zoogicea. In Ascococcus Billrolhii this envelope is so marked that it is the distinguishing feature of the species. While most germs are motile during certain stages of development, others probably at no time exhibit spontaneous movement. It is essential, when beginning the study of surgical bacteriology, to keep constantly in mind two facts, viz., that (1) of the hundreds of germs known to bacteriolo- gists only a small number are pathogenic, with the corollary that constant investigation is transferring individuals from the non-pathogenic to the pathogenic group; and (2) that it is not the micro-organisms as such, but poisonous alkaloidal or albuminous bodies, produced by the growth of the germs in a favorable pabulum, which produce the pathological effects; this latter fact in a measure explains the toxic effects noticed in certain cases of anthrax, where the number of bacilli found is not great; or of tetanus, where no germs occur in the blood. The forms assumed by the cells vary; those which are round or egg- shaped are called cocci, with the prefix when large of mega, and when small of micro—megacocci and micrococci. Such germs multiply by 64 SURGICAL BACTERIOLOGY. fission, and if the two cocci remain attached a diplococcus is formed ; if the cocci are linked together, a chain-coccus or streptococcus results. When division occurs in two directions, four cocci result, forming a tetracoccus; while if the planes of fission pass in three directions at right angles to one another, one coccus is so divided that a sarcinococcus results—that is, one formed of eight cells arranged in a packet-form. When cocci are irregu- larly massed together they are called, from their resemblance to a bunch of grapes, a staphylococcus. A bacterium or bacillus is a rod-shaped organism, which, if very short and having rounded ends, closely resembles an oval coccus, but differs in that two of the sides are parallel. Other forms, which are of no surgical interest, as far as at present known, are the vibrio, or bent rod ; the spirillum, or corkscrew rod ; the straight filament, leptothrix; and the wavy, looped or entwined, the spirochseta. While somewhat modified by their environment, these forms are never inter- changeable. Although fission is the more common method of multiplica- tion, some bacilli (as also spirilla) generate spores, as that of anthrax, where endospores are formed, or Leuconosfoc mesenleroides, where arthrospores are alleged to occur. It is believed that spores have a double-layered cell-wall, to which they owe their greater power of resisting destruction by desiccation and the action of heat and chemical reagents, as compared with that possessed by the parent germs. Owing to this tough capsule spores are difficult to stain, and until this dense envelope has been soft- ened by either heat or a strong acid, the aniline dyes cannot penetrate it; moreover, once stained they resist decolorizatiou. The requisites for the growth and development of bacteria are oxygen, nitrogen, carbon, water, and certain mineral salts ; but some require the free access of oxygen, while others obtain this from the oxygen-containing substances in natural or artificial culture media. Pasteur's division of bacteria into the aerobic and anaerobic is only relatively accurate, but is a practically useful dis- tinction between those that cannot grow without free access of the oxygen of the air and those which flourish either in the entire absence of this ele- ment or upon the amount of the gas which they can derive from the com- pounds containing it in the medium in which they grow. A trivial diminution in the amount of oxygen will inhibit the growth of some spe- cies (the obligate-aerubic) ; again, others can grow well either with abun- dance of oxygen or where no oxygen is present (facultative-aerobic bac- teria); to this last class belong most of the pathogenic germs. The soil markedly influences bacterial growth, it being impossible to cultivate some germs artificially, while others grow only in special media, some requiring an alkaline and others an acid reaction of the same culture material, while, again, an alkaline reaction of one medium and an acid of another mav equally favor the growth of a few varieties. Cold, even—55° C, can only inhibit, but cannot destroy germs. The tubercle bacillus can only grow between 30° C. and 40° C, but manv germs can develop between 5° C. and 45° C, and, although at the two extremes they are inactive, with their restoration to a favorable environment thev again germinate. Nearly all pathogenic germs flourish at the temperature of the blood. Moist heat from 50° C. to. 62° C. will destroy all pyogenic bacteria, but not their spores. The spores of all pathooenic bacteria quickly perish at 100° C. (212° F.), even those of anthrax requiring only four minutes' exposure ; a lower temperature, if maintained, has the same effect; thus anthrax bacillus can be destroyed by twenty minutes' exposure to a moist heat of 50° C Moist heat is preferable for most surgical pur- poses, as for the disinfection of instruments, because exposure to live steam 1 According to Chauveau, quoted by Sternberg, Manual of Bacteriology, MORPHOLOGY AND PHYSIOLOGY OF MICRO-ORGANISMS. 65 or boiling water for half an hour is absolutely reliable, while a much shorter time—ten minutes—will usually suffice ; the addition of about two per cent, of sodium carbonate will prevent the rusting of steel instruments. For dry aseptic dressings, dry heat of 150° C, maintained for at least one hour, is requisite, the material being so loosely arranged that the heat has free access to every part. As the surface of the body and the depths of wounds cannot thus be sterilized, certain substances must be employed which will either chemi- cally destroy germs or inhibit their growth. Those most commonly employed are carbolic acid and some of the salts of mercury, generally the mercuric chloride. This latter substance, clinically, where most of its power is expended by combining with the albumen of the wound fluids, should not be employed in the weak solutions which Koch has found ex- perimentally efficient in preventing further growth in artificial culture media, but in the strength of from 1-3000 to 1-1000. Its efficiency is, much increased by adding a proper proportion of tartaric, citric, or dilute hydrochloric acid, which prevents the precipitation of the drug in com- bination with albumen, the compound thus formed being almost inert. Carbolic acid (1-30) suffices for all surgical purposes. It must not be for- gotten that several recent investigators have demonstrated that many of the germs are not actually killed, but that the mercuric chloride forms a chemical combination with their capsules—should they have any—or with their cell-walls, so that when placed in culture media they can no longer multiply ; in the tissues, the same results probably obtain, but it is alleged that in the circulating blood, and possibly in very vascular tissues, this chemical combination is destroyed, after which the germs can multiply. Clinically, however, the statements made are correct, because when the so-called germicides are used in the strengths usually employed, germ growth is completely inhibited, and therefore until some true germicide is discovered, those which have been found clinically efficient should still be used. Micro-organisms are found in the air, water, soil, and possibly in the healthy blood ; in the last, their alleged presence is probably due to an error of observation, and, even if detected, they are accidentally present and promptly removed, perhaps to be stored up in the spleen to give sub- sequent trouble if the local or general vitality should become lowered. Only in mid-ocean and at an elevation of from two thousand to three thousand metres above the sea-level can we find the air absolutely free from germs, while the respiratory and gastro-intestinal tracts and the urethra swarm with them. Certain organisms can only live and develop in dead or dying tissues, causing their decomposition, whence they are called saprophytic or saprogenic ; others flourish in living tissues, giving rise to various morbid processes, and thus gaining their name of pathogenic bacteria ; the pyogenic germs are those from whose development pus-formation results. A word of caution is requisite here to the effect that, because germs abound in a given case of disease, the conclusion must not be formed that they are necessarily causative, for possibly they may only be accidentally present. Owing to the splitting up of organic substances effected, during the growth of the saprophytic bacteria, alkaloidal substances are produced, such as cadaverin, putrescin, etc. Certain pathogenic germs, however, instead of producing poisonous alkaloids, manufacture albuminoid toxines, some of these substances, when present in sufficient concentration, prob- ably eventually inhibiting the further multiplication of the very organisms which produced them. Bacteria, therefore, produce their pathogenic 5 ij<5 SURGICAL BACTERIOLOGY. effects indirectly; thus the saprophytic, during the fermentative change- which they induce, generate the alkaloidal ptomaines and ferments ; the latter dissolve the intercellular cement between the cells of the forming granulation tissue in wounds, cause coagulation-necrosis, fatty degener- ation, and death of the cells, and finally, soaking into the surrounding tissues, so destroy or lower their vitality that the germs can multiply in a continuously spreading area, since these micro-organisms can only flourish in dead or dying tissues. When a large dose of ptomaines is absorbed, one of the most rapid forms of blood-poisoning results, viz., saprsemia or septic intoxication; smaller doses produce the septic traumatic fever; while repeated small doses, taken up through imperfectly formed granu- lation-covered surfaces, as in psoas abscesses which have been opened, etc., induce hectic. It should never he overlooked that these substances do not increase in the blood or tissues, that they can be eliminated, and that, if further absorption be prevented before a fatal dose is absorbed, recovery may be secured, even in severe septic intoxication. Where in- fective micro-organisms are concerned—that is, pathogenic germs which can not only live and multiply in living tissues, but also produce, wherever growing, ptomaines or toxalbumins—the conditions are very different; in the septic diseases the effects are in proportion to the dose, the poison does not increase in the system, and may be eliminated; but in infective processes the poisons are being continuously elaborated in the organs and tissues, and while they may be eliminated, their cause, viz., the germs. too often cannot be removed, and in consequence a continuous toxaemia is kept up. A word must be said as to immunity, not that given by one attack of a specific disease against a subsequent one, for surgically this does not occur, but of the tissues or organism, as a whole, against patho- genic germs. The growing belief, strengthened by experiment, seems to favor the view that certain of the white cells of the blood are phagocytes, as Metchnikoff contends, and that thev actually destroy and remove germs; moreover, it is highly probable that owing to their capacity for incorporating foreign substances by virtue of their amoeboid movements. all white blood-cells aid in the mechanical removal of bacteria. The well- known germicidal effect of blood-serum is explained by the rapid dis- integration and solution of certain of these phagocvtes. Only those germs produce disease which remain after the capacity of the tissues to remove and destroy bacteria, or inhibit their growth, is reached. Whether this exhaustion of " the vital resistance" of the tis- sues, as it is termed, means that they are left of a chemical composition which affords suitable pabulum for germs, cannot, as yet, be determined. It, is believed that such microbic diseases as erysipelas, typhoid fever, glanders, and anthrax, can be transmitted from the mother to the foetus through the placental circulation, and there is experimental proof to this effect as far as the last two named diseases are concerned. Again it has been claimed that, as tuberculosis has been found in the foetus and as tubercle bacilli have been detected in the semen of individuals not suffer- ing from genital tuberculosis, therefore this disease can be conveyed to the foetus during conception ; this has not as yet been demonstrated bevond cavil, so that only the verdict "not proven" can be rendered. The Relations of Miero-Organisms to Inflammation__Ac- cording to the prevailing view at the present day, those pbenomena'whkh attend the reparative processes that effect union of wounds and the repair of injuries do not belong to true inflammation, or at least this form is so radically different in its results from destructive inflammation that it should be distinguished by some distinctive prefix, such as aseptic and RELATIONS OF MICRO-ORGANISMS TO INFLAMMATION. 67 only such deviations as result from microbic infection should be considered disease-processes; certain it is that all the unpleasant and disastrous wound- complications result from microbic infection. It is unquestionable that, if the results and complications of suppuration could be excluded, the diffi- culties of cure after traumatisms, accidental or operative, would be re- duced to a minimum, and in many instances all the risks of wounds would be avoided ; hence a study of the chief points of interest concerning the pyogenic microbes is of paramount importance to the surgeon ; after these, the germs productive of the more important diseases complicating wounds will be considered, premising, however, that in the space allotted only a most superficial description can be given of the principal varieties. It has already been stated that innumerable germs can be destroyed or removed by the healthy tissues, but the converse must be emphasized, viz., that lowered resistance of these, from injury or disease, favors suppura- tion ; in other words, a place of diminished resistance (locus minoris re- sistentiee) and the presence of more germs than even normal tissues could resist, usually coincide to produce suppuration. Clinically, acute suppuration is invariably caused by micro-organisms, and their complete exclusion will assuredly prevent its occurrence. The fluid resulting from aseptic chemical irritation is puruloid, but is not pus; it is only obtainable under exceptionally favorable laboratory con- ditions ; it is merely a fibrinous exudate containing numerous cells, which produces no pernicious effects if injected into animals, does not undergo spontaneous evacuation as genuine pus does—because the peptonizing action of the bacteria contained in the latter readily dissolves the inter- cellular cement and prevents the coagulation of the new exudate and the absorption of old—and, finally, is never found clinically; the injection of such a ptomaine ascadaverin merely reproduces the conditions which would be furnished if bacteria were present. The common absence of cocci from chronic abscesses is explained by the two facts that as these are really tubercular, (1) under certain circumstances—very rarely it is true— tubercle bacilli have been proved to be pyogenic, and (2) the pyogenic cocci originally initiating the suppuration in the tubercular focus may have died, either from lack of pabulum or self-poisoned by their own excretions ; moreover, the contents of most cold abscesses are not pus, but liquefied caseated tubercle, not a single pus-cell being present. In man the simultaneous growth of more than one species of micro- organism, that is, a " mixed infection," increases the pathogenic properties of each; again, the growth of aerobic germs, such as those of pus, so abstracts the oxygen that the development of an anaerobic bacterium like that of tetanus can readily occur. The first effect of the localization of pyogenic cocci is coagulation-necrosis. While pyogenic germs are believed never to remain long in the healthy blood or tissues, yet it is in- disputable that, under certain unknown conditions of general or local impairment of vitality, micro-organisms can survive in both. The pyo- genic staphylococci in old foci of disease may apparently, as has been well said, "lie dormant in the tissues for years, to be again aroused into activity" by some fresh injury or malady. The streptococcus pyogenes, moreover, is now believed to be the cause of erysipelas, not being dis- tinguishable from that of Fehleisen by culture methods, microscopic ap- pearances, or pathological effects. Although true of this variety of streptococcus, there are many others growing and looking alike which yet produce widely differing pathological effects upon animals, and can only be differentiated by such experiments. Many, if not all, pathogenic 08 SURGICAL BACTERIOLOGY. germs lose a portion of their infectiousness unless passed through the bodies of animals from time to time. Staphylococcus Pyogenes Aureus.—This organism (Plate I.. Fig. 2) is spherical, and is apt to form cluster-, but often appears linked in pairs; its diameter is from 0.7 to 0.87 of a micromillimetre; it multiplies by fission, and can grow either in the presence or absence of oxygen. It stains well in watery solutions of the ordinary aniline dyes, but will not decolorize when stained by Gram's method It liquefies gelatin, and forms on nutrient agar a moist, glistening layer with wavy outlines, at first pale but afterwards of a golden yellow. It has a " sour-paste" odor inarti- ficial cultures, produces no ptomaine, but a toxalbumose, a soluble pep- tonizing ferment, and ammonia. When dry heat is employed, 90° to 100° C. is requisite for the destruction of the desiccated germs, while only ten minutes' exposure to 56° to 58° C. moist heat is requisite for recent cultures. A solution of mercuric chloride, 1-81,400, inhibits their growth, but although nearly all succumb after ten minutes' exposure to a 1-1000 acid solution, a few survive from ten to thirty minutes. As has been already said, most of the germs even then are merely prevented from multiplying, this power being restored by the breaking up of the chemical compound formed by the drug with the cell- wall; nevertheless, clinically, the germs are harmless. Habitat. While found exceptionally in the air, water, and soil, the surface of the body and that of the mucous membranes are its normal habitat. The axilla and around the umbilicus, the urethra, and the pharynx will nearly always supply any number of these germs. Pathologically, this and the two fol- lowing varieties of staphylococcus are found chiefly in circumscribed sup- purations, such as acute abscesses, furuncles, adenitis, osteomyelitis, etc. The Staphylococcus Pyogenes Albus and Citreus are mor- phologically and physiologically similar, except for the absence of pigment in one and the lemon color of the >taphylococcus citreus. The staphylo- coccus albus is less pathogenic than the staphylococcus aureus, while as to the staphylococcus citreus its morbid action is somewhat doubtful. The Staphylococcus Epidermidis Albus of Welch is probably an attenuated form of the staphylococcus pyogenes albus, and has onlv feeble pyogenic properties. Streptococcus Pyogenes.—These streptococci arrange themselve- in chains varying from four to ten, or even thirty, elements. Their diam- eter is somewhat greater than that of the staphylococci, being about one micromillimetre. They grow readily on the culture media usually em- ployed—except on the surface of potatoes—at a temperature of from 30c to 37° C, either in the presence or absence of oxygen ; they do not liquefy gelatin, and in stick-cultures they form small, round, translucent, whitish colonies. Ten minutes' exposure to a moist temperature of from 52° to 54° C. will destroy these germs ; mercuric chloride acts as it does upon the staphylococci, but requires a longer time for any given strength. These germs stain with the ordinary aniline dyes and by Gram's method. Hab- itat. This organism is found in the nasal cavities, urethra, and vagina ; pathologically it seems to produce progressive suppurations, such as those <>f phlegmonous cellulitis, erysipelas, and the secondary deposits of pyaemia. The Streptococcus Erysipelatis is now regarded as identical with the germ just described. (Plate I., Fig. 1, a. b.) Bacillus Pyocyaneus.—This germ, producing in the presence of abundance of oxygen, and, therefore, at the edges of dressings, "Teen or blue pus, is a small, narrow, actively motile rod, with rounded ends which sometimes form chains consisting of from five to six links. In plate cul- EXPLANATION OF PLATE. Fig. 1. a. -Streptococci from a case of pyaemia resulting from infection of the umbilical cord. (University Hospital, Ann Arbor, Mich.) b.—The so-called Streptococcus erysipelatis of Fehleisen. (From a pure culture.) Fig. 2. Pure culture of Staphylococcus pyogenes aureus. FiG. 3. Bacillus of malignant oedema, grown on agar. a.—Double-contoured spores. Fig. 4. Bacillus of tetanus. (From a pure culture obtained from Kitasato.) Fig. 5. Pure culture or Bacillus anthracis. Fig. 6. Gonorrhoeal pus from a case of gonorrhoeal proctitis. (Oil immersion, T'z.) a.—Pus cell containing numerous gonococci, adherent to vegetable fibre ; nucleus disintegrated. b.—Mucus. d.— Epithelial cell containing two gonococci; nucleus much broken up. e.—Free gonococci. Fig. 7. Bacillus tuberculosis, from pus obtained from a sinus left after an operation for tuberculous empyema. (University Hospital, Ann Arbor, Mich.) a.—Disintegrating pus cells. b.—Tubercle bacilli. PLATE I. Fig. 1. Fig. 2. Fig. 3. Fig. 4. Fig. 5. Fig. 7. Fig. 6. 4^ V—< BACILLUS TUBERCULOSIS. 69 tures the whole surface presents in from two to three days a pale green hue, the surface colonies liquefying the gelatin in the " funnel-form," while the deeper ones are yellowish, spherical, and translucent, with granular contours. Habitat. It is only found in pus, and its pyogenic properties are doubted by some observers, since it is only found in open wounds. Gonococcus; Micrococcus Gonorrhoeae.—These germs usually occur in diplococci, but as the division occurs alternately" in two planes, groups of four are frequently observed. They are flattened—"biscuit- shaped"—their surfaces facing one another, separated by a slight clear space in stained preparations. Each diplococcus measures from 0.8 to 0.6 of a micromillimetre. They occupy for the most part the interior of the pus corpuscles, or adhere to the epithelial cells. This organism is difficult to cultivate, but can be grown upon human blood-serum1 when other cocci are excluded. It is so highly aerobic that it can only flourish on the sur- face of mucous membranes, preferably those covered by cylindrical epi- thelium ; hence gonorrhoeal buboes and other suppurative complications and strictures must be the result of a " mixed infection" from the presence of other pyogenic organisms. Gonococci are easily stained with any of the aniline dyes, but most satisfactorily with methylene-blue, and they are best demonstrated by the " cover-glass" method presently to be described. It is said that they can be differentiated from pyogenic cocci by the fact that they decolorize when stained by Gram's method. (Plate I., Fig. 6.) Bacillus Pyogenes Fcetidus.—This is a short rod with rounded ends, is motile and aerobic, and does not liquefy gelatin. It is 1.45 micro- millimetres long by 0.58 broad, and usually is linked to form pairs or short chains. It grows in the ordinary culture media at the temperature of the room, giving off a disgusting odor. The ordinary reagents readily stain this germ. Habitat. It seems to be only found in the human body, and chief!y in abscesses near the anus, but it has also been found in abscesses of the brain and of other localities (Park), thus explaining their otherwise unaccountable fetor. Bacillus Tuberculosis.—These bacilli are non-motile aerobic rods, with rounded ends, measuring from 1.5 to 3.5 micromillimetres, slightly curved or angular, and with a diameter of about 0.2 micromillimetre. They are difficult to stain, and when this is done are not easily decolorized, even by strong acids. In some specimens unstained portions are found, from two to six, perhaps, in a single bacillus; it is still an open question whether these are spores or not. They are difficult to cultivate, but the addition of from five to six per cent, of glycerine to nutrient agar or gelatin will tend to secure this end if a temperature of about 37° C. be maintained for some weeks, the first signs of growth upon glycerine agar appearing only at the end of a fortnight. The colonies are "round, wThite, opaque, moist, and shining masses." By cover-glass impressions of the earlier growth on blood-serum, the bacilli are found to be arranged in parallel columns, which form sigmoid and variously curved figures. Desiccation acts only slowly as a destructive agent, since dried sputum retains its infective properties for from nine to ten months. Direct sunlight promptly kills the bacillus, while diffuse daylight does the same, but much more slowly. Iodoform-ether, one per cent., requires five minutes; carbolic acid, five per cent., thirty sec- onds; and mercuric chloride, 1-1000, ten minutes, to kill this germ. Ex- posure to steam at 100° C. for from two to five minutes destroys the bacillus, and probably a moist heat of 65° C, maintained for ten minutes, 1 A combination of blood-serum, one part to two or three of nutiient agar, has re- cently been claimed to be the better culture medium. 70 SURGICAL BACTERIOLOGY. would suffice. In a tubercular growth the bacilli are found chiefly in the giant-cells, usually upon the side opposite to the nuclei, which are apt to be closely packed in a crescentic form ; again, the nuclei may be irregu- larly disposed throughout the cell. The bacilli are also found between the lymphoid cells, and in the epithelioid cells. In the caseous material from the centres of old nodules bacilli often cannot be detected microscopically, but inoculation of susceptible animals with the same caseous material shows that the virus is active, and hence some observers infer the presence of spores; but in view of the well-known difficulty often experienced in de- tecting tubercle bacilli when few in number, this conclusion is certainly unwarranted. Habitat. Tubercle bacilli can only develop in the living tissues, as far as is at present determinable. (Plate I., Fig. 7.) Sputum and urine being the substances in which these bacilli are com- monly sought, the following method of staining is to be recommended: Where recognizable, pick out of the sputum with a platinum needle the small, lenticular, yellow masses so often seen, as free from mucus as possi- ble, or, if these cannot be found, any of the purulent material. Place a little of either of these in the centre of a cover-glass, lay a second glass upon the first, and, rubbing them gently together, spread out the material in a thin layer; slide the cover-glass apart and air dry. When urine is to be examined, let it stand in a conical glass; spread a portion of the sedi- ment upon a cover-glass, either with the needle, or, if muco-pus be present, by rubbing two cover-glasses together, as just described, and air dry ; if the sediment be small in amount, a second or third drop may be spread out upon the same cover-glass and dried. Next, pass the cover, held with forceps, thrice through the flame of a Bunsen burner or alcohol lamp. Now pour carbolic-fuchsin upon the cover-glass and gently warm over the lamp- flame until steam arises; remove temporarily from the flame, but heat gently again and again from one to two minutes; wash with water, quickly decolorize in a 25-per-cent. solution of nitric or sulphuric acid, re- moving as soon as the red tint becomes grayish, wash in 60-per-cent. alco- hol, and, washing well again, contrast-stain with meihylene-blue; wash and examine at once, or, when dry, mount in balsam ; if the decolorization be incomplete after removal from the alcohol, the cover must be again dipped in the acid solution, then in alcohol, etc. Since the digestive fluids cannot destroy tubercle bacilli, the milk of infected animals is dangerous to man, while the occurrence of intestinal tuberculosis secondary to pul- monary disease is thus readily explained, because infected sputum is being constantly swallowed. While it is contended that these germs can pene- trate intact mucous membranes, it is much more probable that they reach the circulation through insignificant cutaneous or mucous lesions which either are not, or, from their position, cannot, be detected. A toxalbumin, tuberculin, is produced by these germs, and it is probable that in animals rendered immune an anti-tuberculin is formed, which may be found serviceable in the treatment of tuberculosis. Bacillus of Tetanus—This (Plate I., Fig. 4) is a straight, slender bacillus with rounded ends, but long filaments may sometimes be observed. Spherical spores develop at one end of the rod, giving the germ the " drum- stick" form. It is strictly anaerobic, liquefies gelatin, is motile, and grows best at a temperature of from 36° to 38° C; it ceases to develop at 14° C. From one to two per cent, of glucose added to nutrient gelatin or agari which must be slightly alkaline, favors abundant growth. In stick-cultures in gelatin, development only occurs along the deeper portions of the punc- ture, forming radiated outgrowths with slight liquefaction of the gelatin. The germ stains readily with the usual aniline dyes. Habitat. The spores BACILLUS ANTHRACIS. 71 are found in the superficial layers of garden soil, and as the germs are said to develop, when swallowed with food, in the intestinal tract of horses, the bacillus is common in manure. The spores retain their vitality for months when dried or in putrefying material; while they resist one hour's expos- ure to a temperature of 80° C, only five minutes'steam-heat at 100° C. kills them. A five-per-cent. solution of carbolic acid, rendered faintly acid by hydrochloric acid, destroys them in two hours, and 1-1000 sublimate solution in three hours, or in thirty minutes if 0.5 per cent, of hydrochloric acid be added. Two ptomaines—tetanin, producing tetanic symptoms in animals, and tetano-toxin, of doubtful activity—with a most deadly toxalbumin, are separable from pure cultures. Animals rendered immune by gradually in- creasing doses of the tetanic virus have developed in their blood an albumi- nous tetanus-antitoxin, which will render other animals immune, and which has lately proved successful in the treatment of tetanus in man, the injec- tion of the blood-serum of immune animals being employed for this purpose. Bacillus of Malignant (Edema— This is a straight, slightly angular, or curved bacillus, from 3 to 3.5 micromillimetres long by 1 to 1.1 broad, often linked in pairs or forming triplets ; the ends are rounded. It is strictly anaerobic, liquefies gelatin, causing a free evolution of gas, is motile, spore-bearing, and grows best at a temperature of 37° C. This bacillus readily stains with the ordinary reagents, but is decolorized when treated by Gram's method. It is so rare as a cause of disease in man that it demands no more extended description. Habitat. In the superficial layers of the soil, in dirt, putrefying substances, foul water, etc. Al- though sometimes detected in cases of traumatic gangrene, these or- ganisms produce a characteristic disease of the cellular tissue, where alone they can thrive, since when injected only into the blood of animals they do not produce the " gangrene gazeuse" as the French term this rare disease in man. (Plate I., Fig. 3 ) Although many organisms have been described in other gangrenous diseases, their etiological relations are still so doubtful, that in such a short resume of surgical bacteriology as this, no further space will be con- sumed with their consideration. Bacillus Mallei—These organisms, which cause glanders, are straight or slightly curved rods with rounded ends, somewhat resembling the tuber- cle bacillus, but much thicker. They are aerobic, non-motile, and grow best at a temperature of 37° C. in glycerine-agar. They are usually solitary, but sometimes form chains of several elements. Unstained spaces some- times observed, similar to those seen in tubercle bacilli, have been claimed to be spores, but this seems to be more than doubtful. In the nodules which these organisms produce in the tissues, the germs occupy the more central portions. The ordinary staining agents will act, but better if they are rendered slightly alkaline. Desiccation for a few weeks kills them, as does ten minutes' exposure to a temperature of 55° C, three minutes' immersion in a three-per-cent. carbolic-acid solution, or two minutes' immersion in a 1-5000 sublimate solution. Grown on potatoes, after two or three days in the incubator, a characteristic thin, honey-yellow, trans- parent layer is developed, which gradually loses its transparency, until at the end of about one week it has acquired a reddish-brown tint, external to which the potato assumes an irregularly outlined greenish-yellow color. Habitat. It is improbable that this bacillus can grow outside an animal body. The disease which it causes is probably always acquired by man through the inoculation of some trivial cut or abrasion. Bacillus Anthracis.—As this bacillus (Plate I., Fig. 5) is the cause of malignant pustule and wool-sorters1 disease in man, a brief consideration 72 SURGICAL BACTERIOLOGY. will be accorded it. The bacilli are spore-bearing rods, from 5 to 20 micro- millimetres long by from 1 to 1 25 broad, developing under favorable cir- cumstances into long filaments composed of rectangular segments which are often combined to form twisted, convoluted bands. The germ is aerobic, but can grow without free oxygen in the human body, is non-motile, grows in many media at a temperature between 20° C. and 38° C, but ceases to develop at one below 12° C. or over 45° C. The spores, bright, glistening bodies in the centre of the rods, do not form in the living animal, but only after its death. In gelatin-plate cultures small opaque, greenish-white colonies form in about twenty-four hours, after- wards becoming surrounded by a brownish mass of wavy, tangled fila- ments, the whole forming the so-called "Medusa head:" this bacillus is best stained by Gram's method, if not left too long in the iodine solution. The adult germs are destroyed by exposure for ten minutes to a tempera- ture of 54° C, but the spores require, when dry, three hours at 140° C, or in liquid four minutes at 100° C. Mercuric chloride, 1-1000, destroys the spores in a few minutes, while a solution of 1 to 10,000 is effective after a more prolonged exposure. Habitat. The bacilli escape in num- bers in the discharges from the mouths and noses of moribund animals, as well as in their urine and feces ; they find congenial soil in decaying animal or vegetable material; in the presence of oxygen, spores develop, and these ai*e dispersed by air or water, so that grazing animals become inoculated through abrasions of the buccal mucous membrane, or of that of the intestines or lungs, or, again, from the bites of insects which have fed upon dead or infected animals. In man, inhalation of the spores and their entrance through the pulmonary or intestinal mucous membrane produces " Wool-sorter's Disease," while when inoculated through exter- nal abrasions, or by the bites of insects, " Malignant Pustule" results. The microbic origin of syphilis has as yet received no experimental proof, so that the question of such origin must still be considered as "sub judice," as must the relation of psorosperms to carcinoma. While many other organisms than those described in this chapter have occasionally given rise to disease-processes, or at least have been asso- ciated with them, their true relations have not as yet been ascertained, and consequently their consideration has been purposely omitted; because this chapter is merely intended to be an introduction to the subject of surgical bacteriology, illustrated by a few striking instances of the relation of micro-organisms to certain surgical diseases, and does not even pretend to enter into minutiae concerning the varieties of germs treated of. Only a few general directions can be given concerning the method of microscopic examination, and for details the student is referred to such works as those of Crookshank and Sternberg. Of course, it is presup- posed that anyone attempting bacteriological work has had some practical acquaintance with microscopic technique. Some form of condenser, such as Abbe's or Gibbes's, preferably with an iris-diaphragm, is absolutely requisite, with oil-immersion objectives of at least T', inch, although lower powers may demonstrate, in an unsatisfactory way, that germs are present in a given specimen. Watery solutions of "the aniline dyes, usually con- taining a small proportion of alcohol, such as methylene-blue, fuchsin, methyl-violet, gentian-violet, etc., are those most commonly employed as stains. Tissues can be most easily hardened for the average worker bv placing small cubical portions in dilute alcohol for forty-eight hours, and then in absolute alcohol until fit for cutting, when they should be embedded, sections cut, and these latter stained with fuchsin or gentian- violet, decolorized in alcohol or acidulated water, washed, dehydrated in CIRCUMSTANCES AFFECTING RESULTS OF OPERATIONS. 73 alcohol, and mounted in balsam; contrast-stains are often useful. Al- though there are more desirable methods in certain instances, they require more technical knowledge than most practitioners are likely to possess, and the limits of this work will not admit of their description. CHAPTER IV. 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 yet 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 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, unless 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 path- ology and therapeutics (or, in other words, to be an accomplished physi- cian) 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 74 OPERATIONS IN GENERAL. 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 lie 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 palienVs health exercises an important influence upon the success of an operation. Hence it is observed that those whose occupation has been of an exhausting or otherwise unhealth}' 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 disease of the heart. Our army medical officers can testify to the unfavor- able influence upon the results of operations exercised by the chronic diar- rhoea 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 oruans, and especially from diabetes or the chronic forms of Bright's disease. The'con- dition of pregnancy may be considered a contra-indication to anv opera- tion 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 individual- of which appear to be of a lymphatic temperament, seem to tolerate opera- CIRCUMSTANCES AFFECTING RESULTS OF OPERATIONS. 75 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 habit- ually overtaxes his digestive powers by too much indulgence in rich and stimulating food, or who exhausts his nervous system by intoxication. Those who have long been exposed to a close and impure atmosphere, or who have constantly inhaled noxious exhalations, 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 surroundings of the patient at the time of operation are also of great importance. Except in case of necessity, no operation should be done in very hot weather, or during the prevalence of an epidemic, es- pecially 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 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 followed 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 administration of heavy or irritating food, the patient must not be starved, under the impression that such a course can prevent the develop- ment of inflammation. I know of no food better adapted to the condition of a patient immediately after an operation than milk, and hence I com- monly 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 submitted to an operation should be con- ducted 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 apartment up to the standard. Too much stress cannot be laid upon the importance 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 rid""e ventilation, close, as they would invariably have been had the patients 76 OPERATIONS IN GENERAL. 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 arti- ficial ventilation which have been proposed of late years ; it may be doubted whether anything can compensate for the absence of large windows upon both sides of a ward. While the surgeon 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 widow, 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 once removed to an isolated apartment, or at least separated as widely as possible from other wounded patients; these 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 G. Morton, is an ad- mirable contrivance. (Fig. 10.) The most important feature of this apparatus is an arrangement by which the solution employed—usually of corrosive sublimate, one part to two thousand of water—is drawn from a portable reservoir, so that every wound can be washed with a fresh, run- ning stream. 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 awa}r after once using.1 The lint, or other material employed in dressing wounds, should never be used twice; hence the great importance of finding inexpensive substitutes, as was in- geniously done by Dr. Hewson and Dr. Agnew, in introducing paper lint as a cheap surgical dressing. It is well for the surgeon to wash his own hands frequently in o-0m. 80 OPERATIONS IN GENERAL. tutional symptoms which must be treated on the same principles as guide the practitioner in treating a case of diphtheria occurring under other cir- cumstances. 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 very 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 loco parentis, and do fearlessly what he thinks best for his patient. If, however, an adult in full posses- sion of his faculties refuse an operation, or if, in the case of a child, the parents refuse for him, I cannot think it the duty of the surgeon to persist in operating under such circumstances; he should remember that spon- taneous recoveries do occasionally occur in the most unpromising cases, and that, on the other hand, death may very likely follow the most eligible and best-executed operation ; and when the true state of the case and the imperative necessity (humanly speaking) of the operation have been clearly and fully explained, 1 cannot think that the surgeon should be held respon- sible 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 considerable distance to undergo an operation, it is proper to wait until they have rested from the fatigues of travelling, and have become some- what 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 PREPARATION OF PATIENT FOR OPERATION. 81 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 anaesthetic 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-cloth and a clean sheet, or by folded blankets; it should be placed in a good light (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 da}', 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- 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 assis- tants 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 mav seem almost superfluous to say that on such an occasion the surgeon's personal demeanor should be quiet and dignified ; eccentricities of costume and conduct should be avoided, the perfection of an operation consisting 6 82 OPERATIONS IN GENERAL. 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 sren 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 ad- vance, 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 ;' 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 bold- ness into stabbing rashly into his patient's body—a course which is never requisite, and which may occasionally lead the surgeon much deeper than he 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. After operations in cases of tuberculous or malignant disease, Felizet advises that the raw surfaces should be sub- jected to momentary contact with the flame of a blowpipe. The introduc- tion of stitches is best done while the patient is still in a state of anaes- thesia, though if there have been much shock or hemorrhage, it should be deferred until reaction has taken place. The sutures may be made of cat- gut, silk, ordinary thread, silkworm-gut, or 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 employed in preference to other forms of suture. For small wounds and generally for those about the face, my preference is for sutures of silkworm-gut or of fine black silk. 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 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. ANAESTHETICS. 83 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 anaesthetic. The after-treatment has already been referred to (see page 75). 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 between his visits. Insanity after Operations.—111, Graube, Werth, Shepherd, Thomas, and other writers have called attention to the occasional occurrence of severe mental disturbance, either mania or melancholia, after gynaeco- logical 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 posi- tive dementia, 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 VIII.), with which condition it must not be confounded. The prognosis is generally favorable. Anesthetics. It must be acknowledged that a great change has been brought about in the practice of operative surgery by the introduction of Anaesthetics; pa- tients will now submit to operations which formerly they would rather have died than endure, and thus many operations which without anaes- thesia 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 unquestionable; the patient is saved entirely from pain, and in a great degree from the mental anxiety and disquietude which formerly necessarily preceded 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? Statistics have been collected on either side of this question, Sir J. Y. Simpson maintaining that the mortality after operations has diminished since the use of anaesthetics, and Dr. Arnott that it lias increased. My own impression is that, as a matter of figures, the latter statement is cor- rect. 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 bene- 84: OPERATIONS IN GENERAL. fited, 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 aban- doned to certain death. In the large majority of cases, the chances for each individual are, I believe, made better by the use of anaesthetics. I have myself repeatedly noted an improvement of the pulse during the inha- lation or" 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 amesthesia. 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 auaesthetics 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 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, 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, i More recently the late Dr. Aug. Waller has shown that muscular relaxation and anesthesia may, in some cases, be effectually induced by pressure on the cervical por- tions of the vagi. 2 A claim of priority has been made on behalf of Dr. Crawford W. Lono- of Georgia who is said to have used ether in surgical operations as early as 1842. °I hope that I may be pardoned for saying that the evidence in Dr. Long's favor setms to me quite inconclusive. ANESTHETICS. 85 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 1846, 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 anaesthetic 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 anaesthetic 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, the anaesthetic 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 oper- ator 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, pre- ferred 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 anaesthesia, 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 believe that anaesthesia 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. In particular cases, however, chloroform would be preferable ; thus in ex- traction of cataract, if general anaesthesia were required, the greater strug- gling and risk of vomiting produced by ether would be contra-indications to 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 needed.1 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 many years I have abandoned chloroform altogether. 86 OPERATIONS IN GENERAL. Precautionary Measures.—Whatever anaesthetic 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 anaesthetic, and hence I cannot think its use in such cases improper. It would, however, be right, if disease of the heart were suspected, to watch the administration with special care, and particularly to give no more of the anaesthetic than was absolutely necessary. The patient 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 anaesthetic 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 mor- phia, immediately before the administration is begun; if the operation be very much prolonged, further restoratives may be given from time to time, the use of the anaesthetic being suspended sufficiently to allow the action of deglutition to be performed. The patient is best placed in the recumbent position to inhale any anaesthetic, though this is less important in using ether than in using chloroform, when it is absolutely essential. The inha- lation 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 in- sensibility. Effects of Anaesthetics—The first effect of an anaesthetic is upon the nervous system ; there is excitation, usually pleasurable, followed by in- sensibility to pain and complete unconsciousness, though some of the muscles may remain slightly rigid and tense, and reflex motion be not totally abolished ; 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.1 In the next stage there is complete relaxation of the muscular system, while the force of the circulation and respiration is much diminished. This condition must be induced for the performance of the more delicate operations, and for the reduction of dislocations. The ap- proach of this stage may be known by the test of touching the conjunc- tiva; if reflex motion be suspended, this action will not produce winking. When anaesthesia 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 anaesthetic either removed or continued in lessened quantity and with extreme care. Dr. H. 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 a«-ain begins to dilate ; sudden dilatation marks the occurrence of asphyxia, or, if the administration has been stopped, of sickness. Stertorous breathing, as pointed out by Lister, is of two kinds : one, the palatine, which is caused 1 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 b« 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. Bonwill state that a condition of " analgesia," sufficient for the endurance of minor operations, may be induced simply by rapid breathing. ANAESTHETICS. 87 by vibrations of the soft palate, may occur (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 arytenoid cartilages, and is always indicative of extreme danger. Death from the administration of an anaesthetic 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 experience, 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 Lister, the appearance of respiration may continue after the superven- tion of true laryngeal 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 when- ever death appears imminent during anaesthesia: 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 anaemia, advise that the patient should be in- verted, so as to favor the flow of blood to the brain. Inhalations of nitrite of amyl are suggested by Schiiller and by Burrall, and have been success- fully employed by Bader and others. The lower jaw should be forcibly pushed forwards, or the tongue drawn out as far as possible with tenacu- lum or forceps ; extreme protrusion is necessary to insure opening of the larnyx.1 Artificial respiration should be at once employed, and is most conveniently effected by alternately 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 suggests intravenous injections of ammonia, while Baillie' advises the in- troduction 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 anaesthetic, it should be done with renewed caution and watchfulness. Noel, having constantly ob- served a venous pulse in the jugular and subclavian veins during the stage of awakening from chloroform anaesthesia, 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 anaesthetics. These are headache, sick stomach, and bronchial irritation. In nervous women hysterical svmptoms are sometimes developed, which may continue for some time and may cause a good deal of annoyance. It is said that apoplexy or paralysis may be produced in oldpersonsby the use of anaesthetics, but I have never met with such an occurrence in my own practice. Fatty degenera- tion of the heart and other organs, in rabbits, is found by linger 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 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. 88 OPERATIONS IN GENERAL. agent or ether, the administration of which is very commonly followed by temporary suppression of urine. 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 symptoms may often be prevented by giving a hypodermic injection of morphia before the state of anaesthesia 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 hyoscvamus ; 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, according to the general condition of the patient. These unfortunate consequences may follow even when the anaesthetic has been given with the greatest care and judgment; they are, however, more likely to ensue when 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, which 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 anaesthesia has begun, the sponge may be closely applied, and need not usually be removed, except when 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 anaesthesia by taking deep inhalations ; he should, therefore, be constantly urged by the sur"-eoi" 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 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 voiun- ANESTHETICS. 89 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, a nd, therefore, wastes more ether. Dr. Lente 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. H. 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 inhale the ethereal vapor from a pig's bladder closely fitted to the mouth. Dr. A. F. M filler employs a face-piece con- nected by 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 Dublin), but I am not aware that they fig. n—ams's ether inhaler. possess any practical advantages over the simple method which I have recommended. 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 irritation from the contact of 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 anaesthetic 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 or 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 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. Various inhalers have been devised with a view of regulating 90 OPERATIONS IN GENERAL. 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 person, I believe that the greatest safety to the patient is that sense of immediate responsibility which should always be felt by the giver of chloroform, and that hence the best inhaler may occasionally prove injurious by inspiring a false sense of security. Mr. Clover's apparatus is probably the best; but even with this instrument, according to Kappeler, at least five fatal cases have occurred, and I believe that no mechanical arrangement, how- ever accurate, can take the place of the personal care and attention of the surgeon. Langenbeck, Stobwasser, Iterson, and Fischer believe that special dangers attend the administration of. chloroform by gaslight, the anaesthetic vapor combining with the gases produced by combustion, and causing sudden asphyxia which occasionally proves fatal. Zweifel attrib- utes the occurrence of catarrhal pneumonia after operations by artificial light, when chloroform is given, to the same cause, and Dr. J. S. Miller has reported a case corroborative of this view. A mixture of ether and chloroform, or of alcohol, chloroform and ether (A.-C.-E. mixture), is frequently used, 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 such a combination, that the operation had to be temporarily abandoned, when the patient was only restored by a prompt recourse to artificial respiration.1 Various other substances, principally belonging to the group of ethers, have been found to possess anaesthetic 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 Chisolm, nor the ethidene dichloride, 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. Ore* and other European surgeons. Nitrous oxide, or laughing gas, which, it will be remembered, was the substance employed by Dr. Wells in his early experiments, has been re- introduced in this country and is very extensively used in dental practice. I have seen an amputation done while the patient was rendered uncon- scious by the use of this gas, and though the symptoms presented were 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, which, 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 (Clover), though it'is con- stantly used in the extraction of teeth. It has been suggested by 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 coin- 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 1 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. ANAESTHETICS. 91 operations, where unconsciousness on the part of the patient is unnecessary or undesirable. It may be produced by the application of cold to the part to be operated on, either by meatus of a mixture of ice and salt, as recom- mended by Arnott, or by the rapid evaporation of ether, rhigolene, or other very volatile substance, as proposed by Dr. Richardson. The freez- ing mixture may be applied in the proportion of two parts of powdered ice to one of salt, being kept from the surface to be anaesthetized by in- closure 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. Richardson's method consists in ap- plying 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 Letamendi, the occurrence of anaesthesia 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 anaesthesia has been used success- fully in an operation as important and severe as ovariotomy; 1 cannot but think, however, that general anaesthesia 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 anaesthesia, which was highly recom- mended by Squibb, Wilson, and Bill, is the topical application of carbolic acid; but in order to get the anaesthetic effect the acid must be applied in such concentrated form that sloughing is apt to follow. The local use of hydrochlorate of cocaine or cucaine, introduced by Dr. Koller, of Vienna, is now very general; it is constantly resorted to in operations on the eye, and with great success. 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 anaesthetic 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,2 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 instru- ment specially devised for the purpose. By compressing the surrounding tissues with a ring or elastic cord, the effects of the drug can, as shown by the last-named writer, be concentrated sufficiently to allow the perform- ance of operations involving the deeper structures. The carbolate of cocaine is said by Von Oefele and Veasey to be as efficient as the hydro- 1 Death followed the injection of 12 grains of cocaine into the urethra in a case recorded by J. H. C. Sirnes, 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 iu one recorded by F. Johnson. 2 According to Reclus, it is not safe to use hypodermically a solution of more than two per cent., and never more than three grains should be employed at one time. The patient should always be in the recumbent posture, and the injection should not be carried deeper than the true skin. 92 MINOR SURGERY. chlorate, and to be less likely to cause systemic poisoning, and the same claim is made by Geissel for another alkaloid of the coca plant, which he calls tropacocaine. Other substances which have acquired reputation as local anaesthetics are drumine, kava-kava, tropsin, the haya poison, etc. Before leaving the subject of anaesthetics, I may give the student one caution, which is, never to give an anaesthetic 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-in- vestigation 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 anaesthetic which bad 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 V. MINOR SCRGERY. 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 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 band- ages used by the surgeon are the spiral, the figure-of-8 or spica, and the recurrent. BANDAGING. 93 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 direction receding from the trunk, as well as upwards. The plain spiral bandage, as it name implies, consists of simple turns of the roller around a limb or other part in a spiral direc- tion. It is applicable only where the part to be bandaged has a uniform diameter, as in the limbs of very 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 previous turn of the bandage with the fingers of the left hand, and, holding the roller lightly in the right band, 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 band- age. It will be found advantageous, in applying 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 bandage thus put on is much more likely to retain its position than one consisting of reversed turns alone. Figure-of-8 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, Fig. 12.—Reversed spiral of the lower extremity. Fig. 13.—The posterior figure-of-8 of the knee. 94 MINOR SURGERY. Fig. 14—The spica of the shoulder. Fig. 15.—The four-tailed bandage of the chin. may be ; the recurrent turns are secured by additional circular turns corre- sponding 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 T 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, ami the double T 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 conveniently used for the knee-joint, or in case of fractured jaw, while the bandage of Scul- tetus, which consists of numerous, short, overlapping strips of bandage (Fig. 16), may be resorted to in the treatment of compound fractures, and is of great ifse in the after-treatment of excisions of the knee. Handkerchief Bandages.—An ingenious Swiss surgeon, M Mayor, introduced some sixty or more 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 indeeed rival it in general utility, yet it is well for the surgeon to bear in mind the possibility 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.—Various substances have been em- ployed of late years to give greater firmness and solidity to the ordinary roller bandages, and may be applied either to the common spiral and spica BANDAGING. 95 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, with the silicate of potassium, and with paraffine. Whatever material be used, there is apt to be some constriction exercised upon the limb in the process of dry- ing, and hence it is best to protect all the bony prominences with a mode- rately thick layer of cotton wadding, the elasticity of which will prevent any injurious consequences 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, which should be coarse and of loose texture—crinoline is a suita- ble 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 application 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 con- stitutes, I think, the best form of immovable apparatus. It is an excel- lent 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 applied. It requires four or five hours to become dry. The dextrine band- age was particularly recommended by Velpeau; 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 m'nutes, it is ready for use. Velpeau used two rollers, 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 was considered by Prof. Hamilton to be as satisfactory as either. The silicate of potassium (liquid or soluble glass) has been used by several German, 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 band- ages 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 reconi- Fig. 16.—Bandage of Scultetus. 96 MINOR SURGERY. mended by the late Prof. Darbv, of New York, a.s was glue, mixed with oxide of "zinc, by Dr. Levis, of this city. Melted paraffine is employed by Tait and Macewen, the former applying it upon flannel bandages, and fig. is.—Seutins rately fitting splints are formed, constituting what the piers. 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, which is removed when the bandage has set, leaving a hollow, longitudinal ridge, which can by 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 redness 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 " 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 Furncaux 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 by means of the ordinary blister ^^HT'-----"^5*®l» Plaster» made with the officinal y//wStUm /) 111 cantharidal cerate of the Phar- Amnmmj^ 40mL^^ml" niacoPceia; cantharidal collodion ri^j£fKsBL!^^ii^f^^tk Wii may be painted over the part to Fig. 19.—Corrigan's button cautery. not t0° thick, will be found a Very prompt and convenient mode of REVULSION AND COUNTER-IRRITATION . 97 producing vesication ; or the solid stick of nitrate of silver may be used as a vesicant, or the strong aquaammoniae, or iron heated by immersion in boil- ing 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 when a profound impression is desired. Caustic issues may be made with Vienna paste ; this is a mixture of five parts of caustic potassa with six of quicklime. It is made into a paste with alcohol, and applied through a perforation in a piece of adhesive plaster. 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 outwards. When suppuration is fairly established, the issue may be kept open by the use of irritating ointments, or by the application 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 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 pos- sesses. It is applied by means of irons of various shapes, heated to a red or white heat in a convenient charcoal furnace. The gas cautery is used by direct- ing a jet of burning gas upon the part to be cau- terized, while the galvanic cautery, originally sug- gested by Heider, and 7 ' Fig. 20. Porte-moxa. Fig. 21.—Different forms of cautery irou. 98 MINOR SURGERY. made practically useful by Marshall and Middeldorpff. consists of a pair of forceps with long and narrow blades, holding copper or platinum wires, which are applied cold, and afterwards heated by means of the galvanic cur- rent (Fig. 22). Bitter has invented, and Faure has improved, a " secondary Fig. 22.—Marshall's galvanic cautery. battery," by which electricity can be stored away, as it were, for future use. This Very ingenious addition to the galvanic cautery has been suc- cessfully employed by Buchanan, of Glasgow. Paquelin has introduced a modification of the actual cautery, which acts by utilizing the property Fig. 23.—Paquelin's cautery. of heated platinum-sponge to become incandescent when exposed to the action of certain gases, and particularly the vapors of naphtha or rhigolene. (Fig. 23.) 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. Eleclro-puncturation is effected by passing a current of electricity through the ordinary acupuncture needles, which are previously intro- duced. 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 remedies which arc much used' in BLOODLETTING. 99 surgery by hypodermic injection are morphia, atropia, digitalis, and strychnia, 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 solu- tion 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 drug 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 ch an, its use is apt to be followed by considerable irritation, and some- times 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 em- ployed in cases of surgical shock, as well as in those of collapse from post- partum hemorrhage. Vaccination__Vaccination is usually performed by the physician or accoucheur, rather than by the surgeon ; still, it may be regarded as a surgical operation, and a brief reference to it will, therefore, not be out of place. Vaccination may be effected either with the lymph of the vaccine vesicle, or with the dried scab ; the latter has been largely employed in this country, 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 applied, and slowly worked in. Some surgeons prefer to introduce the vaccine 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 wash 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 insusceptible 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 influence 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. Vaccination, 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 em- ployed. The best age for vaccinating infants is, I think, about the end of the third month, though it may, if necessary, 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 ; 100 MINOR SURGERY. 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 tn 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 may 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. Cupping 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 bv 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 FiG.24.-Mechan- spirit-lamp for a few seconds into the interior of the cup, ical leech. which is then quickly applied. The scarificator is provided 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 mav 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 bv the use of the cup without the scarificator; it may be employed as a derivative in eases in which depletion 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. 24), small instruments are sold which ombine in one a cup, an exhausting apparatus, and a scarificator- thev 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' TRANSFUSION OF BLOOD. 101 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. Puncturalion 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.—Venesection, 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 the blood flows slug- gishly, 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 lightly dressed with a small compress and a figure-of-8 bandage. When bleeding 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 immediately 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. 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 drawn, 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 required in cases of profuse hemorrhage, as in flooding during or after labor. The chief precautions necessary are to prevent the blood from coagulating before it is injected, and to avoid introducing air into the patient's vein. Blood from a healthy bystander is drawn into a tumbler, kept at the temperature of the body by being surrounded with warm water, and, having been defibri- 102 MINOR SURGERY. nated1 by "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 ordinary sy- ringe (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 or a pint. By using a sy- ringe with a sharp-point- ed nozzle, the vein may be injected without hav- ing been previously ex- posed An ingenious but Fig. 25.—Apparatus for transfusion of blood. i , i- '^ somewhat more compli- cated apparatus for transfusion of defibrinated blood has been devised bv Mr. T. W. Carroll Jones. The late Prof Gross employed a convenient instrument by which the blood was made to flow into an exhausted receiver, and thence by a gum-elastic tube directly into the patient's vein, while M. Maisonneuve used a simple flexible tube with a bulb provided with valves, so as to pump the blood direct]v 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. Duncan advises, in cases of dangerous hemorrhage during an operation, ihat re-infusion of the patient's own blood should be substituted for transfusion. The blood is caught in a vessel containing a five-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 ■ •pen vein. Arterial transfusion, or the injection of defibrinated blood into the radial or posterior tibial artery, is recommended bv Hueter as preferable to the ordinary procedure. Dawbarn recommends the intro- duction of hot saline soiutions into the femoral artery, and in an emergency advantage may be derived from saline injections into the subcutaneous areolar tissue, whence the fluid will be gradually absorbed (hypodermo- clysis). Saline injections into the veins have been tried with some suc- cess in cases of cholera collapse, as has the injection of milk bv Dr. E. M. Hodder. Milk injections have also been employed under various circum- stances, with more or less benefit, by Thomas, Howe, Billiard. Pepper, Hunter, E. Wilson, Meldon, and other surgeons; according to Laborde, the amount injected should not exceed 200 grammes (about f.^vj) at one sitting. Karst, Schmeltz, and Ziemssen recommend hypodermic injection of defibrinated blood as a substitute for transfusion, while Ponfick, Bizzo- zero, Kaczorowski, and Golgi advise similar injections into the peritoneal cavity, a procedure, however, which caused fatal peritonitis in a case re- corded by Mosder. Rutgers employs saline solutions by the intraperitoneal method, and Wylie recommends the use of hot saline enemata, as a sub- stitute for transfusion. Fabrini suggests inhalations of defibrinated blood, administered with an ordinary spray apparatus. According to Lombroso and Atthill, the operation of transfusion is in itself not free from risk, and 1 Afanassiew, a Kussian physiologist, suggests that the blood should he peptonized instead ot being defibrinated. ASPIRATION. 103 should not be resorted 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 introduction 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. 26), consists of a jar or bottle connected by flexible tubes on one side with an ex- hausting pump, and on the other with a deli- cate canula carrying a fine trocar, the appa- ratus being provided with stopcocks to pre- vent 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 withdrawn, any fluid that 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. Fig. 26.—Aspirator. CHAPTER VI 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 never done except with a view of saving life which is more or less en- dangered, 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 writers, and it is probable that 104 AMPUTATION. 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 word "amputation," as now used, is generally understood to apply to the removal of a limb, though we still speak of amputating the penis, and some writers employ the term also for excision of the breast. A limb mav 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, was 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 was 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 was introduced by Morel, in 1674, and a few years later an English surgeon, named Young, devised, apparentlv 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 which 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, was perfected by Benjamin Bell and Hey towards the latter part of the last century. Another form of circular amputation was 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, however, 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 others in France. In the meanwhile, amputation by means of a flap cut from without inwards, was introduced, or, according to Velpeau, re-intro- duced, by Lowdham and Young in England, and shortly afterwards the formation of a flap by transfixion, by Verduin, of Amsterdam. The flap operation was subsequently improved by several other surgeons, and was CONDITIONS REQUIRING AMPUTATION. 105 finally adopted and brought into common use by the labors of Liston and Guthrie in England, of Klein and Langenbeck in Germany, and of Dupuy- 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 lie no question as to the propriety of amputa- 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. J fortification, 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 well established: thus, in the form of gangrene resulting from the intensity of the inflammatory process (as after frost-bite), no operation should be done while 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 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 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. 106 AMPUTATION. 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, Kii-ster, and some others, with favorable results. It is obvious, however, that the additional risk from the opera- tion itself would be so great, that it could only be 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 sepa- rated, 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 per- formed when the line of separation has been clearly established. In cases of burn or scald, it is proper to wait until the sloughs have spontaneously come away, and until the reparative power of nature has been fully tested, when, 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 which 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 prac- tice 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 arm v surgeon ; and. indeed, in no case is it more truly the " humane opera- tion" 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 arthrectomy, and to the modern improved methods of treat- ing 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 way. [). Morbid growths may render amputation imperative. Even non- malimiant 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. 10. Tetanus has been considered a cause for amputation, and the opera- tion has occasionally been followed by recovery from the disease. The ex- INSTRUMENTS. 107 perience 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 operation, 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 addi- tional reason for the performance of the operation. Amputation is not justifiable in cases of hydrophobia, nor in those of poisoned wound, from bites of serpents, etc. 11. Finally, amputation may be required for the relief of deformity, whether natural or acquired. These are operations of complaisance, aiid 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 andtenacula, 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 amputation safer than the best directed manual pres- sure; for while the latter can only check the flow of biood through the main ves- sels, a tourniquet controls all the arteries at once, and it is often t he smaller vessels that give the most trouble. Fig. 27.—Esmarch's apparatus for bloodless operations. To prevent loss of venous blood, Silvestri 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 operation may be per- formed in temporarily bloodless tissues. Esmarch's method is largely em- ployed by surgeons at the present clay, and with very general satisfaction ; I regard it as an invaluable resource in cases in which the anaemic state of the patient renders it more than ordinarily important to avoid the loss of 1 It has heen maintained that pycemia is caused by the use of the tourniquet, which is supposed to cause venou^ thrombosis at the point of application; but all that is known of the circumstances under which pyaemia occurs discountenances such an idea. 108 AMPUTATION. 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, its its use has been sometimes followed by troublesome consecutive hem- orrhage, by paralysis or even gangrene of the limb to which it has been applied, and, it is said, by embolism of the pulmonary artery and death. To prevent the oozing which follows the removal of the tube, Nicaise ad- vises compression of the wound with a sponge dipped in a 1-50 solution of carbolic acid, while Riedinger applies an induced current of electricity. Esmarch himself 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 de- vised 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 distance between which is regu- lated 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 com- press 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 instru- ment 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, provided that the compress is placed over the artery, it makes no fig. 28.-Petit's tourniquet. difference to what part of the limb the 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 diametricallv 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 instru- ment be applied as tightly as possible. Hence, as a rule, the tourniquet plate should go immediately over the artery ; where this is not practicable, a.s in the case of the axilla or the popliteal space, it should be placed at a point diametrically 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 <>-o over the INSTRUMENTS. 100 vessel; it is no better than the common garrot, or Spanish windlass (Fig. 29), made with a stick and handkerchief. Other forms are the horseshoe, or Signoroni's tourniquet (Fig. 30), Skeifs tourniquet (Fig. 31), and the Fig. 21).—Spanish windlass. Fig. 31.—Skey's tourniquet. Fig. 30.—Signoroni's tourniquet. Fig. 32.—Lister's aorta-compressor. (Frichsen.) various artery compressors, which are designed so as not to control the smaller vessels; however useful these maybe for cases of aneurism or accidental hemorrhage, they are not, I think, as good as Petit's instru- ment for employment in ordinary amputations. In certain special opera- tions, however, the}' are very valuable; thus hip-joint amputation is 110 AMPUTATION. shorn of half its terrors by the use of Skey's tourniquet or Lister's aorta- coinpressor (Fig. 32). 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. 34) are used Fig. 34.—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 ex- ceed three eighths of an inch. Besides the ordinary amputating knives the surgeon should have at hand one or two strong" bistouries or scalpels (Figs. 35 and 36), about three inches long, while for smaller amputations, as of the fingers, a verv slender knife with a heavv back will be found conve- nient. The blade of such a knife should be about two inches long and an eighth of an inch wide. The measurements which I have given are rather Fig. 36.—Scalpel. smaller than those usually directed, but are I think, such as will be found satisfactory ,n 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 he' R '"ft ahV,DS 'T" h ^^ amp,G GVen f°r aQ -.putattn at or ro TbLwhh"?T of amputating knives should be of fluted metal or rough ebony, uh.cb is less apt to slip than either bone or ivory. MvKM-.r.r**** t>t-*sj r Fig. 37.—Amputating saw. i *^-» r r M-t^rr r^/jv***^,^.,.* Saws.—Thy amputating saw should be about ten inches lono- bv two and a half wide; it should be strong, with a heavy back so as tn , L 1 d.t,on.l firmness, and the teeth not too widely *f™i*Z*£Z£ INSTRUMENTS. Ill vent binding. For operations about the hand or foot, a small saw with a movable back (Fig. 38) will often be found useful. Fig. 39.—Bone-nippers. Fig. 40.—Legouest's periosteotome. Fig. 38.—Small amputating saw. Bone-nippers or Cutting 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 rough- ened to prevent the hand from slipping. The Periosteo- tome or Raspatory (Fig. 40) is used for separating a cuff of periosteum which, after sawing the bone, is drawn down over its end and secured with catgut sutures so as to avoid necrosis and prevent adhesion of the soft tissues. Artery Forceps and Tenacula are used for taking up the vessels; the best form of forceps is essentially that invented by Liston, and known as the " bull-dog forceps ;" the blades should be expanded a short 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, as is the ordinary haemostatic forceps now so much used, or, which I think is better, be pro- vided with a spring which keeps them closed except when opened by pressure of the surgeon's fingers. The tenaculum, or sharp hook, must be of sufficient size and but slightly curved ; it is not as good an instrument as the for- ceps for most cases, but is sometimes useful, especi- ally where the parts are matted together by inflammation, and the artery cannot be separated by the forceps; sometimes it is necessary to take up a little mass of muscle or areolar tissue with two tenacula, and throw a ligature around the whole. Though I have never seen any harm result from this ligature en masse, it should not be practised when it can be avoided, and, as far as possible, each vessel should be drawn from its sheath and tied separately. Fig. 41.—Artery forceps closing by their own spring. Fig. 42.— Tenaculum, or sharp hook, with which the arterial orifice is picked out. 112 AMPUTATION. 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 pro- vided with a cutting slide to divide the ligature, thus enabling the surgeon to dispense with the aid of an assistant. Ligatures may be made of a variety of materials, such as catgut, 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.1 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 which can be better understood from the annexed cut than from any description (Fig. 43). 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. 43.—The reef-knot. Fig. 44.—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- 44), and both ends should be cut short. Some surgeons apply a single knot only to small vessels. I see no advantage in this plan, which is certainly not as safe as the use of the common reef- knot. Ballance and Edmunds recommend what they call the "stay-knot,'' made by placing two or more ligatures in close apposition, tying the first hitch with each one separately, and then making the second hitch of the reef-knot with all the ends together. Acupressure may be used to secure arteries after amputation, as may various ingenious modifications of acupressure, in which a wire is used instead of a needle; these will be considered in the chapter on wounds of arteries. The Retractor consists of a piece of muslin, six 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 fig. 45.—surgical needles. to keep the soft tissues from being 1 For ligation of arteries in their continuity, chromicized catgut is preferable. OPERATIVE PROCEDURES. 313 injured by the saw, and to prevent bone-dust from being caught among the muscles, an occurrence which might interfere with the healing process. A metallic retractor is preferred by some surgeons. 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 in a handle and with the eye near the point, such as is used in the operation of strangu- lating a nasvus, 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 circulation should be controlled by means of a tourniquet, or by manual pressure exercised by an assistant, while another assistant Fig. 46.—Amputation by circular method. (Druitt.) holds the affected limb in such a position as is convenient for the operator. The latter should stand so that his left hand will be towards the patient's trunk ; thus in amputating the right leg the surgeon stands on the patient's right side, while in removing the left leg he stands between the patient's limbs. The surgeon then, steadying and drawing upwards the skin with his left hand, slightly stoops, and carries his right hand, which holds a knife of sufficient length, around the patient's limb, so that the back of the knife is towards his own face. Pressing the heel of the knife well into the flesh, he makes a circular sweep around the limb, rising as he does so, and thus being enabled to complete the whole or at least the greater part of the cutaneous incision with one motion; a few light touches of the knife will now allow considerable retraction of the skin, and, if the limb be slender, this degree of retraction may be sufficient. The first incision must completely divide all the structures down to the 8 114 AMPUTATION. muscles. If the skin have not retracted sufficiently, the surgeon now, either with the same knife or with an ordinary scalpel, rapidly dissects up a cuff of skin and fascia, about half as long as "the limb is thick. In doing this, care must be taken to cut always towards the muscles; neglect of this rule will cause division of the cutaneous vessels and consequent sloughing of the part. Having done this, the operator grasps the cuff of skin with his left hand, and, with a large knife, 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 retrac- tion of the cut muscles; if it be not sufficient, however, the surgeon quickly separates the muscular structures from their periosteal attach- ments, with the finger or the handle of a scalpel, pressing them back and thus 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. 40), 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 saw nor to allow the bone to break before the section is completed. As soon as the limb is removed the surgeon secures the vessels, momentarily loosening the tourniquet, if necessary, that the gush of blood may 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 ca^es 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 only one flap, more commonly two, or even a larger number. The flaps mav 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 in- wards, 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 mav 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, 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. OPERATIVE PROCEDURES. 115 he brings the point out diametrically opposite its place of entrance. Hold- ing the blade in the axis of the limb, he then shapes his flap by cutting at first downwards, with a rapid sawing motion, and then obliquely forwards. Turning up the flap, he re-enters the knife at the same point as before, carries it on the other side of the bone, brings it out with the same pre- cautions as at first, and cuts his second flap. He then applies the retractor, makes a circular sweep to divide any remaining fibres, and saws the bone as in the circular operation. In many situations, as in the front of the leg where the bone is superficial, it is impossible to make a flap by trans- fixion, and in any part, if the limb be large, the flap thus made is unwieldy, the skin retracting more than the muscles, which project and interfere with the closure of the wound. Hence it is often better to make at least one flap by cutting from with- out 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 p , , . , . . n Fig. 4/.—Amputation by antero-posterior flap operation. and trouble by making flaps (Beyant) of skin only ; but apart from the danger of sloughing which always attends 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 ob- scure the line of the second. In making lateral flaps, the outer should be the first cut, and, generally, it may be stated that 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 metacarpo-phalangeal joints, and, with a slight modification, constitutes Larrey's well-known method of amputating at the shoulder-joint. Another form of the oval operation, which in this case should rather be called elliptical, is particularly adapted to the knee and elbow-joints, though it is applied by the French to other parts as well. 116 AMPUTATION. 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. Syme. It may be regarded as the ordinary circular operation, with the skin cuff slit on both sides and the angles trimmed off. It is done by cutting with a suitable knife two short curved skin-flaps, and dividing the muscles with a circular sweep of the instrument: it is particularly adapted to amputations through very muscular limbs. Fig. 48.—Modified circular amputation. (Skey.) Teale's 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 two 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, which is in shape a perfect square, is, after sawing the bone, folded on itself, and at- tached by points of suture to the short flap (Fig. 49). The advan- tages of this mode of amputating i ig. 49.—Teaie's amputation. (Bryant.) 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 pres- sure in adapting an artificial limb; its disadvantage is that, if used upon a OPERATIVE PROCEDURES. 117 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 sug- gested 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, however, the rectangular shape of the flaps), and have found it to answer quite as well as the original. Relative Merits of the different Methods.—I do not purpose to enter into a discussion of the supposed advantages of one method of amputating over another, believing that excellent results may be obtained by any of these 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 think, confine himself to any one method exclusively, but should vary his putation. (From a patient under the Fig. 51.—Synchronous triple amputation. (From care of Dr. Jackson.) a patient under the care of Dr. Lowman.) mode of operating according to the exigencies of the particular case. If any general rule were t# be given, I should say that the circular incision or Teale's method gave the best stumps in the forearm, the circular or modi- 118 AMPUTATION. Fig. 52.—Primary synchronous amputation of left leg and right hip-joint. (From a patient in the Uni- versity Hospital.) fied 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 between the knee and ankle, and the oval opera- tion 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 ampu- tations. Simultaneous, Synchro- nous, or Consecutive Am- putation__It occasionally be- comes necessary, in cases of severe injury, to remove two or more limbs by primary amputa- tion at the same time. Some- times this has been done by two surgeons operating simultane- ously, but it is better for one to do both amputations consecu- tively, beginning with the limb that is most severely hurt. Though the prognosis of these double amputations is always unfavorable, yet recoveries have • followed with sufficient fre- quency to justify the surgeon in having recourse to the knife when the condition of the patient will at all permit it. If the hemorrhage can be effectually controlled by tourniquets, both limbs may be removed before stopping to take up any vessels ; though if the first amputation have produced much depression, it may be necessary to pause and administer restoratives be- fore proceeding to the second. Among the most remarkable cases of syn- chronous amputation on record are that of Dr. George E. Jackson, of Lakota, who has kindly sent me the photograph (Fig. 50) of a patient from whom he successfully am- putated 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. Luckie, Alexander, Koehler, Lowrifan, and Armstrong, the first-named surgeon having twice, and the others each once, removed both legs and one arm simultaneously, all six patients Fig. 53.—Simultaneous triple amputation. (From a patient in the University Hospital.) DRESSING OF THE STUMP. 119 making excellent recoveries in spite of these severe mutilations. Fig. 51, 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. 52) for a railway injury occurring in a lad of fifteen, and in eighteen double major amputations have had eight successes. 1 have twice synchronously amputated three limbs from the same patient, one case ending in recovery (Fig. 53), but the other patient, an adult of intemperate habits, dying on the tenth day.1 Dressing of the Stump.—After an amputation the stump should not be dressed until all hemorrhage has ceased. Sometimes, after all the recognizable vessels have been secured, a troublesome oozing continues from the face of the stump ; this is usually venous bleeding, and will com- monly cease of itself when the tourniquet is removed. If it do not, it may probably be checked by elevating the stump and pouring over it a stream of cold or very hot water, or by sopping it with alcohol.2 Bleed- ing from the medullary cavity of the sawn bone may be stopped by inserting a pledget of antiseptic gauze or a pellet of previously softened white wax, armed with a wire thread to facilitate its withdrawal; the latter is perfectly unirritating, and therefore may be allowed to remain when the flaps are brought together. A plug of catgut is preferred by Riedinger. Hemorrhage from the nutritious artery of the bone may be checked by a catgut plug, or by compressing the bone with strong forceps. 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 mean- ■ while 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 at one or both angles of the wound, as may be most convenient; it has been sug- gested to bring each one through the face of the flap by a separate punc- ture, but such a plan seems to 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 heav}r, 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 escape freely from the stump, it will inevitably produce irritation. Various modes of dressing a stump have been employed; Mr. Teale directed what has been called dry-dressing, 1 Quadruple amputations, or amputations of hoth upper and hoth lower extremities, have been successfully performed by Dr. Alfred Muller, Acting Assistant Surgeon, U. S. A., Dr. Begg, M. Champenois, Dr. J. H. Wroth, and other surgeons, but it does not appear that, except in Dr. Jackson's and Dr. Wroth's cases, the operations in any of the nine to which I have references were synchronous. Triple amputations, besides those mentioned in the text, are attributed to Stone, L6seleuc. Ritter, Marten, Bruberger, Field, and other surgeons. 2 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. San. Commission Surgical Memoirs, vol. i. pp. 237-250.) 120 AMPUTATION. 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 recom- mended the exposure of both amputation and other wounds to the air, calling the scab produced by this exposure a " natural wound lute." Dr. J. R. Wood, of New York, went still further, treating stumps by what he called the "open method,'1 without either sutures, plasters, or dressings. MM. GueYin and Maisonneuve, on the other hand, devised ways of treating stumps in exhausted receivers, giving their respective plans the euphonious titles of " pneumatic occlusion" and " pneumatic aspiration." A. Guerin recommended the employment of cotton as a means of excluding the deleterious germs which are supposed to exist in the atmosrjhere. The ''antiseptic method" of Prof. Lister is now generally used in the treat- ment of stumps, and is found very satisfactory. A very good dressing, which I formerly employed, consists of a piece of sheet lint soaked in pure laudanum, covered with oiled silk or waxed paper, and secured in place with a light recurrent bandage; the local use of the narcotic is soothing to the patient, while the styptic and antiseptic properties of the alcoholic menstruum are often useful. In military practice cold water is a con- venient application to a recent stump, and, if not too long continued, answers very wrell. 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, and, if the antiseptic method has been employed, the dressing may often go for a week or ten days without renewal; under other circumstances, when the first dressing is removed, diluted alcohol or lime-water may be substituted, or any other substance that the condition 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. Silk 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. Catgut ligatures disappear spontaneously... 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- nozzlcd 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, which consists of from eight to twelve layers of sublimated gauze, freshly wrung out of the solu- tion ; this deep dressing is laid under the stump, folded over its face, and doubled up from the sides, and is then covered with the superficial dress- ing, consisting of an equal number of layers of dry gauze, with a sheet of mackintosh, or waterproof paper, interposed between the outer layers. AFFECTIONS OF STUMPS. 121 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 additional pad of cotton and another bandage. The dressings are usually renewed after five or six 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 a piece of lint spread with boracicacid ointment. Structure of a Stump__A stump continues to undergo changes in its structure for a long while after cicatrization is completed ; the muscular substance wastes, and the muscles and tendons become converted into a dense fibro-cellular mass which surrounds the bone ; the boue itself is rounded off, and its medullary cavity filled up ; the vessels are obliterated up to the points at which the first branches are given off, firm fibrous cords marking their place below ; the nerves1 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 addi- tional bearings upon the neighboring bony prominences ; thus for an amputation of the leg, the artificial limb should bear upon the knee, while in the case of a thigh stump, the tuber ischii and hip should receive the principal pressure. One of the best artificial legs in the market is that made with an aluminium socket and a foot of India-rubber. Affections of Stumps__Any one of the constituents of a stump may give trouble after an amputation, and the treatment of the morbid conditions of a stump is a very important matter for the surgeon's con- sideration. 1. Spasm of the muscles often occurs, and causes much suffering a few hours after an amputation ; it is best treated by the use of a moderately firm bandage around the part and by the exhibition of anodynes. 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 while the tension is removed; or extension may 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, Leyden, and Dreschfeld, while Chuquet, Luys, Beck, and Bourdon have observed cerebral atrophy on the opposite side. Be>ard, many years ago, noted atrophy of the anterior roots of the spinal nerves corresponding to the amputated part. 122 AMPUTATION. Fig. 51.—Thigh stump, with splint for extension. (Bryant.) be applied by means of a weio-ht and broad strips of adhesive plaster, or a light splint, as in Fig. 54. There is, however, another cause for the pro- duction of conical stumps in cases of young persons, apart from muscular retraction or wasting by suppuration ; this is a positive elongation of the bone by growth subse- quent to amputation. This is chiefly seen in the leg and upper arm, and its occurrence in these situations, rather than in the thigh or forearm, is easily accounted for by re- membering the physiological fact, that the upper extremity grows principally from the upper epiphysis of the humerus and the lower epiphysis 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 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 eud of the bone ; this is fortunately a proceeding which is attended with but little risk, and its results are usually satisfactory. 3. Erysipelas or diffuse cellular inflammation may attack the tissues of a stump; and either constitutes, under these circumstances, a very serious affection. All sutures should be at once removed, soothing and emollient dressings applied, and the general treatment adopted which will be described when speaking of those diseases. 4. Secondary hemorrhage may occur from the vessels of a stump at any time before complete cicatrization has taken place. If it be not pro- fuse, elevating the part, and the application of cold, or pressure, will often be sufficient to check the bleeding; if it continue, or recur, more decided measures must be adopted, which will be discussed in the chapter on wounds of arteries. 5. Aneurismal enlargement of the arteries of a stump occasionally occurs ; the annexed wood-cut (Fig. 55), from Mr. Erichsen's Surgery, il- lustrates a case of aneu- rismal varix occur- ring after amputation through the ankle-joint. 6. Neuroma, or pain- ful enlargement of the nerves of a stump, oc- casionally occurs. This distressing affection is, according to Mitchell, not due to the bulbous enlargement of the nerve (which is, indeed, met with in all stumps), but to the existence of neuritis,1 or of a sclerotic condition resulting from inflammatory changes. Should the pain evidently arise from any distinct tumor connected with a nerve, it would be proper to 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. Fig. 55.—Aneurismal varix in a stump. (Erichsen. AFFECTIONS OF STUMPS. 123 Fig. 56.—Neuromata of stump, after am- putation of the arm. Large neuromatous mass at a; opposite 6, the tumors are more denned. (Miller.) cut down and remove it; under other circumstances the nerve may be stretched, or a portion excised at a higher point, or re-amputation per- formed, though unfortunately these are by no means infallible remedies; Dr. Nott gives a case in which a man sub- mitted to three re-amputations and three nerve excisions for neuralgia of a stump, deriving at last only questionable benefit from this large experience in operative surgery. As a palliative remedy, the application to the stump of the strong tincture of the root of aconite is occa- sionally useful, or hypodermic injections of morphia may be used, as in other cases of neuralgia. Girard records a case in which relief was obtained by the repeat- ed employment of electro-puncture. Leeches, ice, and counter-irritants may also prove serviceable in some instances. 7. The tendons in the neighborhood of a stump may become contracted and cause troublesome deformity ; thus, after Cho- part's amputation of the foot, the natural arch of that organ being de- stroyed, the tendo Achillis may be drawn up by the powerful muscles of the calf, and a painful form of club-foot result, the cicatrix being thrown against the ground in walking. The occurrence of this condition should, if possible, be prevented by the use of appropriate splints and bandages, and it may be sometimes even necessary to resort to tenotomy when milder measures wil not suffice. 8. Periostitis, osteitis, and osteo-myelitis, one or all, may occur in a stump, and may defeat the surgeon's anticipations of a successful issue. If acute and extensive, these affections endanger life, and, especially in the femur, are apt to terminate fatally. The diffuse suppurative form of osteo- myelitis is especially apt to occur when the division of the bone has exposed the medullary cavity, and is almost sure to end in pyaemia and death ; the best mode of treatment is re- amputation at the nearest joint, which is of course an almost desperate remedy, though Kbuig effected a cure in one case by scooping out the diseased medulla and stuffing the cavity with cotton saturated 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 nat- ural separation of the necrosed part, which will then be exfoliated as a ring of dead bone, or as a long conical sequestrum (Fig. 57). 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 some- times called, or more properly diffuse subperiosteal suppu- ration, it may be necessary to amputate to save life, just as Necrosis of the it would be under the same circumstances occurring else- bone after ampu- where than in a stump. tation. (Liston.) 124 AMPUTATION. 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 f3ss; Acid. acet. dilut. vel Aceti alb. f5'ijss. 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 establishing 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 com- ing 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 was particularly investigated by Dr. Hewson. He found that, at the Pennsylvania Hos- pital, the mortality varied from 11 per cent, with an ascending, to 20 per cent, with a stationary, and 28 per cent, with a falling barometer. While the column of mercury was rising, the average duration of life, in fatal cases, was only seven days, but was thirteen while the column was falling: and of all the cases that died within three days, over 75 per cent, proved fatal while the barometer was rising. Valuable statistics as to the influence of the age of patients upon the results of amputation have been collected by several surgeons, including Dr. T. G. Morton, Mr. Golding-Bird, Dr. Gorman, and Mr. Holmes, the latter of 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." Besides 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 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., 1877; and Boston Med. and Surg. Journ., 1871. 3 Surgical History of the War. * Legouest, Chirurgie d'Armee, pp. 722-735. MORTALITY AFTER AMPUTATION. 125 Table showing Mortality of Amputations in Different Parts of the Body, for Traumatic Causes, in Civil and in Military Practice. Civil Hospitals. American and Crimean Wars. Aggregates. Locality. Cases. 367 Deaths. 197 Mortality per cent. 53.68 Cases. ' Deaths.' Mortality per cent. \ 8157 ] 5003 61.33 Cases. Deaths. Mortality per cent. Thigh . . 8524 5200 61.00 Leg . . . 633 264 41.71 6382 ! 2231 ! 34.95 7015 2495 35 56 Arm 332 86 25.90 6415 1805 | 28.14 6747 1891 28.03 Forearm . 298 1630 41 588 13.76 36.07 2181 444 20.35 2479 24,765 i 485 10,071 19.56 Totals . . 23,135 9483 40.98 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. Macleod. Otis and Huntington. . 87.2 86.8 53.8 , 58.5 55.3 44.5 , 55.0 50.0 53.6 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. 03 652 610 1252 2514 Mortality per cent. C3 O ... 947 1107 629 -5 la ft 406 251 117 Mortality per cent. CC U 1599 1717 1881 5197 OS R Mortality per cent. French Hospitals1 . . English Hospitals2 . . American Hospitals3. . 378 57.98 250 40.98 400i 31.95 42.87 22.67 18.60 28.85 784 501 517 49.03 29.18 27.49 Aggregates . . . 1028 40.89 '2683 774 1802 34.67 1 Malgaigne (Arch. Gen., Avril et Mai, 1842), and TreTat (Legouest, op. citat., p. 707). 2 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. 126 AMPUTATION. The mortality which attends amputations of expediency has been par- ticularly 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 i> 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 Avhich 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 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. 1 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 (p 12T), and in which the results of primary amputations, or those performed in the pre-inflammatory stage, are compared with those of all others for traumatic causes. 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, scarcelv 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 savin"- the limb, while consecutive amputations are, on the other hand, performed in cases which are to a certain extent selected. Moreover, the least hopeful cases among any large number are eliminated by death before the secondary period is reached, so that even if the numerical chances of consecutive operations were the best, it would by no means be proved that more lives would not have been saved had more limbs been primarily amputated. CAUSES OF DEATH AFTER AMPUTATION. 127 Primary. i Secondary and Intermediate. Obsf.rvations from Civil Hospitals. ■a 34 :£ s — 0) S3 O o 5 £=• 69.4, k o 20 CO R 13 03 O 65.0 Reporter. Reference. 49 Malgaigne. Arch, de Med., 1842. [vol. xvii. 64 15 23.41 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 52.71 43 26] 60.5 Laurie. James, loc. cit. 169 62 36.7 53 3769.8 Steele. Ibid. [367. 180 oc 33.3 87 61 70.1 McGhie. Macleod, Surg, of Crimean War, p. 50 9 18.0 6 ] 16.7 Hussey. Ibid. [p. 81. 48 lc 37.5 43 19 44.2 Erichsen. Science and Art of Surgery, vol. i. 40 8 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 16.1 37 13 35.1 Callender. Med.-Chir. Trans., vol. xlvii. 144 61 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 14 48.3 13 7 53.8 Lente. Trans. Am. Med. Assoc, vol. iv. 656 164 25.0 118 45 38.1 Morton. Surg, in the Penna. Hosp., 1880. 241 84 34.9 87 32 36.8 Chadwick. Bost. Med. and Surg. Journ., 1871. 164 68 41.5 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 Varick. Am. Journ. Med. Sci., 1881. 55 16 29.0 17 8 47.0 Ashhurst. Internat. Encycl. of Surg., vol. i. 258 1— 89C IS.2 32.3 119 910 29 L___ 414 24.3 Cnpples. Aggregates. Report of Surgery in Texas, 1886. 2755 45.5 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 oc- curred, and before the injured part has become inflamed; but if by any chance this golden opportunity has been lost, and the intermediate or in- flammatory stage has come on, operative interference must, if possible, be postponed until the inflammation has measurably subsided, and till the patient's condition has become assimilated to that of a case of chronic disease rather than of 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— 128 AMPUTATION. "1. That a considerable proportion of cases must occur in hospital practice in which death is really inevitable, although it is not known to be so at the time of amputation..... . "2. That of the fatal cases which remain, in about one-half death is due mainly to previous disease or injury. " 3. That secondary hemorrhage is hardly ever a cause of death, except in persons 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 phagedaena 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 wards." (St. George's Hospital"Reports, vol. i. pp. 321,322.)' 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 . . 5.6 " " 1.33 Cerebral *• . . 3.0 " " .66 Abdominal " . . 1.4 " " .33 Penal " . . 3.0 " " .66 Hectic " . . 3.0 " " .66 Traumatic " . . 7.0 " " 1.66 Pyaemia is the chief cause of death after pathological amputations, after those of expediency, and after primary amputations for injury. Exhaustion is the chief cause of death after secondary amputations for injury, and ranks next to 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 171 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 disease 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.y 1 Mr. Holmes':« second paper, based on 500 cases (St.George's Hospital Reports, vol. viii.), confirms the above conclusions. 2 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 alter amputation, for which I have not space here. AMPUTATIONS OF THE HAND. 129 CHAPTER VII. 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 done by cutting suitable flaps with a straight bistoury, and dividing the bone with cutting pliers or a small saw. Ampu- tation 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 prom- inence of the knuckle is due to the upper bone, and that hence the incision must be made below the knuckle, or it will not expose the joint. The palmar flap may be made first, either by transfixion or other- wise, and the joint'opened subsequently ; FlG 58._Amputation of partof a finger I think, however, the plan first mentioned by cutting from above. (Erichsen.) is the best. Another method is to attack the joint from the side, cutting one lateral ligament, disarticulating, and then making a long lateral flap from the other side of the finger; this has been particularly recommended in the case of the fore and little fingers, but 1 do not see that it possesses any advantage over the common palmar Hap 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 9 130 SPECIAL AMPUTATIONS. of the finger, and obliquely upwards to the point of commencement; a few light touches of the knife free this oval flap, and disarticulation is then effected by cutting the extensor tendon (if it be not already divided) and the lateral ligaments. In the case of the forefinger the knife should be entered on the radial side, and in the case of the little finger on the ulnar side, instead of at the back of the joint. Some difference of opinion exists as to the propriety of removing the head of the metacarpal bone in these amputations. The hand may indeed be rendered more 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 bead 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 by cutting it with strong pliers (Fig. 59), 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. Fig. 59.—Amputation of an entire finger. Fig. 60.—Amputation of the left thumb. (Skey.) (Erichsen.) 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. 60), 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 of entrance, and cutting downwards and outwards. In amputating the right thumb, it is more convenient to make the palmar flap first, by trans- 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, AMPUTATIONS OF THE ARM. 131 Fig. 61—Partial amputation of the hand. (From a patient in the Episcopal Hospital.) 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 palms should be respected as much as possible, the necessary in- cisions being preferably made through the dorsum of the hand. It is better to leave the carpal ends of the metacarpal bones, so as to avoid opening the wrist-joint. Any part of the hand that can be kept should be scrupulously pre- served, as even a single finger, with the thumb, is far more useful than the best artificial substi- tute. Fig. 61, from a case formerly under my care at the Episcopal Hospital, shows the re- sult of an operation of this kind. If a metacarpal bone be injured without injury of its corre- sponding 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 Professor Joseph Pancoast. The risks of amputation below the carpus are slight, 7902 cases referred to in the third volume of the Surgical History of the War, having fur- 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 Wi-ist.—The hand has occasionally been removed at the carpo-metacarpal articulation, or between the rows of carpal bones ; the stumps thus formed are, however, irregular, and the carpal bones are apt to become subsequently diseased and to require removal. Hence, when it is necessary to invade the carpus at all, it is better to go at once to the radio-carpal joint, and amputate at the wrist. Amputation at the wrist-joint may be conveniently effected by the 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 uhia. 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 Fig. 62—Amputation at the wrist. (Erichsen.) 132 SPECIAL AMPUTATIONS. 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 interosseous 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 Fig. 63.—Amputation of forearm by modified circular method. (Bryant.) be encountered. In any of the flap operations, particularly in the lower third of the forearm, trouble may be caused by the tendons projecting from their sheaths. Under 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 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 making an anterior or an external flap by transfixion. It is sometimes recommended to leave the olecranon in place, dividing the ulna below it with a 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 saw. In amputating the arm, the possibility of a high division of the main artery must be remembered; occasionally the brachial will be the only vessel that requires ligature, though usually there will be 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 AMPUTATION AT THE SHOULDER-JOINT. 133 artery compressed as it passes over the first rib, by means of a wrapped key in the hands of an assistant. Another plan is to transfix the limb with two mattress-needles and apply an Esmarch's tube above them, as in Wyeth's "bloodless method" for amputation at the hip-joint. 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 successful. 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 down- wards (and slightly convex, if the limb be muscular), so as respectively to terminate at the points where the anterior and posterior folds of the axilla end in the tissues of the arm ; it is usually directed that the anterior incision should be made first, as the posterior circumflex artery is larger than the anterior, but if the subclavian be well commanded over the first rib, there need be no fear of hemorrhage, and it will then be most con- venient to make the posterior incision first, that its position may not be obscured by bleeding from the other. The surgeon next disarticulates, Fig. 65.—Result of Larrey's amputa- Fig. 64.—Amputation at shoulder-joint by Larrey's tion. (From a patient in the Episcopal method. Hospital.) rotating the arm first outwards so as to make tense the subscapular mus- cle, 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 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 through the tissues of the arm, either from 13-1 SPECIAL AMPUTATIONS. without or from brachial artery) Fig. 66.- Amputation at shoulder-joint; Dupuytren's method. (Bryant.) within. Before this final incision (which divides the is made, an assistant should slip his thumb into the wound and control the vessel, which may al- ways be found in the first muscular inter- space from the ante- rior edge of the axilla, or a ligature may be thrown around the artery with an aneu- rismal needle, after dividing the skin ; the limb being removed, the vessels are to be secured, and the edges of the wound brought together so as to make a linear cicatrix. The appearance of the stump resulting from this operation is well shown in the accompanying illustration (Fig. 65), from the photograph of a patient on whom I per- formed 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 difficulty is in disarticulating, to accomplish which (in the case of fracture preventing the use of the arm as a lever in effecting rotation) it may be necessary to intro- duce the forefinger of the left hand into the capsule, and forcibly drag down the head of the bone so as to expose the ligamentous attachments. In making the deltoid flap by transfixion, the knife should be entered about an inch in front of the acromion process, and, being pushed directly across the joint and cap- sule, should be brought out at the poste- rior fold of the axilla. As in Larrey's operation, an assistant should slip his thumb into the wound, and secure the artery before the final incision is made. 3. Lisfranc's Operation consists in making antero-posterior flaps, which come together very much as the inci- sions in Larrey's method, over which it presents no particular advantage. The shoulder-joint can also be reached by a Fig. 67.—Result of amputation by Dupuy- tren's method. (From a patient in the Epis- copal Hospital.) AMPUTATIONS OF THE FOOT. 135 circular incision, as practised by Yelpeau 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 de- scribed 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 occa- sionally required in cases of accident or of disease. No special rules can be given for the performance of this operation, to which, whenever possi- ble, excision of the parts concerned is to be preferred. In cases of in- jury, the surgeon must make his flaps as best he may, in view of the extent and direction of the laceration, and in cases of amputation for tumors, etc., must be guided by the size and shape of the morbid growth. 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 171 cases are on record which, though the arm and a part or the whole of the scapula were torn off by accidental violence, terminated favorabty, while 892 cases in which 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 65 recoveries and only 22 deaths, the result in two instances being uncer- tain, and the mortality of terminated cases being only 25.3 per cent. Lower Extremity. Amputations of the Foot.—The require amputation, but, if neces- sary, this little operation may be conveniently done, as in the case of the fingers, by opening the joint from the dorsum and covering the stump with a plantar flap. Amputation at the Metatarso- phalangeal Joint is best done by the oval incision. It must be re- membered that the web reaches about half-way between the joint and the end of the toe ; hence the incision must be placed high, or the joint will be missed. Disar- ticulation is facilitated by forcibly flexing the toe, and dividing the extensor tendon by a transverse incision. It is sometimes recom- mended that in amputating the great toe, the head of the metatar- sal bone should be also removed ; I do not think this desirable, as by phalanges of the toes seldom io. 68.—Removal of metatarsal bone of great toe : flap formed; joint being opened. (Erichsen.) 1 The late Dr. Stephen Rogers collected 12 cases in papers published in the American Journal of the Medical Sciences tor October, 18b8, and the New York Medical Journal for December, 1870. Additional cases have been since reported by Kathaletzky, Ellis- Jones, George, Lonmeau, Ogilvie, and Stennett. The result in Dr. George's case I do not know, but all the rest are said to have terminated successfully. 2 In the fifth edition of this work 75 cases were tabulated, to which may be added 14 recorded by Wyeth (two cases), Thiersch, Czerny, Lewis, Sondermayer, Parkes* Weinlechner, Southani, Martin, Chavasse, McLeod, Hutchinson, and Senn. 136 SPECIAL AMPUTATIONS. so doing a very important point of support to the arch of the foot would be taken away, an evil which would not be compensated for by the greater symmetry of the resulting stump. Amputation of the Great Toe, with a part or the whole of the Meta- tarsal Bone, may be required. If the anterior portion or head only is to be removed, an oval incision may be employed, which is pro- longed backwards for a sufficient distance on the side or back of the foot. The bone may be divided by cutting-pliers or by a chain saw. If the whole bone is to be removed, it is better to shape an antero-lateral flap, by entering the knife on the back of the foot, between the first and second metatarsal bones, and on a level with the tarso-metatarsal joint, cutting forwards to the ball of the toe, then across to a point corresponding to the position of the web, and then backwards again along the inner edge of the sole; this flap is dissected up, taking care to keep it as fleshy as possible. The knife is then re-entered between the metatarsal bones, and made to cut directly forwards through the web. Then pressing the toe away from the next one, the surgeon, with the point of his knife, cautiously effects disar- ticulation, and separates the part to be removed, taking care not to wound the dorsal artery of the foot. Hemorrhage having been checked, the flap is brought down and attached by points of suture in the usual way. Amputation of the Fifth Metatarsal Bone mayT be effected by the oval incision, made so as to avoid wounding the sole. The point of the oval is usually made on the dorsum of the foot, and may be extended in a curve downwards and outwards to the edge of the sole, thus forming a curved triangular flap, which is dissected down to give more space. A somewhat similar modification of the oval incision is practised by A. Guerin in am- putating the metatarsal bone of the great toe. Amputation of two or more of the Metatarsal Bones may be conveni- ent^ done by the oval operation, the point of the oval beginning on the dorsum above the joint at which disarticulation is to be effected, and its branches spreading to embrace the requisite number of toes. Amputation through the Continuity of all the Metatarsal Bones is best done by cutting a short dorsal and a long plantar flap, the latter of which may be made, if preferred, by transfixion, sawing the bones on the same level, and bringing up the long flap, so as to free the cicatrix from pressure in walking. The resulting stump is well formed and useful. Amputation of the entire Metatarsus (which is said to have been practised by the North American Indians as a means of preventing the escape of prisoners) may be effected by making a long plantar and a short dorsal flap. The general line of the articulation is irregularly oblique, the base of the first Fig. 69.—Amputation at the tarso-metatarsal joint. (Skey.) metatarsal being much lower than that of the fifth. The second metatarsal dips in between the first and third, while this again articulates at a lower level than the fourth or fifth. ' ^be plantar flap AMPUTATIONS OF THE FOOT. 137 may be cut first from without inwards, as directed by Hey, or disarticula- tion may be effected first, and the long flap made last, as practised by Lisfranc. The guides to the articulation are the prominent tuberosity of the fifth, and the tubercle of the first metatarsal bone (Lisfranc), or the tuberosity of the fifth metatarsal, and the prominence of the scaphoid (Hey). The French operation is a pure disarticulation, but Hey sawed across the projecting internal cuneiform bone. This amputation is some- what difficult of operation, and is now seldom performed. Chopart's Amputation removes all of the tarsus except the astragalus and the calcaneum. As in the case of the last described operation, the plantar flap may be made first, or not until after disarticulation has been effected ; the former plan is in some respects the best, as allow- ing the flap to be more regularly shaped. The incision should start on the outside of the foot from a point midway between the exter- nal malleolus and the tuberosity of the fifth metatarsal bone, and on the inside from a point about half an inch behind the prominence of the Scaphoid. Disarticulation may Fig. 70.-Choparfs amputation. (Bryant.) be much facilitated by forcibly bend- ing the foot down so as to make tense the anterior ligaments of the joint. The scaphoid bone has often been left, unintentionally, in performing this operation, the resulting stump being nevertheless quite satisfactory. Care must be taken, in the after-treatment, to prevent retraction of the heel, which is apt to occur, and which may require division of the tendo Achillis. Mr. Hancock collected 152 cases of Chopart's amputation, of which 120 resulted in recovery with serviceable stumps, 2 in re-amputation, and 11 in death, while in 15 the result as regards utility of the limb was uncer- tain, and in 4, though life was preserved, the stumps were not satisfactory. The mortality is thus only 7.2 per cent. Sub-astragaloid Amputation.—In this operation all the bones of the foot are removed except the astragalus. Lisfranc did this amputation by cut- ting a dorsal flap, Lignerolles with two lateral flaps, and Malgaigne by taking a single flap from the inner part of the plantar surface. The best plan, however, and that which I have myself followed, is to make a flap from the heel, as in Syme's operation (to be presently described), which flap is then brought over the astragalus and attached to a short dorsal flap in front. Mr. Hancock collected twenty-two cases of this operation, the results of which appear to have been unusually satisfactory. Pirogoff's Amputation—In this operation the whole of the foot is taken away except the posterior part of the os calcis, which is brought up and placed in contact with the sawn extremities of the tibia and fibula, from which the malleoli have been removed.1 The operation is thus done: a somewhat oblique incision, convex forwards, is carried across the sole of the foot from one malleolus to the other, and the flap thus marked out dis- st cted backwards for about a quarter of an inch ; a second incision, slightly 1 Sir W. Fergusson, Prof. Agnew, and Dr. Qnimby have modified this operation by leaving the malleoli and pressing up the sawn os calcis between them. I. S. Wight, of Brooklyn, saws through the calcaneum, and then removes the foot and malleoli together, without disarticulating. Tauber makes a flap from the inner side of the sole, splits the calcaneum longitudinally, and takes away its outer portion. 138 SPECIAL AMPUTATIONS. convex forwards, is then made across the front of the ankle, so as to open the joint; the astragalus is next disarticulated, when the surgeon, apply- ing a narrovv-bladed saw or a " Butcher's saw" to the upper and posterior part of the calcaneum. behind the astragalus, divides it obliquely down- wards, in the line of the plantar incision. The malleoli and articulating surface of the tibia are then likewise sawn off, and the two cut surfaces of Fig. 72. — Bony union be- tween calcaneum and tibia, after Pirogoff's amputation. (Hewson.) bone approximated. If Butcher's saw be used, the position of the blade may be reversed for the latter part of the operation, so as to saw off the malleoli from behind forwards. This amputation makes an admirable stump, the remaining portion of the calcaneum becoming firmly attached to the bones of the leg, and the natural length of the limb being retained. It is particularly adapted to cases of injury, though it may also be employed in those of disease, providing that the os calcis itself be not involved. Hancock collected 70 cases of Pirogoff's amputation, done by British surgeons, death occurring in only 6, while a useful stump was known to have resulted in 57. Five required re-amputation. Seventy-seven opera- tions collected from all sources by Gross (of Nancy) and Pasquier, gave only eight deaths, while useful limbs were known to have been obtained in 44 cases. Stephen Smith and Hewson have particularly investigated the merits of Pirogoff's amputation, and the latter believes it to be, in one point, superior to any1 operation done higher up, in that it enables the patient to run upon his stump as well as walk. The accompanving cut (Fig. 72), from Hewson's paper, shows very well the bony union between the calcaneum and the tibia in a successful case of this operation. The same precautions as to retraction of the heel are necessary in the after-treat- ment of this, as in that of Chopart's operation ; the purpose was well ac- complished in Hewson's case by applying a weight of four or five douikIs to the back of the leg, by means of a broad strip of adhesive plaster. Amputation at the Ankle-joint (Syme's Operation)..__The following is Mr. Syme's own description of this operation: "The foot beino- held at a right angle to the leg, the point of a common straight bistoury should be introduced immediately below the fibula, at the centre of its malleolar 1 Mr. Syme also claimed this advantage for his operation at the ankle-joint. Fig. 71.—Pirogoff's amputation. Application of the saw to os calcis. (Erichsen.) AMPUTATIONS OF THE FOOT. 139 Fig. 73 —Syme's amputation. (Skey.) projection, and then carried across the integuments of the sole in a straight line to the same level on the opposite side. The operator having next placed the fingers of his left hand upon the heel, and inserted the point of his thumb into the incision, pushes in the knife with its blade parallel to the bone, and cuts close to the osseous surface, at the same time pressing the flap backwards until the tuberosity is fairly turned, when, joining the two extremities of the first incision by a transverse one across the instep, he opens the joint, and carrying his knife downwards on each side of the astragalus, divides the lateral ligaments, so as to com- plete the disarticulation. Lastly the knife is drawn round the extremities of the tibia and fibula, so as to ex- pose them sufficiently for being grasped by the hand and removed by the saw. After the vessels have been tied, and before the edges of the wound are stitched together, an opening should be made through the posterior part of the flap, where it is thinnest, to afford a de- pendent drain for the matter, as there must always be too much blood retained in the cavity to permit of union by the first intention." This operation has been varied by other surgeons, some making the heel flap longer,1 and others shorter, than directed by Syme himself. Again, some only dissect back the flap to the point of the heel, dividing the tendo Achillis and completing the separation of the calcaneum after disarticula- tion. However it be done, an excellent stump results, provided that care be taken to keep close to the bone in making the heel flap, so as not to destroy its vascular connections. The death-rate of Syme's operation is but small, 219 cases collected by Hancock having given but 17 fatal termi- nations, a mortality of less than 8 per cent. The stump is, according to Stephen Smith, better than that of Pirogoff's operation, for use with an artificial limb. Macleod and J. Bell modify Syme's operation by preserving the periosteum of the os calcis. Other Amputations on the Foot —Mr. Hancock ingeniously combined Pirogoff's with the subastragaloid amputation, preserving the ankle-joint and bringing the sawn surface of the os calcis into contact with a trans- verse section of the astragalus; in this operation the head of the latter bone was also removed. In the course of lectures in which this operation, which may be called Hancock's, was described, the same surgeon ably ad- vocated the propriety of looking upon the foot as a whole, for operative purposes, and of dividing the tarsal bones with a saw, without regard to the position of the joints, taking care merely to remove all parts that were diseased or irretrievably injured. This is a revival of the old teaching of Mayor, and, though contrary to the generally received views of modern 1 Dr. Wyeth has shown, by numerous dissections, that the chief blood supply to the heel flap is from the calcaneal branches of the external plantar artery, and that hence a long flap is more likely to preserve its vitality than a short one. 140 SPECIAL AMPUTATIONS. surgerv, is, I think, founded in reason; acting upon this principle, I my- self in one case removed the front portion of the foot, sawing through the scaphoid bone, the posterior part of which was healthy, and re- moving the anterior diseased sur- face of the calcaneum ; the case did perfectly well. By this pro- ceeding amputations of the tarsus are greatly simplified, it being merely requisite to make antero- posterior flaps of sufficient size, and to saw off the diseased or injured parts of the foot. Tripier has modified the subastragaloid opera- tion by leaving the upper part of the calcaneum, which he saws through on a level with the sus- tentaculum tali, and at right angles to the axis of the leg ; the external incisions are made as in Chopart's amputation. A further modification of Pirogoff's method has been de- vised by Mikulicz, who removes the astragalus and calcaneum, saw- ing through the scaphoid and cu- boid, and approximating the an- terior tarsus to the resected ends of the tibia and fibula ; the resulting stump somewhat resembles the foot of pes equinus.1 This operation has been resorted to in about 30 cases by various surgeons, among others by MacCormac, Fenger, Stephen Smith, F. H. Gross, and W. B. Hopkins. Of 22 cases tabulated by the last-named surgeon, 17 ended in recovery, and none proved fatal. A special boot must be worn after recovery, as shown in Fig. 74, while, as the limb is lengthened by the operation, an ordinary high-soled shoe is worn upon the other foot. The statistics of amputations of the foot and ankle are quite favorable; thus, in our late war, 1398 determined amputations of the toes and foot gave 81 deaths, or 5.7 per cent., and 159 of the ankle-joint gave 40 deaths, or 25 1 per cent.2 Amputations of the Leg.—The leg may be amputated at any part, the rule being to give the patient, in every case, as long a stump as possi- ble. It was formerly customary, in the case of laboring men, who could not afibrd to procure costly artificial limbs, to amputate just below the tubercle of the tibia, that a peg might be adapted which would press on the front of the knee; but by using a short peg with a socket, the limb can be fixed in the extended position, so that the benefits of a long stump can now be equally well given to patients in all conditions of life. 1 A claim of priority in the introduction of this operation has been made by Skli- fosovsky on behalf of his countryman Wladimiroff. 2 Larger's tables, however, derived principally from French sources, give a less favorable picture—149 complete amputations of the foot having furnished but 90 re- coveries, and 80 partial amputations but 57 recoveries. Fig. 74.—Result of Mikulicz's operation. (Stephen Smith.) AMPUTATIONS OF THE LEG. 141 Amputation at the Lower Third of the Leg may be conveniently per- formed by the ordinary circular method, or by making two lateral flaps principally composed of skin, and dividing the muscles by a circular in- cision a short distance above. Amputation at the Middle or Upper Part of the Leg, provided that the limb be not too muscular, may be done by the common double flap method, a short anterior skin flap being cut from without inwards, and a long pos- terior flap by transfixion. When the calf of the leg is very large, this plan gives an unwieldy posterior flap, which must be trimmed before adjust- ment, and is even then clumsy and troublesome ; hence in such cases the flap should be cut from without inwards, or, better still, Se'dillot's or Lee's method may be adopted. Sedillot's plan consists in cutting by transfixion a single flap from the outside of the limb, while the tissues on the inside are divided by a transverse incision slightly convex forwards ; after sawing the bones, the large flap is brought around and attached by stitches, forming a beautiful stump. I have modified this operation by cutting an external flap from without inwards, beginning, as directed by Se'dillot, with an in- cision along the inner edge of the tibia, and adding an internal flap of nearly the same length. The result is an admirable stump, with the bone well covered by the tissues of the external flap. Lee's method, like that of Teale, consists, in making rectangular flaps, of which, however, the longer is formed from the tissues of the calf; it embraces only the super- ficial layer of muscles, the deep layer being transversely divided on a level with the line of the short flap. In whatever way the flaps are formed, the bones must be cleared for the saw by a circular sweep of the knife, and in cutting between the bones special care must be taken not to turn the edge of the knife upwards, lest the tibial arteries should be cut at too high a point—an accident which by the subsequent retraction of the vessels might cause trouble in arresting the hemorrhage. In sawing the bones, the fibula should be divided half an inch higher than the tibia; it is often recommended to saw the edge of the latter obliquely, under the impression that it is thus less likely to perforate the anterior flap ; I believe, however, that, except from undue tension, this accident is not likely to occur, and that the risk of necrosis is increased by the oblique division of the tibial spine. If it be *•„ ~- ™ /♦• ,.i. , , .. . . , ^ Fig. io.~Flap amputation of the leg. done at all, it is best done by round- (Erichsen.) ing off the bone with a Butcher's saw, as has been advised by Mr. Porter, of Dublin. A preferable plan is, I think, to preserve a short flap of periosteum, which is allowed to fall over the sawn surface of the tibia, as recommended by Oilier, of Lyons. Four or five arteries usually must be tied in amputations of the leg, and in cases where the vessels are enlarged by the inflammatory process a much larger number may need ligatures ; while, on the other hand, if the section be made above the origin of the tibials, the popliteal alone may require attention. A great deal of trouble is occasionally experienced in endeavoring to secure the anterior tibial, owing to its retraction above the section of the interosseous membrane. A very good plan in such a case is to turn the patient on his face, when the weight of the stump will tend to extend the limb, thus bringing the artery into the direction of a 142 SPECIAL AMPUTATIONS. straight line, and making it much easier of access. For all amputations of the leg or parts below, the tourniquet may be conveniently applied to the popliteal artery, a large compress being placed over the vessel, and the plate of the instrument fixed at a point diametrically opposite, above the knee. Amputation at the Knee-joint is comparatively a modern opera- tion. Its introduction into general surgical practice is principally due to the efforts of Velpeau, though it has probably been more frequently re- sorted to in Great Britain and in this country than on the continent of Europe. It may be done by either the circular or the elliptical incision, or by means of flaps. Elliptical Method.—In this operation, which bears the name of Baudens, the surgeon enters his knife three fingers' breadth below the tuberosity of the tibia, cutting at first transversely, then obliquely upwards and around the limb to a point in the popliteal space one finger's breadth above the joint; the incision then passes transversely across the back of the limb, and is continued obliquely downwards to its point of commencement. This oval flap is dissected up to the line of the joint, and disarticulation is easily effected by severing the ligamentum patellae, and the lateral, crucial, and posterior articular ligaments. The semilunar cartilages are usually removed, though A. Guerin advises that they be allowed to remain. The articular cartilage may properly be left, though, if preferred, it may be removed by sawing around the condyles of the femur with Butcher's saw, or the condyles themselves may be removed in the same way; the statistics of the operation show, however, according to Dr. Brinton, that it is rather better to allow the condyles to remain. Some difference of opinion prevails as to whether or no the patella should be removed. I think, with Mr. Erichsen and Mr. Pollock, that it is better to re- tain it, and its retraction may be prevented, as suggested by the first-named surgeon, by turning up the flap and dividing the insertion of the quad- riceps femoris muscle Anterior Flap Method.—This, which is the best of the flap methods, consists in making a long, rather square, cutaneous flap from the front of the leg, disarticulating, and cutting a somewhat shorter posterior flap by transfixion, or, which I prefer, from without inwards. The posterior fig. 76.-Long anterior flap at fiaV method, in which a large flesh)' flap is formed knee. (Erichsen.) from the calf, is easier of execution, but less satis- factory in its results. The lateral flap method, of Rossi, was a good deal employed during our late war, and has the ad- vantage of affording room for drainage at the lowest part of the wound. In any form of knee-joint amputation, the popliteal artery, with perhaps some of its branches, and the articular arteries, will require ligation. The statistics of knee-joint amputation have been investio-ated bv Dr. John H. Brinton, who finds that 164 cases from American°and foreign sources gave 111 recoveries and 53 deaths, a mortality of 32.31 per cent. The annexed table shows the respective mortality of amputations of the leg and of the thigh, compared with those of the knee-joint, in cases of gunshot injury. AMPUTATIONS OF THE THIGH. 143 Cases. Deaths. Mortality per cent. Amputation of the leg1 .... 6382 2231 34.95 " at the knee-joint2 . . .296 181 61.15 " of the thigh1 . . . 8157 5003 61.33 In amputation at the knee-joint for chronic disease, the mortality is given by Dr. Brinton as 22.58 per cent., a death-rate which does not differ materially from that of amputation under similar circumstances either just above or just below the joint; the death-rate of this amputation for trau- matic causes generally he gives as 40.62 per cent. Amputation through the Condyles of the Femur, or at the knee as dis- tinguished from the knee-joint, may be done by Garden's method, the superiority of which over that proposed by himself was candidly acknowl- edged by Prof. Syme. In this operation a single broad flap is taken from the front of the knee, the condyles being sawn through on a level with a simple transverse incision made below. The patella is removed, and the condyles may be advantageously divided in a curved line by usingButcher's saw. This operation gives an excellent stump, and is particularly appli- cable to cases of disease of the knee-joint, for which, indeed, it was claimed by Mr. Syme to be in every way superior to the operation of excision. Its results are very favorable, 30 cases of all kinds having given in Mr. Carden's hands a mortality of but 5, and 32 cases in A'olkmann's hands a mortality of but 7. The resulting stump is longer and more serviceable than that from amputation of the thigh, and, the medullary cavity not being involved, there is less risk of diffuse suppurative osteomyelitis and con- sequent pyaemia. In my own practice I vary this operation by making a short posterior, in addition to the long anterior flap, and by preserving the patella, which readily adapts itself to the sawn end of the femur, and renders the stump rounder and firmer. Amputations of the Thigh—Amputation of the thigh is frequently required in cases of both disease and injury. The operation may be done at any part of the limb, and the mortality is directly proportional to the proximity to the trunk of the line of section. Supra-condyloid Amputation of the thigh is the name proposed by Stokes for a modification of Carden's method of amputating at the knee ; in this modification an oval flap is taken from the front of the leg, there being also a posterior flap fully one-third of the length of the anterior ; the femoral section is made at least half an inch above the anterosuperior edge of the condyloid cartilage, and the cartilaginous surface of the patella is removed by means of a small saw. A similar operation is that known as Gritti's, from the name of an Italian surgeon by whom it was first sug- gested. Weir has collected 76 cases of one or other of these operations occurring in civil practice, the number of deaths having been 22, or nearly 29 per cent. Amputation in the Lower Third of the thigh may be conveniently done by the ordinary double-flap operation Mr. Erichsen recommends the operation by lateral flaps, for this situation, and I doubt not that an ex- cellent stump may be obtained by this method. But I have myself always practised, in amputating at the lower third of the thigh, the antero- posterior flap method, and I have found it perfectly satisfactory. The anterior flap is cut first, from without inwards, and should be about four inches in length, extending to the upper edge of the patella; it should be rather square in shape, with the corners rounded off, and should embrace all the tissues down to the bone. The posterior flap, which contains the 1 See Table on page 125. 2 See Dr. Brinton's paper, and Legouest, op. cit., p. 735. 144 SPECIAL AMPUTATIONS. main artery, is made in the same way, or in the case of a slender limb by transfixion, and should be about the same length as the other, thus allow- ing for the inevitable retraction of the muscles at the back of the thigh. Both flaps are then turned back, when a circular sweep of the knife clears the bone for the application of the saw. When the flaps are adjusted, it will be found that the bone is well covered by the front flap, and that the resulting cicatrix is drawn entirely behind the line of pressure. Seven or eight vessels usually require ligature, though, if the case be one of chronic joint disease, the number may be larger. Amputation in the Middle or Upper Third of the thigh, if the limb be not too muscular, may be done in the same way, by antero-posterior flaps, one or both made by transfixion, according to circumstances. But if the limb be a large one, a better stump can be made by resorting to the modi- fied circular operation, as practised by Syme and Liston, making short skin flaps, and dividing the muscles at a higher point by a circular incision (see Fig. 48). The posterior muscles of the thigh always retract more than the anterior, and should, therefore, be cut rather longer. In amputating at the upper portion of the thigh, there is scarcely room for the application of the tourniquet, and the surgeon, therefore, commonly has to rely upon the Esmarch tube alone, or even upon manual compression of the femoral artery as it passes over the brim of the pelvis, though in some cases the aortic tourniquet may be advantageously employed. If manual pressure be resorted to, the assistant who has charge of this department should grasp the great trochanter with the fingers of the hand corresponding to the limb to be removed, and press firmly on the artery as it emerges from beneath Poupart's ligament with the thumb of the same hand ; the opposite thumb is superimposed to assist and regulate the pressure, and to prevent any risk of slipping. In cases of injury, the form and extent of the laceration will often com- pel the surgeon to make irregular flaps, and to cover his stumps as best he may under the circumstances. Oblique flaps may be employed in such a case, or a single long flap from any part of the thigh ; it is more important to make the amputation at as low a point as possible, than to follow any one or other particular mode of operating. Amputation through the Trochanters may be occasionally required in cases of injury, or of malignant tumor involving the lower part of the femur. It is a procedure of less risk than exarticulation of the whole limb, and, in cases of malignant disease, appears to be no more likely to be fol- lowed by a return of the affection than the graver operation. It is, more- over, very easy to convert this amputation into a disarticulation, by dis- secting out the head and neck of the femur, if these parts be found to be diseased. Teale's Amputation by Long and Short Rectangular Flaps makes a beautiful and most serviceable stump when applied to the thigh, but it is objectionable on account of requiring the bone to be sawn at a much higher level than would be necessary with the ordinary operations: thus, if the laceration of the soft tissues extended to the upper border of the patella, and the thigh was only sixteen inches in circumference (by no means a large measurement), the long flap would need to be eight inches square, and the bone would be divided at just about its middle, fullv four inches higher than would be required by the common double-flap operation. Amputation at the Hip-Joint—This, which may fairly be con- sidered the gravest operation in the whole range of surgical practice, is a procedure of comparatively recent introduction. The first case which is usually classed as an amputation at the hip-joint, is that in which Lacroix AMPUTATION AT THE HIP-JOINT. 145 (1748) removed the right thigh at the joint, on account of gangrene, which affected both limbs, and had been produced by the use of ergot. The am- putation had been nearly completed by nature, and he merely divided with scissors the round ligament and the sciatic nerve. Four days afterwards he amputated, through the line of separation, the left thigh at the tro- chanters; the patient, who was a boy of fourteen, survived the last opera- tion for eleven days. Perault, in 1774, performed a somewhat similar operation in a case of gangrene from external violence, the patient re- covering. The first genuine case of hip-joint amputation through living parts was done by Kerr, of Northampton, about the same time, on a girl of eleven years, suffering from hip-disease complicated with pelvic abscess and pulmonary phthisis; she died on the eighteenth day. The first case of this amputation for gunshot injury was Larrey's, in 1793; while the first, undisputed, successful casein military practice was that of Brownrigg, in 1812. A great many different plans have been suggested for effecting disarticu- lation at the hip-joint—Farabeuf has collected more than forty-five—but I shall content myself with describing six principal methods, viz., the oval, the modified circular, that by a single flap, that by antero-posterior, and that by lateral flaps, and Dieffenbach's and Jordan's operation, which may be called the method a deux temps. Oval Method.—This has not been employed very often. It is done by entering the point of a strong but short knife on the outside of the limb, either over the trochanter or below the anterior superior spinous process Fig. 77.—Amputation at the hip by the long anterior and short posterior flap. a. The femoral and profunda vessels, with branches of the anterior crural nerve, b. The great sciatic nerve and its com- panion artery. A large branch of the sciatic artery is seen in front, c. The muscular mass from the tuber ischii and the obturator externus muscle. Large branches are seen on either side from the profunda and gluteal, d. The psoas and other muscles immediately in front of the joint. (Holmes.) of the ilium, and making two oblique incisions, one forwards and down- wards, and the other backwards and downwards, to meet in a transverse line on the inside of the thigh. The muscles are divided in the same lines or a little higher, and disarticulation being effected from the outside of the joint, any remaining tissue is severed, as in Larrey's shoulder-joint ampu- tation, by a single stroke of the knife. Malgaigne recommends a prelimi- 10 146 SPECIAL AMPUTATIONS. nary longitudinal incision, by which the operation is still more assimilated to that of Larrey on the shoulder. On a slender limb this form of ampu- tation would give an admirable stump, but it is obvious that under opposite circumstances the abductor muscles of the thigh would form a cumbrous mass, which would require retrenchment before the wound could be properly closed. Modified Circular Operation.—This is done by cutting, from without inwards, short antero-posterior cutaneous flaps, and then dividing the muscles on a level with the joint by a circular incision. This method has been successfully employed by several American surgeons, including the late J. Mason Warren, and is particularly adapted to cases of tumor en- croaching on the upper part of the thigh. Single Flap Method—In this operation, a single, large, anterior flap is cut, either by transfixion (Manec), or from without inwards (Plantade, Ashmead). The soft parts on the back of the limb are divided by a circular incision, either before or after disarticulation. In other forms of this operation the flap has been taken from the inside, or even from the back of the limb. The single flap method might be desirable in a case in which the laceration of the soft parts was such as to forbid any other, but, when the surgeon has a choice of operations, it is better to employ either the oval or modified circular, or the double flap method of Guthrie, which will be presently described. Antero-posterior Flap) Method.—There are three varieties of this oper- ation, which bear the names, respectively, of Beclard, Lis- ton, and Guthrie. Beclard's operation consists in making both flaps by transfixion. It is thus performed : The point of a long straight knife is entered a little above the posi- tion of the great trochanter, thrust across the limb, dipping slightly backwards so as to graze the back of the cervix femoris, and brought out at the innermost part of the gluteal fold; a posterior flap is thus cut from the gluteal muscles, and the surgeon then, re-entering his knife at the same point, pushes it in front of the joint, and, bringing it out as before, cuts an anterior flap from the front of the thigh. The plan which is more commonly adopted in England and in this country, and which is essentially that of Liston, differs from Beclard's in that the anterior flap is cut first, and that the knife, instead of being entered just above the trochanter, is thrust in about two fingers' breadth below the anterior superior spine of the ilium, and, having grazed the front of the joint, is brought out just above the tuber ischii; the flaps thus formed are more oblique than in the French operafon. Guthrie's plan Fig. 78.—Result of hip-joint amputation by Guthrie's method. (From a patient in the Episcopal Hospital.) AMPUTATION AT THE HIP-JOINT. 147 which seems to me to be better, differs merely in that the flaps are cut from without inwards; the operation is done with a small knife, and the posterior flap should be cut first. It is not quite so rapidly executed as the operation by transfixion, but is more certain of affording well-shaped flaps, and, I think, gives a better stump; this operation has been several times employed in this country, and is that to which I have myself resorted in four out of six cases in which I have had occasion to perform this operation. Lateral Flap Method.—This method, as its name implies, consists in making two flaps, from the outside and the inside of the limb. Larrey and Lisfranc made both flaps by transfixion, the former cutting the inner flap first, while the latter began with the outer. Dupuytren modified this operation by shaping the internal flap from without inwards. Neither of these plans appears to present any advantages over those which have been previously described. Dieffenbach's and Furneaux Jordan's Method.—In Dieffenbach's oper- ation the surgeon makes his incisions as for a circular amputation in the continuity of the thigh, and after sawing the bone and securing the divided vessels, proceeds to remove the upper end of the bone by an inci- sion on the outer side of the stump, as in an excision of the hip-joint. Furneaux Jordan's plan consists in disarticulating the head of the bone as in an excision, dissecting out the shaft through an external wound, and finally cutting through the soft tissues by a circular incision at a lower point. Hemorrhage may be prevented by tying an elastic band around the soft parts before they are divided. Senn modifies this method by perforating the tissues on the inner side of the thigh after enucleating the upper por- tion of the femur, introducing a double elastic tube, tying one part over the anterior tissues, crossing the other posteriorly, finally bringing it around the whole limb and securing it in front, thus doubly constricting the great vessels. The limb is then removed by cutting a long anterior and a short posterior skin flap. Whatever method be employed in amputating at the hip-joint, the surgeon must take special precautions against the occurrence of hemorrhage, for a very few jets from the femoral artery, in this situation, will almost insure the death of the patient. Larrey directed that the main vessel should always be secured in the groin, as a preliminary measure, and this plan has been since frequently followed, and may properly be adopted in any case in which the surgeon is unprovided with an aortic compressor, or with abundance of skilled assistance. It seems to me, however, that the exten- sive separation of the artery from the sur- rounding tissues, which is unavoidable in this preliminary ligation, must expose the patient to greater risk of secondary bleed- ing than when the vessel is simply picked up by forceps or tenaculum, after division, as in other amputations. Hence, I think Fig. 79.-Abdominai tourniquet. it better to rely upon mechanical means to control the circulation, or, in the absence of these, to trust to the manual pressure of intelligent assistants. The circulation can be conveniently controlled by compressing the aorta, 148 SPECIAL AMPUTATIONS. either with Lister's instrument (Fig. 32), a modification of Dupuytren^s compressor, or with the apparatus which has been repeatedly used in this city under the name of the abdominal tournimarch's tube above them, then amputating at a lower point and ultimately enucleating the remaining AMPUTATION AT THE HIP-JOINT. 149 portion of the bone. By inserting the outer needle at a higher point than directed by Wyeth. and by drawing the tube very tight, Lanphear has succeeded in disarticulating without the previous lower amputation. After the operation the stump may be closed in the usual way, the deep parts of the wound being approximated by the use of suitable compresses. The statistics of hip-joint amputation are more favorable than might be expected from the severity of the operation : of 633 cases of all kinds col- lected for me by the late Dr. F. C. Sheppard, 220 are known to have ended in recovery, and 393 in death, while the result in 20 is undetermined; of these, there were 43 cases of re-amputation of stumps, of which 28 were successful. My own tale of cases is six operations, with two recoveries and four deaths. The following tables exhibit—first, the comparative mortality of hip-joint and thigh amputations, for the causes met with in civil life and in military surgery ; second, the comparative mortality of these operations, according as they were performed, in civil life, for injury or disease: and third, the statistics of hip-joint amputation for gunshot injury, with reference to the periods at which the operations were per- formed. Table showing Results of Hip-joint, as compared with Thigh Amputation, for Causes incident to Civil Life, and in Military Surgery. Amputation. Hip-joint1 Thigh2 Civil Practice. Gunshot Wounds. J LGGREGA1 Cases. Deaths. Mortality per cent. Cases. Deaths. Mortality per cent. Cases. Deaths. 395 2090 1S6 862 47.1 41.2 238 3516 207 2715 87.3 77.2 633 5606 393 3577 Mortality per cent. 64.1 63.8 Table showing Mortality of Hip-joint, and of Thigh Amputation, for Injury, and for Disease, in Civil Life. Amputation for Injury. For Disease. Locality. Cases. Deaths. Mortality per cent. Cases. Deaths. Mortality per cent. At hip-joint3 . . . .71 In continuity of thigh4 . . 964 47 576 66.1 59.7 276 1465 105 477 40.25 32.5 Table showing Results of Hip-joint Amputation in Military Practice, according to the Period at which the Operation was performed.6 Period of Operation. Cases. Died. Recovered. Doubtful. Death-rate. Primary .... Intermediate Secondary .... Re-amputations . Not stated .... 96 63 27 7 45 89 59 17 3 39 7 4 10 4 5 1 92.7 93.6 62.9 42.8 88.6 Aggregates 238 207 30 1 87.35 1 International Encyclopaedia of Surgery, 2d ed.. vol. i. p. 682. 2 Ibid., p. 636. 3 ibid., p. 682. 4 Erichsen's Surgery, vol. i. p. 5 Doubtful cases omitted in computing percentages. B International Encyclopaedia of Surgery, 2d ed., vol. i. p. 682. 150 EFFECTS OF INJURIES IN GENERAL. CHAPTER VIII. EFFECTS OF INJURIES IN GENERAL ; WOUNDS. External violence or injury, of whatever kind, affects the state of the part to which it is immediately applied, and the general condition of the patient at the same time. Hence the effects of injuries are said to be both local and general or constitutional. The local effects of external violence vary according to the nature of the violence and the circumstances under which it is inflicted ; the constitutional effects, though very different in degree, are the same in kind for all forms of injury. Constitutional Effects of Injuries. These may be either immediate or remote. The immediate constitu- tional effect of injury is called shock, which, if present in an aggravated degree, constitutes collapse. Shock or Collapse is a condition, of the essential nature of which, it must be confessed, we are as yet in ignorance. It is often spoken of as purely an affection of the nervous system, and an analogy is drawn be- tween this and hemorrhage as an affection of the vascular system; yet this view is contradicted by the fact that very serious lesions of the nervous system are not necessarily, nor indeed commonly, accompanied by shock. Experimental physiology has shown that large portions of the brain can be cut away from birds without the development of this con- dition, except in so far as would be accounted for by the mechanical injury, and a similar experience is revealed by the study of morbid anatomy. In fact, here, as we saw in studying the process of inflammation, it is im- possible reasonably to mark out and divide the nervous from the vascular system, or either from the parenchymatous structures around them, and say this is, and that is not, the seat of the affection. Shock is the general or constitutional effect of injury, and as the synergy of health unites all the tissues of the human body in normal life and action, so under the effect, of injury they are still united by sympathy, and one tissue cannot suffer without the others. Still, this sympathy is brought out through the agency of the nervous system, by a process of reflex action in fact, and, accordingly, it is not surprising to find that the symptoms of shock can be artificially induced by irritation applied directly to certain nervous structures, and that the shock attending operations such as nerve-stretching, etc., is out of all proportion to their gravity. Drs. Mitchell, Morehouse, and Keen, who have devoted special attention to this subject, give the following explana- tion as to the probable mode in which the symptoms of shock are brought about: "These very interesting states of system," they say, "may be due, it seems to us, either to an arrest or enfeeblement of the heart's action through the mediation of the medulla oblongata and the pneumo- gastric nerves, or to a general functional paralysis of the nerve-centres, both spinal and cerebral, or finally to a combination of both causes-" and from an experimental investigation of the subject, Dr. C. C. Seabrook concludes that the phenomena of shock are due to paralysis of the vaso- SHOCK OR COLLAPSE. 151 motor centres. Roger, on the other hand, maintains that shock is due to excessive excitation of the nervous system, and that its phenomena are of an inhibitory character. While, therefore, it is incorrect to speak of shock as exclusively an af- fection of the nervous system, it is through the agency of that system that its phenomena are brought about, and it is to a clearer understanding of the laws of nervous action that we must look for more definite and pre- cise ideas as to the essential nature of this curious physical condition. A good deal of confusion exists as to the meaning of the word shock, from this condition not being distinguished from others which often co- exist with it, especially cerebral and spinal concussion and mental pertuba- tion. Thus, a violent blow on the head may doubtless be accompanied by shock, but it will also probably be accompanied by cerebral concussion, an entirely distinct affection, and yet one which is not unfrequently spoken of by surgical writers as a typical instance of shock. Again, mere mental emotion, trepidation, or fright, may cause fainting or even death, and yet this is not shock in the true sense of the term. That true shock is a purely physical condition is seen from its occurrence in the lower animals, even in those which are cold-blooded, and from its being met with after ope- rations done while the patient is under the full influence of an anaesthetic, and while mental emotion is therefore out of the question. Still, so intimately connected are mind and body, that it is often in practice difficult, if not impossible, to separate the mental condition from the purely physical state of shock. Causes of Short.—While in general terms it is correct to say that every injury produces a certain amount of shock, yet there can be no doubt that certain classes of injury are more liable to be followed by this condition than others, that shock is particularly apt to follow injuries of certain parts, and that the susceptibility to shock of any individual may vary with the particular circumstances to which he is subjected at the time of re- ceiving the injury. Gunshot wounds have always been looked upon as especially apt to be followed by shock. " When a bone is shattered," says Mr. Longmore, "a cavity penetrated, an important viscus wounded, a limb carried away by a round-shot, pain is not so prominent a symptom as the general perturbation and alarm which supervene on the injury. . . . This emotion is in great measure instinctive; it is witnessed in the horse mortally wounded in action no less than in his rider; it is sympathy of the whole frame with a part subjected to serious injury, expressed through the nervous system." Severe lacerated and contused wounds, such as are produced by railroad and machinery accidents, are very frequently followed by shock in a marked degree. One of the most decided instances of shock that I have ever witnessed was in the case of a lad whose thigh was caught in a machine called a "lapper," in a rope factory. The whole limb, from the toes to above the middle of the thigh, was marked by punctures from the teeth of the machine, which were of steel and over three inches long; the thigh was broken, one of the punctures rendering the fracture compound, while another penetrated the knee-joint. There was comparatively little hemorrhage, and absolutely no exhibition of mental emotion ; yet there was profound shock from which even partial reaction did not occur until nearly thirty hours after the accident. Burns and scalds, involving a considerable extent of surface, are apt to be at- tended with severe shock, which not unfrequently proves fatal without the occurrence of reaction. Other things being equal, the degree of shock is usually proportionate to the severity of the injury received, but the modifying circumstances are 152 EFFECTS OF INJURIES IN GENERAL. so many and so effective, that the exceptions to this rule are almost as numerous as its instances. The degree of shock varies with the part of the body injured; in the case of the extremities, the shock appears to be greater as the lesion is nearer the trunk, while wounds of the abdominal cavity are attended with more shock than those of the chest. Drs. Mitchell, Morehouse, and Keen infer from the cases which they have examined, that gunshot wounds of the upper third of the body are more likely to be attended with shock than those of other regions. The shock attending injuries of the head or spine is very apt to be complicated by concussion or paralysis. Wounds of the testicle are frequently accompanied by a state of shock much more marked than can be accounted for by the severity of the injury. The various circumstances by which a patient is surrounded at the mo- ment of receiving an injury greatly influence the degree of shock expe- rienced. Anything that tends to weaken a patient increases the liability to shock, and thus hemorrhage, chilling of the surface, previous ill-health, certain forms of visceral disease, etc., are all found to have an unfavorable influence upon the results of operations by increasing the risk of shock. The most remarkable examples of the influence of surrounding circum- stances are, however, seen on the field of battle; one man, moved by a sense of dut}r and heavy responsibility, will continue in the front, though he has received a severe and, perhaps, painful injury ; while another, not necessarily a coward, may be completely unmanned by a comparatively slight scratch, and, forgetting everything else, cry like a child, or scream like a maniac. Symptoms of Shock.—In a slight case of shock there may be merely a momentary, almost imperceptible, change of color, with a feeling of sink- ing in the precordial region, and perhaps slight qualmishness. In more marked cases there are evidences of great prostration; the patient lies helpless, and almost unable to move, the muscular relaxation affecting sometimes even the sphincters ; the whole surface is very pale, even the lips appearing utterly bloodless; the skin seems shrunken, and the flesh softened; the surface is bathed in a cold SAveat; the features are pinched, the eyelids drooping, and the whole appearance is that of impending dis- solution. The heart's action is always feeble, sometimes preternaturally slow and intermitting, but more usually fluttering and rapid; the pulse is commonly small and compressible, and in bad cases almost or altogether imperceptible. The respiration is feeble and gasping—sighing, as it is termed—or it may be so weak as scarcely to be noticed. There are often vertigo, dimness of vision, and slight deafness ; though, on the other hand, there may be perfect mental clearness, and unnatural sensibility to light and sound. There may be various nervous manifestations, such as hiccough or subsultus, and in slighter cases, or during recovery from those which are more severe, there is frequently vomiting. The temperature in cases of shock has been particularly investigated by Wagstaffe, who finds that a marked difference exists in the depression in temperature observed during collapse in fatal and in non-fatal cases. Thus, assuming the normal temperature to be 98.4° Fahr., a fall of 2° or more affords ground for a very gloomy prognosis. In exceptional cases, how- ever, a very low temperature (91.2°) has been found compatible with re- covery, and one still lower (81 75°) with existence.1 According to Redard, who has also paid attention to this subject, if the temperature be below 1 Nicolaysen reports a case in which, from exposure to cold, the temperature fell to 76.4° Fahr., and yet the patient recovered. SHOCK OR COLLAPSE. 153 35.5° Cent, (about 96° Fahr ), the injury will almost certainly prove fatal, and no operation should be performed ; while in any case in which reaction as regards temperature is not observed within four hours from the moment of injury, the prognosis must be considered unfavorable. When death occurs directly from shock, it is from the heart ceasing to act; post-mortem examination shows the heart (especially the cavities of the right side) and the great venous trunks distended with blood, which is sometimes fluid, and always coagulates with difficulty. In recovery from shock, the patient passes through the stage of reaction; the pulse gradu- ally becomes stronger and more regular, the respiration grows deeper, and, after a few profound sighs, is perhaps re-established, vomiting often occurs, the temperature rises, the color improves, and the patient, from lying on his back, turns to one or the other side. The stage of reaction often passes too far, a feverish condition being developed, with great mental excite- ment, constituting Traumatic Delirium (see page 154), or the reaction may be incomplete, and that stage come on to which Travers gave the name of ''prostration with excitement." There seems to be no definite relation between the different stages of shock, as to their duration and severity. The first stage, or that of depression, may be slight, and may last so short a time as to escape observation, the stage of excitement, accompanied sometimes by the wildest delirium, being the first that attracts the surgeon's attention. Curious cases illustrating this statement may be found in works on military surgery, and it is suggested by Longmore, Legouest, and others, that the state of great excitement in which a soldier in action naturally must be, may probably determine the occurrence of these phenomena. When shock proves directly fatal, it is, as has been said, through the heart that death occurs. Shock may, however, be complicated with other conditions, the result of the local effects of injury, the symptoms of which may gradually supersede those proper to shock, and life may thus be ex- tinguished in other ways. Thus there may be concussion of the brain or spine coexisting with shock; or an important viscus, such as the liver, may have undergone* laceration, when death may occur before reaction, and yet not from shock, but from internal hemorrhage or incipient peritonitis. Treatment of Shock.—The object of the surgeon in managing a patient suffering from shock is, of course, to bring about reaction. As death from shock depends on the heart ceasing to act, the treatment must be directed to increasing the force and the regularity of the cardiac pulsations, and, in some few cases, this may perhaps best be done, as pointed out by Mr. Savory, by resorting- to venesection. It is known that after death from shock the heart is filled with blood, and is, in fact, paralyzed from disten- tion ; it is known from experiments on the lower animals that in such a condition, even after all pulsation has ceased, the heart's action can be restored by mechanically relieving the organ by a puncture in the right auricle, or in the jugular vein ; hence the inference is reasonable, and is confirmed by experience, that when—as in shock—death is imminent from engorgement of the right side of the heart and venous trunks, relief may be afforded by bloodletting. To make this as effective as possible, the blood should be drawn from the jugular vein. It is, of course, only in extreme cases, and in such as have not already suffered from hemorrhage, that this mode of treatment can be required, and it should be looked upon as an extreme remedy. In all cases of shock, stimulation, both internal and external, should be employed. Dry heat is to be applied to the surface by means of hot bottles, hot bricks, etc.; sinapisms may be placed on the abdomen and chest, and 151 EFFECTS OF INJURIES IN GENERAL. cordial draughts administered if the patient be able to swallow, and if not, stimulating enemata resorted to instead. The general treatment of this condition has been already referred to in Chapter IV., in discussing shock as a cause of death after operations, and I will merely repeat here that the arterial stimulants administered should be preferably such as are evanes- cent in their effects, as the preparations of ammonia ; though in any severe case the use of brandy will be found essential, and, indeed, is often retained by the stomach better than anything else. Subcutaneous injections of ether may be employed with the greatest advantage. As during the stage of depression absorption is greatly impeded, if not altogether checked, it is idle to give food until at least partial reaction has occurred, and even then it should be given with caution, and in small quantities at a time. For the same reason, opium, which is an invaluable remedy in these cases, is more effective when given hypodermically than by either the mouth or the rectum. In any case, as long as the heart's action continues, there is hope; and if natural breathing fail, artificial respiration should be resorted to, and continued systematically and perseveringly. Electricity is often used to excite the heart to renewed activity, but, at least in my own experience, without much benefit. Easley and McCuire recommend large doses of quinia, before operations, as a prophylactic against shock, while the same remedy, in combination with the camphorated tincture of opium, is em- ployed in the form of enema by Lund. Atropia and digitalis are useful in some cases. Traumatic Delirium.—When reaction occurs it is often excessive. In the treatment of Traumatic Delirium (p. 153) the surgeou must keep in mind that he is dealing with increased action, not with increased power. In fact, this condition always approaches more or less to Travers's "pros- tration with excitement," though the degree of debility of course varies in different cases. The symptoms of Traumatic Delirium are very much those of the ordinary Delirium Tremens, and, indeed, in the case of hos- pital patients, many of whom are habitually hard drinkers, it is often quite impossible to draw an exact line, and say which condition is actually present. There are the same brightness of eye, heat of head, slight accel- eration of pulse, constant and irrepressible muscular action, and sleepless- ness, with wandering delirium and rapid succession of spectral delusions, usually of a frightful and painful character. I do not believe that deple- tion is ever necessary in cases of pure traumatic delirium; if complicated with cerebral inflammation the case may be different, but this is a question which will be referred to in its proper place. The head should be slightly elevated and kept cool by means of ice-bags, or Petitgand's apparatus (Fig. 7), and tne patient kept as quiet as possible in a rather dark room; as there is usually constipation with a furred tongue, a mercurial cathartic may be given, though profuse purging should be avoided. An anodyne and diaphoretic mixture will almost always be proper, to which, if there be great cerebral excitement, small doses of tartarized antimony may per- haps be cautiously added. The most important remedy in the treatment of traumatic delirium is opium, which should be given freely, and with brandy or whiskey in quantities proportioned to the debility of the patient. Food is quite as important as medicine, and should be regularly adminis- tered in a concentrated form, in small quantities and at frequent intervals, Amputation during Shock.—Before leaving the subject of shock, there is one question which demands consideration, which is whether or no an amputation should be performed during the continuance of this condition. As a general rule, there can be no doubt that it is right to wait for reac- LOCAL EFFECTS OF INJURIES. 155 tion to occur before subjecting the patient to the additional source of depression which must come from the operation, and in any case it would be proper to wait a short time and endeavor to procure reaction in the way that has been directed. In some instances, however, especially in cases of compound fracture from railroad or machinery accident, the mangled limb seems by its presence to act as a continual source of depression, and in such cases prompt amputation, even during the existence of a certain amount of shock, will give the patient a better chance than delay. Particu- larly is this the case when the injured part is very painful, and when bleeding is going on from small vessels that cannot be controlled. Under these circumstances it is a good plan to try the effect of anaesthesia; if the inhalation of ether produces an amendment in the patient's condition, making the pulse fuller and stronger, it is probable that the depression is purely one of shock from the external injury, and the surgeon will be jus- tified in resorting to immediate operation. If, on the other hand, in spite of the anodyne and stimulating effect of the anaesthetic, the patient con- tinues to sink, there is grave reason to apprehend that some severe visceral lesion is superadded to the obvious external injury, and under such circum- stances operative interference will not be advisable. The surgeon may be aided in coming to a decision under these circumstances by observing the temperature of the patient; if this be below 96° Fahr , no operation, as a rule, is admissible (see p. 153). Remote Constitutional Effects of Injuries.—These are even more obscure than those effects which are immediately produced. The state of system to which the older writers gave the name of secondary or insidious shock has already been referred to (p. 78). It is probably due, at least in the majority of cases, to the formation of coagula either in the heart itself or in the great venous trunks; this is a very fatal condition, and not unfrequently causes death after operations. Heart-clots may kill the patient directly by mechanically impeding the cardiac action, or por- tions of a clot may become detached and be carried by the circulation into other parts of the body, where they may prove fatal by plugging important vessels, such as the branches of the pulmonary artery, the internal carotids, etc. This process is called embolism, and the fragments of clot are called emboli or embola. Embolism by particles of fat, is an occasional cause of sudden death in case of injury to the bones involving the marrow, as pointed out by Wagner, Busch, Czerny, Boettcher, Dejerine, Duret, and other surgeons ; and a remarkable case of embolism of the pulmonary artery by a portion of the liver, following rupture of that organ, lias been reported by Marshall, of Nottingham. Fat-embolism from rupture of a fatty liver has been noted by Hamilton, of Edinburgh ; and from a simple flesh wound of the thigh, by Dr. W. H. Bailey, of New York. There are other obscure constitutional conditions which result from injuries, often probably through secondary lesions of the central nervous system. In other cases, again, from some local change, the general nutri- tion of the body may be affected through the medium of the blood. The neuralgic condition which sometimes follows injuries, and which has been particularly studied by Verneuil, may often be relieved by large doses of quinia. Local Effects of Injuries. These may be classified as the effects of violence, embracing contusions, wounds, fractures, and dislocations, and the effects of chemical agents (especially heat and cold), embracing burns, scalds, frostbite, etc. There 15G EFFECTS OF INJURIES IN GENERAL. are likewise certain remote local effects of injuries which have not as yet been thoroughly traced out; thus many chronic affections of bones or joints originate from injuries, while external violence must be considered as at least the exciting cause of the development of many morbid growths, whether innocent or malignant. Contusions.—In a contusion the skin is not broken. There is always, however, laceration of the subcutaneous tissues, sometimes very slight, as in the ordinary bruise, but sometimes causing complete disorganization of a limb or other portion of the body. When all the tissues of a part are completely crushed, it is sometimes said to be pulpefied. The skin itself, though not broken, may be so much injured as to lose its vitality and slough. Every contusion is attended with more or less extravasation of blood ; if in small amount, this constitutes ecehymosis, the blood under- going certain changes in the process of absorption, which give rise to the " black and blue" appearances of an ordinary bruise. If the extravasation of blood be in larger amount, it constitutes a thrombus (when clotted), or a heematoma when remaining as a tumor containing fluid blood. Besides the extravasation of blood, a contusion is always accompanied by the exu- dation of a serous fluid ; this may be very slight and superficial, as seen in the wheal or elevated ridge produced by the stroke of a whip, or it may arise from deep-seated injury, when it makes its appearance in the form of vesicles and bulla?, as is especially seen in parts in which the bones are sub- cutaneous, as over the tibia and ulna. The subcutaneous hemorrhage or ex- travasation which accompanies a contusion is seldom productive of serious consequences, unless from rupture of a large artery. Mr. Erichsen has, however, recorded an autopsy in the case of a boy beaten to death by his schoolmaster, in which the fatal issue appeared to have been principally due to this cause. The amount of extravasation varies with the part affected ; where the areolar tissue is of loose structure, as in the eyelids, it is very great, and the swelling correspondingly well marked. The causes of contusion are simple pressure, blows, and falls, or, in other words, direct and indirect violence. The symj)toms are local pain and tenderness; swelling (from extravasation and exudation), preceded perhaps by a temporary depression or indentation from the force of the blow; momentary loss of color, followed by increased redness, and subsequently by various modifications of hue owing to the changes in the extravasated blood, increase of temperature, etc. In cases of severe contusion, vesica- tions make their appearance in the course of from twelve to twenty-four hours, and by their size and number indicate the extent of subcutaneous injury. The diagnosis of contusion is usually easy. In some cases, how- ever, the appearances are almost identical with those of incipient traumatic gangrene (which may indeed result from contusion), and then the nature of the case must be determined by negative evidence, by the absence of the characteristic gangrenous odor, by the temperature of the affected part, by the firmness of the cuticle (which does not separate from the parts belovv, as in gangrene), by the constitutional symptoms, etc. In some situations, as in the scalp, difficulty of diagnosis arises on account of the extravasa- tion, which in this position imparts to the surgeon's fingers very much the sensation of a depressed fracture. There is a ring of hard tissue with a soft central depression, which often deceives the hasty observer- bv firm pressure the bone can be usually felt in its natural position at the bottom of this depression, and the surrounding hard tissue may be observed to be really elevated above the normal level. A thrombus is sometimes mistaken for a solid tumor, and a hematoma for an abscess; the diagnosis under these circumstances must be made from the history of the case from the STRANGULATION OF PARTS. 157 absence of inflammatory symptoms, etc. Though extravasated blood is usually absorbed, it occasionally becomes encysted, remaining fluid for an indefinite period and thus becoming a starting-point for the development of a tumor, or it may coagulate and remain as a clot, or after coagulation may, as pointed out by Morrant Baker, become again liquid; according to Paget and others, the blood extravasated in contusion may actually become organized, acquiring more or less the characters of connective tissue, but it more frequently acts as a foreign body, exciting inflammation around, and being eventually discharged with the products of the resulting sup- puration. The prognosis of contusion, unless some vital organ be in- volved, is* usually very favorable. Provided that the skin be uninjured, the severest laceration will commonly be recovered from without diffi- culty; but if the atmosphere be admitted to the injured tissues by the smallest wound, or by secondary sloughing of the skin, the characters of a subcutaneous injury are lost, and wide destruction of parts may ensue. Contusions of bones and joints, and of nerves, are, as we shall see hereafter, often followed by secondary consequences of the gravest nature. The treatment of slight bruises is best conducted by the application of gently stimulating embrocations, such as the soap liniment of the Pharma- copoeia, diluted tincture of arnica, or simply diluted alcohol. The absorp- tion of extravasated blood may be assisted by gentle friction or kneading— a mode of treatment which the French have systematized under the name of massage. In severer cases, the part should be wrapped in some warm and soothing dressing, such as lint soaked in oil, with laudanum, or in lead-water and laudanum, in order to keep up the natural temperature, and prevent, if possible, the occurrence of gangrene. All tight bandaging or firm pressure should be strictly avoided. If gangrene should occur, the question of amputation may arise, and should be decided on the principles laid down in Chapter VI. If a thrombus form, the surgeon may endeavor to promote its absorption by moderate pressure and gentle friction ; all rough handling should be avoided, lest suppuration be induced. In case of a collection of fluid blood persisting in spite of treatment, aspiration may be tried, and after the escape of the blood pressure employed, with a view of inducing the walls of the cavity to adhere ; if this fail, or if suppuration occur, a free opening must be made, and the case treated as one of ordinary abscess. Strangulation of Parts___Somewhat analogous to the condition of a part which has been severely contused is that of a part which has under- gone strangulation from the pressure of a tight bandage or other cause of constriction. Strangulation is often intentionally employed by the surgeon in the treatment of various affections, such as nsevus, vascular tumors, hemorrhoids, etc. In such cases the strangulated part becomes mortified, and is removed by the formation of granulations in the line of constriction. The fingers occasionally become accidentally strangulated by being care- lessly thrust into tight rings. The ring can generally be removed by soak- ing the finger in iced water, which causes the part to shrink, or by the use of a silk cord tightly wrapped around the finger and slipped under the ring, which is then worked off in the process of unwrapping. If these expedients do not avail, a director should be insinuated under the ring, which must then be divided by a file or by cutting-pliers. The penis is sometimes strangulated, either by being introduced into a ring, or, as has occasionally happened in the case of children, by the nurse tying a tape around the organ to prevent the child from wetting its bed. Unless the constriction be promptly removed, the most serious consequences will 158 EFFECTS OF INJURIES IN GENERAL. probably ensue, sloughing of the part being almost inevitable, and even death having occasionally followed this accident. Wounds. A wound is a division or solution of continuity of the soft tissues, pro- duced by violence ; an open wound, is one in which the division of the skin is as free or nearly so as that of the deeper tissues, while a subcutaneous wound is one in which the opening in the skin is comparatively very small. Wounds are further classified by surgeons, according to their nature and causes, into incised, lacerated, contused, punctured, and poisoned wounds. Gunshot wounds, and the peculiar form of injury known as brush-burn, are varieties of contused wounds. Incised Wounds__As its name implies, an incised wound is one made by a clean cut with a knife, razor, or other sharp instrument These wounds are constantly intentionally inflicted by the surgeon, in amputating limbs, removing tumors, cutting for stone, etc. They are also frequently produced by accident, from the careless use of penknives or razors, or, among farm-laborers, from that of scythes or axes; many of the wounds produced by broken glass are incised, though these may also partake of the nature of lacerated wounds; the cut-throat of the suicide is an incised wound ; the sabre-cuts, met with in war, being inflicted with a heavy blow, approach in their nature to contused wounds. The pain of an incised wound varies according to the nature of the instrument with which it is inflicted, the part in which it is situated, and the manner in which it is produced. The sharper the knife, the less the suffering which it causes; wounds of the face or hands are more painful than those of the trunk; wounds made from within, less painful than those from without. The reason of these differences is very apparent: a clean cut with a sharp knife produces less dragging and tearing of sensitive parts than a hag- gling incision with a dull one; those parts which are most abundantly furnished with nerve-filaments are most sensitive to pain ; and by first dividing the trunks of nerves, their branches are paralyzed, and there will then be less suffering than under opposite circumstances; hence the advan- tage (before the days of anaesthesia) of the transfixion operation over other forms of amputation. It is well known that a wound rapidly inflicted is less painful than one more deliberately produced, and it has therefore been suggested by B. W. Richardson, and by Andrews, of Chicago, to use a blade connected with a rapidly revolving wheel, and it has been claimed that in this way operative surgery might be rendered painless; it seems to me, however, that such a contrivance would in practice be unmanageable, not to speak of the erroneous principle involved in its conception, which would endeavor to substitute mechanical ingenuity for the immediate per- sonal attention and responsibility of the operator. The amount of hemorrhage from an incised wound varies, of course, with the number and size of the vessels cut. Wounds of the face bleed more freely than those of the extremities, and wounds of the scalp are attended with very profuse hemorrhage, not only from the vascularity of the part, but because, on account of the denseness of the surrounding struc- tures, there is not the same opportunity for contraction and retraction of the vessels, as in parts of looser texture. The existence of inflammation or other circumstances may cause the vessels of a part to be much en- larged ; hence an incision into inflamed tissue will bleed more freely than one into normal structure. In some peculiar cases, in which what is INCISED WOUNDS. 159 called the hemorrhagic diathesis exists, the slightest wound—even that caused by lancing the gums of children—may cause fatal hemorrhage. Beside the pain and bleeding which attend an incised wound, there is always more or less retraction of its edges or lips, which constitutes the gaping of the wound. The amount of this retraction depends upon the nature of the tissue involved, its condition at the time when the wound is inflicted, and the direction of the wound itself. Tissues which are elastic or which contain muscular fibres retract more than fibrous tissues; the following is given by Nelaton as the order in which the soft parts gape when wounded, viz., skin, elastic tissue, cellular tissue, arteries, muscles, fibrous tissues, nerves, cartilages. A wound of a part in which there is much tension, from inflammation or from any other cause, will gape more than one in the same part under ordinary circumstances. Thus an incision into an erysipelatous limb, or over the female breast during the process of lactation, will gape more than if those parts were not in a state of tension. Again, the direction of a wound affects the degree of retraction of its lips ; an incision in the direction of the muscular fibres of a part will gape less than one which crosses that direction at right angles, and in general terms we may say that longitudinal wounds gape less than those which are transverse. Process of Healing in Incised Wounds.—Incised wounds may heal in one of three ways, or, as more frequently happens, partly in one and partly in another of the three. The modes in which incised wounds heal are— ],by immediate union, or by the first intention; 2, by adhesion; and 3, by granulation, or by the second intention. Healing by scabbing, or incrus- tation, is a variety of the first or second method, according to circum- stances ; while the so-called secondary adhesion (third intention, or union of granulations) is a mere modification of the third method—the union by granulation, or by the second intention. 1. Immediate Union, or Union by the First Intention (Hunter).—To understand the processes concerned in the healing of wounds, the reader must bear in mind what was said in the first chapter as to the nutritive and formative changes due to the inflammatory process. It is by means of these changes that the repair of wounds is in every instance effected. For a short time, varying from a few minutes to an hour or two, after the reception of a wound it remains inactive; its edges then become some- what red, warm, swollen, and painful—it has, in fact, become the seat of the inflammatory process. Now, if the wound be a clean cut, if it contain no foreign body nor clotted blood, if its lips be in close and accurate ap- proximation, and if the tissues concerned be homogeneous (that is, if skin be joined to skin, cellular tissue to cellular tissue, etc.), under the most favorable circumstances of general health and hygienic surroundings, the inflammatory process may stop in its first stage, that of temporary hyper- trophy. The parenchyma in both lips of the wound is distended with nutritive material, a few wandering cells, perhaps, pass across the line of incision, the opposed surfaces adhere together, and the wound is healed by immediate union, or the first intention, without the formation of lymph, and, of course, without any resulting scar. This mode of healing is very seldom met with, at least in this country. I believe that I have seen it in cases of very slight cuts of the fingers, inflicted by the sharp blade of a penknife, and once in the face, in at least a portion of a clean incised wound. Sir James Paget has seen this mode of union in a case of excision of the breast. The cases which we read of every day in the journals, of union by first intention after amputation, are, I believe, really instances of the second method by which wounds heal, that by adhesion. 160 EFFECTS OF INJURIES IN GENERAL. 2. Union by Adhesion.—In the accomplishment of this process, the in- flammation reaches its second stage, or that which is accompanied by the first formative change, viz., lymph production. This is what Paget calls union by adhesion (the name which I have adopted), or by adhesive in- flammation—that distinguished surgeon and pathologist considering that the first mode of union is accomplished without any inflammation what- ever ; it is, however, I thiuk, better to look upon that process as neces- sary for the repair of wounds under all circumstances, and to regard imme- diate union, as I have done, as effected by inflammation limited to its first stage, that of temporary hypertrophy without lymph production. For union by the mode which Ave are now considering, lymph is essential. Whether this lymph be the result of cell proliferation, or whether it origi- nate in the escape of white blood-cells from the vessels, cannot at present be considered as determined ; in its appearances, physical properties, and other characters, it is identical with the inflammatory lymph described in Chapter I. To obtain union by adhesion, the patient must be in good condition, the wound healthy, and containing no foreign body or blood, its lips not bruised or otherwise injured, but accurately adjusted, and the cut surfaces strictly in apposition and excluded from the air. The inflam- mation must not pass beyond its second stage, or this form of union cannot be obtained. Perhaps the fairest examples of this mode of healing are to be seen in cases of plastic operation, as for harelip, lacerated perineum, etc. It is possible that in these cases immediate union may be sometimes ob- tained, but the presence of a slight scar after healing shows that, at least in the immense majority of cases, the union has been by adhesion or through the medium of lymph. Union by adhesion should always be aimed at in the treatment of stumps and of most operation wounds, and may be generally secured 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 which 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 by 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 48), 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- INCISED WOUNDS. 161 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 com- monly 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 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 sear 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 accuratel}', to prevent the access of atmospheric air, and to prevent the inflammatory process from passing beyond its second stage, or that of lymph formation. (I) 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) ; 1 D. ,1. 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 adhesion of the cut surfaces, and is soon reabsorbed ; the repair of the wound is due exclusively to proliferation of the connective-tissue corpuscles in its immediate vicinity ; while the leucocytes, which escape from the bloodvessels, act as foreign bodies, and are either reabsorbed or discharged as pus. According to the same writer, granulations 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 integument. 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 substance, of a '.■ol'/zed sponge, to act as a framework for the support of the granulations. This plan lias 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 accomplished 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. 162 . EFFECTS OF INJURIES IN GENERAL. or if sponges be used they should be new and soft, and very gently han- dled. As Sir James Paget well puts it, " Wounds should not be scrubbed, even with sponges." Mr. Callender employed camel's-hair brushes. To determine the freedom of a wound from foreign bodies, the surgeon may put in service his hands as well as his eyes, it being sometimes possible to detect with the finger a grain of sand or spiculum of bone, which, im- bedded 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 lymph (a question of purely theoretical interest), there is no reason to suppose that it is formed more readily, or of a better quality", before than after the closing of a wound ; hence, as soon as hemorrhage has ceased, the sooner the lips of the wound are 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 conve- nient. The needles used by surgeons are of various sizes and shapes, as shown in Fig. 45; it is occa- Fig. 80— Mounted needle, armed with a ligature. sionally advantageous to have a strong needle mounted in a handle (Fig. 80), and with an eye at its point, like the ''naevus needle," for use in situations difficult of access, or when the tis- sues to be penetrated are unusually 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. 81), which is that most frequently used, consists, 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, or with forceps, and introduces, with a quick "j thrust, the needle previously threaded, three or four lines from the cut edge ; he then takes the opposite lip in the same way, and passes the needle in this case from within outwards, taking care that there shall be no undue ten- sion or uneven dragging of the wound. Some surgeons employ two needles, passing both from within outwards; but this causes un- necessary delay, and offers no advantage over the common mode. Each stitch may be se- Fig. 8i.—The interrupted suture, cured as it is introduced or all may be passed, their ends being left loose to be fastened sub- sequently. If silk be employed, it is tied in a reef-knot; if wire, it is INCISED WOUNDS. 163 simply twisted. If the mounted needle (Fig. 80) 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 wound ; 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 be- tween the consecutive points of introduction. The continued or glover's suture (Fig. 82) 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 wound 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. 83 and 84), 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. Fig. 82.—The continued, or glover's suture. Figs. 83 and 84.—The quilt suture. The twisted or harelip suture (Fig. 85) 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. 86), 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 prevent their hurting the patient; or, they may be protected by bits of cork, or by the ingenious " needle guard" devised by Tyrrell, of Dublin. 164 EFFECTS OF INJURIES IN GENERAL. The quilled suture (Fig. 87) is seldom employed at the present day, except in the treatment of lacerations of the perineum. It consists of a number of double threads or wires, passed through the lips of a wound so that the loops shall be on the same side ; through these loops is passed a Fig. 85.—The twisted Fie-. 86.—Tndia-rubber Fig. 87.—Quilled suture. suture. suture. quill or piece of bougie, and, the sutures being tightened, the free ends are secured around another quill, deep and equable pressure being thus made along the whole line of the wound. Various ingenious modifications of the quilled suture have been introduced, among others by Lister, Duplay, and Will, and are principally used in plastic operations. The clamp and button sutures of Dr. Sims and Dr. Bozeman will be again referred to in speaking of the treatment of vesico-vaginal fistula. Except in very extensive 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 wound comes opposite to the middle of the strip (Fig. 81), and they should be applied with care and neatness, so as to support the edges of the wound without dragging or undue pressure. Adhesive 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. INCISED WOUNDS. 165 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 dress- ings, as it can be made to adhere by moistening its surface with an anti- septic 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 May- nard, and which may be most conveniently used in the form of the gauze and collodion dressing, introduced into this city by the late Dr. 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 wound, 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 wound can thus be closed as accurately and as firmly as by the use of sutures. The strips will stay on as long as may be desired, the collodion being imper- meable to water, and the dressing may be hermetically sealed, if thought necessary, 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 sub- stituted for the ordinary collodion in cases in which there is a tendency to oozing; or a combination of these substances with carbolic acid, as sug- gested by an Italian physician, Dr. Paresi, maybe employed in connection with dressings 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. 88) may be used for slight and superficial wounds, either alone or in addition to other measures, when very close and accu- rate union is desired. Sutures and plasters, applied as has been described, only serve to ap- proximate the edges of a wound ; its deep surfaces should be brought into contact by the use of compresses (of lint, oakum, or charpie) and appro- priate bandages, or, in some cases, by the employment of deep sutures [relaxation sutures) passed not through the ed res 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 bandage, which in skilful hands can be made to meet every indication. Ordinary incised wounds should be dressed antiseptically, or, 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 turns of a roller, will commonly be sufficient. Guerin and others fig. 88. commend the use of cotton-wool, which they believe acts as a The serre- filter to prevent the access of deleterious germs to the wound, fine- 166 EFFECTS OF INJURIES IN GENERAL. and Hewson reported very favorably of the employment of dry earth as a primary dressing ; while Prof. Hamilton was equally enthusiastic in his praise of the continuous warm bath, a mode of treatment which, I believe, originated with Langenbeck, and which has been modified by Duplay, who plunges the limb into an "antiseptic bath" containing one percent, of car- bolic acid. In scalp wounds, it is generally right to apply a firm compress, so as to check oozing and prevent bagging of serous and other discharges. Sutures may be removed 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 painful, 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 contused wound is one of which the edges are bruised. These wounds are inflicted by blows from dull implements, such as stones or clubs, by machinery accidents, by injuries from railway trains, etc. Gun- shot wounds are likewise included under this head, but are of such impor- tance as to demand a separate chapter for their consideration. Lacerated and contused wounds present several peculiarities of character and appearance. Thus, their edges are irregular and jagged ; the pain is duller and less acute, though more lasting, than that of incised wounds; there is less tendency to gaping, and there is less bleeding. This arises from the mouths of the vesselsbeing twisted and crushed, ratherthan 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 almost universally in this part of the world, 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 usually separates at the highest point; the muscles protrude, and appear to be tightly embraced and almost strangulated by the skin ; the tendons,1 vessels, and nerves hang out of the wound, of various 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. i In some cases the tendons give way at a point much higher than that at which the other tissues separate. LACERATED AND CONTUSED WOUNDS. 167 The parts which have lost their vitality will be thrown off by the efforts of nature, and the wound will then heal by granulation, or, if the slouch- ing be extensive, amputation may be required. Fig. 89, from a photograph kindly given me by Dr. R. H. Harte, shows the extensive cicatrices follow- ing severe lacerated wounds inflicted by the bite of a shark. (2) There may be gangrene from arterial 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 pa"-e 105). v t o (3) The most fatal form of gangrene is the true traumatic or spreading gangrene,1 which is always of the moist variety from implication of the venous system, and is usually met with in connection with severe compound fractures, or other destructive lacerations produced by railway and machinery acci- dents. One of the most rapidly fatal cases which 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 animal with which he was in the habit of per- forming. Traumatic gangrene occa- sionally, however, follows comparatively slightlocal injuries, and this circumstance has led many authorities to attribute its occurrence to constitutional causes. Cer- tain 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 supervenes, attended with a deep-seated, burning pain. Soon the dusky hue gives way to a dark mottled appearance, vesications and bullae are"formed, the surface becomes soft and boggy, and emphysematous crackling, running along the deep planes of cellular tissue, gives evidence of the formation of gases as the result of decomposition. Below the seat of gangrene, the limb has a cadaveric appearance, while above, oedema and discoloration rapidly extend, especially along the planes of areolar tissue on the inside of the limb, reaching and invading the trunk in perhaps a few hours from the period of commencement. While the gangrene spreads 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. This grave affection has also been described under the names of putrid pneumo- tuemia (Maisonneuve), bronzed erysipelas (Velpeau), gangrenous emphysema, traumatic poisoning (Chassaignac), acute purulent cedema (Pirogoff), acute putrid infection (Perrin), and acute gangrenous septicemia (Terrillon). The malignant cedema of Brieger and Ehrlich is an analogous affection which Bremer found in one case to be complicated with fat-embolism. Fig. 89.—Cicatrices following shark-bite. 168 EFFECTS OF INJURIES IN GENERAL. Treatment of Lacerated and Contused Wounds.—Small portions of the body, especially of the face, even if entirely separated, will occasionally 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. Every year I see one or more cases of extensive sloughing, due quite as much to the over-zealous use of sutures, in these cases, as to the effects of the original injury. A few stitches may be proper, if the wound be large and there be much tendency to gaping ; but it is best to rely chiefly upon the support afforded by 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 water, 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 a warm sublimate solution, diluted alcohol, or diluted laudanum, answers a very good purpose. Cotton- wool, dry earth, and the warm bath are recommended by their respective advocates, as in the case of incised wounds. Chloral in solution (gr. v—f.5j) is recommended by Keen, See, and other surgeons. When the slough is about to separate, poultices, especially those containing yeast or porter, may be advantageously substituted for the previous dressing, to be re- placed 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, 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 removal of the injured limb. Thus, if an arm or leg be entirely torn away, or if all the soft parts and bones be crushed together into a pulp-like mass, there can be no question as to the propriety of amputation. Those cases, however, in which the soft tissues are alone involved, the bones escaping injury, present more difficulty; there is a popular notion that cases of this kind do not require amputation ; it is a mere flesh wound, it is said, and the surgeon ought to be able to cure it. I am well convinced, however, that when the skin and muscles are extensively torn and sepa- rated, even if the bone be whole, especially in the lower extremity, ampu- tation 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 amputa- tion were fully considered in Chapter VI., and need not be referred to here. If an attempt be made to save the limb, however, secondary amputation ANTISEPTIC TREATMENT OF WOUNDS. 169 may become necessary from the occurrence of hemorrhage, or from the onset of one of the forms of gangrene described on page 167. If the true traumatic gangrene should occur, amputation must be at once per- formed, though the chances of a successful issue are, it must be confessed, under these circumstances, very doubtful. It is, perhaps, scarcely neces- sary to give the caution not to be deceived into amputating for a mere superficial slough, an error which can be avoided by carefully watching the case for a few hours, when, if mortification have really taken place" the occurrence of putrefactive changes in the part will sufficiently clear up the diagnosis. When amputation is resorted to under these circumstances, it should be done at a point sufficiently removed from the seat of gangrene to avoid, if possible, the recurrence of 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, oxide of zinc, thymol, crcoline, etc., are also employed, but carbolic acid and the bichloride of mercury are, upon the whole, preferred by most operators. The theory of the method is founded on the observations of Pasteur, and is based upon the belief that suppuration and the various wound-complications are caused by the presence of micro-organisms, and the various substances employed are used on account of their known de- structive effects upon low forms of organic life. The practice of operating and dressing wounds under a spray of anti- septic vapor, at first strenuously insisted upon by Sir Joseph Lister, has now been abandoned, even by himself; and in his latest utterance he de- clares that neither spraying nor antiseptic irrigation'is required, and that germs in the air may safely be disregarded, those only being worthy of consideration which may be found on the surface of thepatient's body, or which maybe introduced by the surgeon's hands or instruments. For cleansing purposes he has returned to the use of a five-per-cent. (1-20) solution of carbolic acid, and while enthusiastic operators in Germany and in this country have been vieing with each other in devising new and complicated modes of securing personal cleanliness, he declares that by using the simple carbolic solution of the strength indicated he is able sometimes to dispense even with soap and water. For dressings he employs gauze prepared with the double cyanide of mercury and zinc, colored with purified rosolane (bydrochlorate of mauveine), an aniline dye, and damp- ened with the 1-20 carbolic solution before using. If much discharge is expected, he employs a piece of Mackintosh in the outer dressing, and in re-dressing (usually after 24 hours) uses a weaker (1-40) solution of carbolic acid for washing the wound. The limits of this volume will not permit a description of all the modifi- 170 EFFECTS OF INJURIES IN GENERAL. 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 tin; 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, a weak boric acid solution, or even distilled or simply boiled and filtered water, is safer 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 prepared with oil of juniper and alcohol, are kept in a similar solution made with glycerine. Instruments are quickly corroded by sub- limate 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 moment of using. I never use the spray, and, indeed, very few surgeons still employ it, and I have long since abandoned the practice of irrigating the wound 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 practised. I use rubber drainage-tubes, of a calibre proportioned to the size and depth of the wound, cut on a level with the skin surface, and kept from slipping in by transfixing their ends with safety-pins. Small and superficial wounds I drain with a hank of carbolized catgut, as advised by Prof. Chiene. I sew up the wound closely with silver-wire, fine silk, or silkworm-gut sutures, and cover it with a strip of "protective;" 1 employ both a deep and a superficial dressing of sublimate gauze, tne 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 bandage, applied with moderate firmness. The dressings are renewed, on an average, once a week, boracic-acid ointment, 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, or in tuberculous cases, 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 the early editions of this work, I expressed a doubt as to the supe- riority of the "antiseptic method" over other plans of wound-treatment, but having now employed it for more than six 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 while I cannot subscribe to the extravagant laudations which this plan receives at the hands of its more enthusiastic advocates, I believe that, when used with judgment, and, if r 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 marked diminution in the mortality after operations by its employment, but I find that the average period of con- valescence is shortened; that the violence of the traumatic fever and the PUNCTURED WOUNDS. 171 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 somewhat 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 for fifteen or twenty minutes, so as to influence the fragment, the presence of which would then be revealed by the deflection of a polarized needle, 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- C&t6Q, 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, when 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 wounds), and to have been 172 EFFECTS OF INJURIES IN GENERAL. introduced into military surgery by Cato, who would not allow doctors in his army, disliking them because they were usually of Grecian birth. Arrow Wounds are frequently met with on our western border in con- flicts with the Indians. They are very serious injuries, being particularly fatal when they involve the abdominal cavity The following tables, taken from Dr. Bill's article in the second volume of the International Encyclopaedia of Surgery, show the relative fatality of arrow wounds in different parts of the body, and the causes of death in fatal cases :— Head or Spinal Column. I Number of cases saved, " " died, Total . . . ___^ _— o B-3 03 Q> a "2 O ~ P O w 4 4 - X. 13 Thorax. j> = i. = 5 = p ' g 5 . 10 I ... 13 I ... 2 IS 10 2 Abdomen. 2 18 11 3 44 17 107 2 1 47 20 ■ 14 46 i 18 i 154 Cause op Pkath. Number of cases 1 H-d bb » C3 r •?_ =- = a . 'Z *■•- rrj ja on 5 J3 o S —.5 ^ 5 "a; z> J5 3 1% Woun heart (shoe Not as taine 10 16 4 «l 1 1 i 1 2 | 8 - 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 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 im- portance of not hastily pulling the shaft away while leaving the head, and the equal importance of careful but persistent efforts to remove the latter. This may 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 some- times better to make a counter-opening, and in case of a chest wound, if necessary for this purpose, even to cut through the rib with a trephine. It is commonly believed that the Indian tribes make use of poisoned arrows ; it would appear, however, from the reports of Dr. Bill and other army surgeons, that in reality this is very seldom done; I am, however, informed by Dr. Schell, who was stationed for some time at Fort 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 suf- fering followed abrasions of the hand received in striking another person on the mouth, and I have myself seen a bite of the thumb followed by fatal tetanus. Syphilis is occasionally inoculated in this way. POISONED WOUNDS. 173 The treatment of punctured wounds consists in the use of antiseptic or simple anodyne 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 (aqua ammonias), 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 re- accumulates, 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 symp- toms disappear almost as rapidly as they came. The constitutional symptoms of rattlesnake-poisoning are those of extreme prostration, the mind often remaining clear until within a few minutes of the fatal issue. Death may take place in a very short time (forty minutes only in a case reported by Dr. Shapleigh), from the direct effect of the poison on the nervous system, or after the lapse of several days or weeks, from extensive sloughing and suppuration resulting from the local injury. The 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 eaude 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 potassse, recommended by Dr. John Shortt.' Prof. Halford, of Australia, has proposed the direct injection into the veins of dilute aqua ammoniae, 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 174 EFFECTS OF INJURIES IN GENERAL. 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 current except when momentarily relaxed by the surgeon ; by the use of this means a small portion of the venom can be admitted at a time into the general circulation, and the enemy, as it were, met and fought in de- tachments. 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. Barber recommends the free use of permanganate of potassium, in a fifteen-per- cent, solution, injected into the surrounding tissues as well as applied to the wound. 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. Lauder Brunton suggests that the alcohol administered in cases of snake-bite does good by coagulating poisonous materials excreted by the stomach, and thus preventing re-absorption ; he advises that the stomach should be washed out with alcohol, while strych- nia is given hypodermically to keep up the respiration. Bites of Rabid Animals, especially cats, dogs, wolves, and, according to Drs. Janeway and Wolf, skunks,' sometimes prove fatal through the occur- rence of Hydrophobia. The peculiar poison which produces this frightful affection appears to be communicated by means of the saliva, though whether it originate in that secretion or be merely mixed with it, coming from other structures of the mouth, is uncertain. The proportion of eases of hydrophobia to the number of persons bitten by dogs or other animals supposed to be mad, is very small, only 71 deaths" from this affection hav- ing 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, the limits of which have been placed at as short a time as one day, and at an interval as long as forty years. The truth appears to be that the stage of incubation may vary from about four weeks to eleven months, sometimes, however, undoubtedly surpassing the latter limit. The difference is supposed by 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 1 Adarni has observed an outbreak of rabies among deer. POISONED WOUNDS. 175 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 usually healed long before any manifes- tations of hydrophobia occur, and the invasion of the latter is often unat- tended by local symptoms, though occasionally shooting pains ahd twitch- ings are felt at the seat of original injury. The development of hydro- phobia 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 Forster considers in themselves sufficient for diagnostic purposes, are intense pain and cutaneous sensibility, and spasms of the pharyngeal muscles, rendering it almost impossible to swallow anything, but especially liquids. To" these there are usually added a feeling of great anxiety and a sense of impending danger, together with delusions alternating with the wildest delirium. There may be general convulsions, while there are almost always spasmodic movements of the mouth and of the laryngeal muscles, with expectoration of viscid and very tenacious mucus and saliva; hence the popular notion that the patient barks and tries to bite. Hydrophobia has, until recently, been thought an invariably fatal affec- tion, 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 preventive measure, excision of the part bitten is usually recommended. 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 consequences, having always used this remedy. I am disposed, however, to question (with Mr. Forster) whether any of these plans is really productive of benefit; the immense majority of bites will not be followed by hydrophobia under any circumstances, and, on the other hand, hydrophobia has occurred even after free excision of the injured part. Dubot;e advises the daily administration of large doses of bromide of potassium during the whole period of incuba- tion. Peyraud suggests inoculations 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 irritation ; his strength must be supported by such concentrated food and stimulus as can be taken, or by nutritious enemata, while an ice-bag may be placed to the spine, as recommended by Dr. Todd and Mr. Erichsen, and the violence of the spasms may be relieved by inhalations of ether, or nitrite of amyl (Forbes), or by the use of large doses of bromide of potassium. Dr. J. B. Read sug- gests the hypodermic employment of gelsemium ; Gingeot that of hoang- nan ; and Nursimula, an Indian physician, that of atropia Bouisson speaks very favorably of the employment of a hot-air bath. Hammond recommends the persistent employment of a primary current of electricity, one pole being applied to the head, and the other to the feet. Skinkwin advises transfusion, and Culver, following a hint of Magendie's, intravenous injections of saline solutions; bromide of potassium, administered in this manner, is recommended by Duboc^; 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 inhala- tions of oxygen, and by the employment of the monobromate of camphor, of aconite, and of cannabis indica. In a case in which symptoms of para- lytic rabies followed the prophylactic treatment by Pasteur's method, Murri effected a cure by intravenous injections of the virus. The only 176 EFFECTS OF INJURIES IN GENERAL. post-mortem appearance visible to the naked eye, which can be considered as characteristic, is, according to Forster, dilatation of the pharynx; but in cases recorded by 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 and by Wassilief.1 Congestion of the nervous structures in the vicinity of the wound, and inflammatory changes in the salivary glands, have been noticed by Nepveu, as have hvperasmia and an accumulation of white corpuscles in the kidneys, by Coats. 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 has isolated a crystallizable ptomaine of ex- tremely poisonous properties from the brain and medulla oblongata of rab- bits suffering from rabies. Inoculation of the nervous centres with virus introduced by trephining is commonly followed by the furious form of the disease, while paralytic rabies is produced by intravenous or hypo- dermic injections. The nature of the animal through which the poison passes modifies its intensity, the period of incubation 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 when inocu- lated 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 successive inoculations a state of insusceptibility to rabies may be induced. If sections of the spinal cord of a dog 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 potency. Pasteur proceeds as follows: Having secured, by successive inoculations upon rabbits, a virus which induces rabies after seven days' incubation, he prepares a series of flasks in which 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. 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 im- pregnated 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 clays' 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 simi- lar plan in inoculating human beings, and believes that insusceptibility may 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 case in which there has been great cerebral excitement. POISONED WOUNDS. 177 be secured by these prophylactic injections even after the person has been bitten by a rabid dog, provided that the treatment is begun with sufficient promptness. In his first case the course of inoculations occu- pied sixteen days, but he has subsequently shortened the time to seven days or less, and sometimes repeats the course. Up to December 31, 188G, he had thus treated 2682 cases with 36 deaths, and other operators had communicated to him the reports of 830 cases with 13 deaths ; 48 cases of wolf-bite, included in the above figures, had given 7 deaths. Of 38f> cases of dog-bite reported by Dujardin-Beaumetz as treated by Pasteur's method in the Department of the Seine during 1888, only 4 proved fatal, or 1.04 percent,, while of 105 cases not so treated, 14 ended fatally, or 13.3 per cent,; of a total of 7893 cases treated at the Institut Pasteur up to the end of 1889, 53, or 0.67 per cent., had, according to Perdrix, proved fatal. Pasteur's experiments have been repeated by Ernst, who finds (1) that in the cords and brains of animals inoculated in Pasteur's lab- orator}7 there exists a specific virus which is capable of producing similar 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 while 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 ani- mals treated by the method of intensive inoculation may themselves be- come 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 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 victim of a dog-bite is really threatened with hydrophobia before advising 178 EFFECTS OF INJURIES IN GENERAL. 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 condition, 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 neighboring lymphatics will probably become involved, with enlargement of the axil- lary glands and a condition of general febrile disturbance. The inflamma- tion may end in resolution, or may run on to suppuration, pursuing very much the same course as a severe whitlow. In other cases there is a posi- tive inoculation of septic material, followed by diffuse cellular inflamma- tion, or by phlegmonous erysipelas, involving a considerable part of the body, and attended by extensive suppuration, and perhaps sloughing; the general symptoms are those of extreme depression, and the patient dies of pyaemia or septicaemia, or recovers after a long and tedious convalescence, with his health, perhaps, permanently impaired. The first s}rmptom 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 soothing applications being made to the injured part, and laxatives and diaphoretics administered internally. In the more serious form, in which there is evi- dence 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 may 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 he opened as soon as fluctuation is detected. The proportion of recoveries from this form of the affection is said by Travers to be but one in seven ; if the case terminate favorably, the patient should be sent as soon as possible to the country, to recruit his shattered health by change of air and scene. CHARACTERS OF GUNSHOT WOUNDS. 179 CHAPTER IX. 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 thirty or more 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 promi- nent features and peculiarities, and to be prepared to perform any of the operations which their treatment especially demands. Characters of Gunshot Wounds.—These vary according to the nature of the projectile by which the wound is inflicted, and the force with which it produces its effect. The momentum of a gunshot 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, as shown in Fig. 90 ; or if the hand be struck, as occa- sionally happens to sportsmen from the premature discharge of a fowling-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 compara- tively 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 going completely through the limb, but causing Fiu. 90.—Gunshot wound of face; destruc- tion of eye, nose, and cheek. (From a pa- tient in the University Hospital.) 180 GUNSHOT WOUNDS. no splintering, and no great laceration of the soft tissues. The peculiar shape of the modern conoidal ball causes it to meet with much less resist- ance 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 gravitv not coinciding with its centre of figure, in its passage through the air it acquires a peculiar dip, causing it to strike obliquely, making a large wound, ploughing and tearing up the soft parts, and splintering the bones in all directions. Thus, it is not uncommon for a long bone, such as the tibia or humerus, when struck by a conoidal ball, to be splintered and split both upwards and downwards, to the epiphyseal lines, or even into the adjoin- ing 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, while 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, 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 velocity. Bardeleben, too, declares that the steel-covered ball of the modem Mannlicher rifle, by its pointed shape and ligbtness, maintains so much of its initial velocity that it inflicts small and clean wounds which are readily dis- posed to heal. On the other hand, for the same reason, its use greatly increases the number of deaths from primary hemorrhage. WOUNDS OF ENTRANCE AND EXIT. 181 of a perforating flesh wound of the extremities, a tubular slough will be separated, representing exactly the course of the ball. I believe, however, that this rule is not invariable; in the early part of our late war, when buckshot were occasionally used in the form of "buck-and-ball-cartridf-es," I saw several cases of very small, perforating flesh-wounds 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 allow 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,1 nor to any fancied development of electricity,' but simply to the excessive degree of contusion inflicted by the ball, which, though usually of small mass, strikes with great momentum. Wounds of Entrance and Exit—Most gunshot wounds have two apertures, one where the ball went in2 and the other where it Game 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 mav 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 comes to the same thing, two balls may enter at one opening, one passing out and the other remaining. Again, there may be more than two wounds. I had under my care, after the battle of Antietam, 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- anee, 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 position 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- 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 ot 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. 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 durinjr life ; and a cnrious case occurred during our late war, in which an officer was mortally wounded through the anus. 182 GUNSHOT WOUNDS. 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 carry- ing portions of tissue before it—a similar explanation to that given by Teevan for .the larger size of the exit than of the entrance wound in cases of punctured fracture of the skull. The statement above given may be considered as generally, though not invariably, correct; thus, it is easy to understand how a conoidal ball, striking with its long axis corresponding to the surface, might make a large and ragged wound, and, undergoing partial rotation from the resist- ance of the tissues, might emerge point forwards, thus making the exit wound smaller and more regular than that of entrance. Again, the dis- tinctive 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 good in the im- mense majority of cases, and the surgeon may often derive valuable in- formation by bearing it in mind ; thus, it has happened that in cases of secondary hemorrhage it has been impossible to discover the source of bleeding, till by placing the patient in the exact position which he occupied when shot, and looking along the line which the ball must have taken,.it has become obvious that a certain vessel was in the way of being wounded, and the proper point for the application of a ligature has been thus made at once evident. A familiar instance of the value in another respect of this mode of examination is that which occurred to Sir Astley Cooper, who, by resorting to this plan in a case of murder, determined that the fatal shot could only have been fired by the left hand, a point of circum- stantial 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 stao-e of shock may be very evanescent, the patient when first seen beino- in a state of SYMPTOMS OF GUNSHOT WOUNDS. 183 wild excitement, delirious, or even maniacal; this is said to be particularly noticeable in wounds about the genital organs. The behavior of men when shot in battle is influenced by a variety of circumstances ; thus, marked differences have been observed in accordance with the race of the person wounded. The Anglo-Saxon is usually calm and philosophical ; the Celt sometimes gay and merry, and at other times depressed and gloomy ; the Teuton phlegmatic. The negro soldiers during our late war were, according to the testimony of Dr. Brinton and other army surgeons, the most patient and enduring of all our wounded ; another "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 pain referred to other and occasionally far different parts of the bodv ; in other cases a still more curious phenomenon is observed, viz., local temporary paralysis of motion and sensation, 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 wheu 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 enable 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. It is said, however, that when the new Mannlicher rifle-ball has been employed, the number of deaths from primary hemorrhage has been greatly increased. 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 (lay ; 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 184 GUNSHOT WOUNDS. 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 remarkable case recorded by Dr. William Hunt, in which fatal secondary hemorrhage 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 of 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 60,206 gun- shot fractures and bone-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 opera- tive interference does not arise, are three in number, viz., (1) to promote reaction. (2) to arrest hemorrhage, and (3) to remove all foreign bodies. The first point has already been sufficiently 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 which 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. 29), 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 improper use of the tourniquet so great, as to render the distribution of these'instru- ments among troops more productive of harm than of benefit. Suppose a surgeon to find a man who 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 allow the clot to remain, in hope that under its protection the wounded vessel would close by the natural processes which will be considered hereafter; and even if the 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 TREATMENT OF GUNSHOT WOUNDS. 185 the wound. If, on the other hand, the wounded vessel were in an easily accessible situation, 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. Particles of gunpowder may be picked out with the point of a sharp knife, or, it is said, may be removed by painting the part with equal parts of bin- iodide of ammonium and distilled water, followed by dilute hydrochloric acid. 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 unglazed porcelain, which, by receiving a metallic streak, surely indicates the presence of a leaden ball, if the latter come in contact with it.1 It was by means of this probe that the eminent French surgeon whose name it bears was enabled to demonstrate the presence of a ball in the wound of the cele- brated Italian General, Garibaldi. Longmore speaks favorably of Lecompte's " stylet-pince," or "probe-nippers," by which the surgeon can withdraw a minute portion of a foreign body for examination. Culbertson has devised a meerschaum probe which serves the purpose of Nelaton's instrument, and is besides provided with a roughened surface to catch and withdraw fila- ments of clothing, etc., which may be in the wound. Electric probes, containing two insulated wires, have been devised by Favre and others, for the detection of balls, the effect of the me- tallic contact being to complete the circuit, and thus indicate the nature of the foreign body. Dr. Bill invented an ingenious magnetic probe, employing the audient of a telephone as an in- dicator. An older instrument is the drum or rever-berating 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. Deneux 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 suitable reagents. Uhler, of Mary- land, injects dilute acetic or dilute nitric acid, and then tests the injected fluid for lead and iron respectively.2 If the course of the ball be very cir- cuitous, advantage may be derived from the use of flexible probes, such a.s 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 em- bedded in bone, it may sometimes be removed by the tirefond, or screw extractor (Fig. 93); while if superficial, it may often be readily turned out with a scoop, or with the extremity of an ordinary 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 1 Dr. Heighway, of Cincinnati, is said to have employed for this purpose, during the Mexican war, the stem of a clay tobacco-pipe. 2 The same surgeon suggests that the presence of a splinter of wood might be recognized by detecting tannic acid in the discharges. 186 GUNSHOT WOUNDS. 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 Fig. 92.—Bullet forceps. splinters of bone produced by gunshot injuries were classified by Dupuv- tren into primary, secondary, and tertiary splinters or sequestra. The *&o Fig. 93.—Screw extractor. primary arc such as are entirely detached, and should be immediately extracted, as they will otherwise produce irritation, acting as foreign bodies ; the secondary sequestra are partially detached, and if very loose should be removed, but if pretty firm may be pushed back into place ; the tertiary should always be preserved, as their vitality is not much im- paired, and they serve a most useful purpose in assisting recovery bv strengthening the new-formed callus. Dressing.—The wound being freed from all foreign bodies, loose splin- ters, etc., the surgeon proceeds to dress it. It was formerly the almost universal custom to enlarge gunshot wounds with the knife, and this prac- tice, under the name of debridement, is still pursued by many European surgeons. It is doubtless useful in some cases, where there is much swell- ing, especially in the suppurative stage, to make more or less free incisions to relieve excessive tension, just as would be done in the case of anv other wound in which the original opening did not give sufficient vent;'but in the immense majority of cases of gunshot injury this treatment is not at all necessary. Gunshot wounds are to be treated on the ordinary principles which guide the surgeon in the management of other injuries, and require no special or exclusive dressing. Cold water was most extensively employed during our late war, and as a primary application answers very well; if too long 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 warm fomentations when the sloughs begin to sepa- rate, and again using more stimulating dressings, such as lime-water, etc., when the process of granulation is fairly established. During the period of separation of the sloughs, if, from the position of the wound, there is reason to fear the occurrence of secondary hemorrhage, it is well'to applv a tourniquet, or an Esmarch's tube, loosely around the limb above the seat of injury, and to instruct an attendant in its use, so that it mav be AMPUTATION AND EXCISION IN GUNSIIOT INJURIES. 1ST tightened on the first onset of bleeding. By the employment of this pro- visional tourniquet, as it is called, many lives may be saved that would otherwise inevitably be lost. Amputation and Excision in Gunshot Injuries.—A mputation may be rendered necessary in cases of gunshot injury bv various circum- stances; thus, if part of a limb be entirely carried awav bv a round shot, or by a fragment of a shell, there is nothing for the surgeon to do but to improve tbe 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 surgeons only recourse. "When it is evident that, from the severity of the injury, amputation will be required, it should, in accord- ance with the principles enunciated in Chapter VI., be performed as soon as possible 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 o?teo-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 whenever the destruction of parts does not mani- festly render the latter operation imperative. Shoulder.—Gunshot fractures involving the shoulder-joint verv 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 luS6 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 eases. 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 ceut. Gurlfs tables embrace 1661 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 any case admitting of a choice between the two operations. Even if the humerus be split for a considerable d^tance downwards through its shaft, excision may still be practised, not a few instances having occurred dur- ing our war in which very large portions of the humerus were removed by excision, a useful hand and forearm being thus preserved. Elbow.—Excision of the elbow, introduced into military practice by Percy, was frequently performed during our war,1 764 cases being noted in Dr. Otis's Surgieal 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 l The first case in American military surgery is attributed to Dr. Otis Hoyt, during the Mexican war (1S47). ° 188 GUNSHOT WOUNDS. 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 is 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 a.s among the gravest injuries met with in military practice. The compara- tive advantages of excision,1 amputation, and expectant treatment in these cases have been fully and ably investigated by Drs. Otis and Hunting- ton, 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 fol- lowing tables:— Kxcisions. ------ Cases. 43 60 41 27 Died. 40 58 26 24 148 Recovered. 3 2 15 3 23 — Death-rate. Primary Intermediate Secondary Uncertain 93.0 96.6 63.4 88.8 Aggregate 171 86.5 Amputations. Cases. Died. Recovered. Doubtful. Death-rate. Primary .... Intermediate . Secondary Re-amputations Uncertain 82 55 40 11 66 254 75 52 33 4 61 7 3 7 7 4 1 91.4 94..") 82 5 36.2 93.8 Aggregate 225 28 1 88.92 Gurlt's statistics show 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 uncomplicated 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 1 First adopted in military practice by Oppenbeim, in 1829. 2 Doubtful cases omitted in computing percentages. AMPUTATION AND EXCISION IN GUNSHOT INJURIES. 189 the limb. The accompanying illustration (Fig. 94), from a photograph, shows the condition of the bone in a case in which I performed (un- successfully) secondary amputation at the hip-joint, for gunshot fracture of the head and neck of the femur. The specimen is now in the museum of the Episcopal Hos- pital. Knee.—" Wounds of the knee-joint," says Guthrie, " from musket-balls, with fracture of the bones com- posing it, require immediate amputation." Unfortu- nately, this rule still holds good. The statistics of excision of the knee-joint, for gunshot injury (first per- formed by Fahle, in 1851), have been particularly inves- tigated by Cousin, Chenu, Lotzbeck, Kiister, Culbert- son, 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 cases of partial excision have given but one recovery and 10 deaths (91 percent.). Of the whole 44 cases, 38 proved fatal, a mortality of over 86 per cent. Chenu's figures, derived from the re- cords of the Franco-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 mor- tality of over 93 per cent. Lotzbeck's and Kiister's statistics, though somewhat more favorable, are still fracture of hip. sufficiently gloomy, (jQ 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 ]-' 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. 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 :— Excisions. Cases. Died. Recovered. Doubtful. Death-rate. Primary .... Intermediate . Secondary Uncertain 69 67 41 13 49 58 25 8 140 18 8 15 4 45 1 1 5 73.1 87.8 62.5 66.6 Aggregate 190 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 1 Doubtful cases omitted in computing percentages. 190 GUNSHOT WOUNDS. 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 per cent. 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. 191 109 10 116 108 18 Recovered Humerus Bones of forearm Metacarpal bones Femur .... Bones of leg Metatarsal bones 4771 856 104 51 275 75 Undeter- mined. Total. 696 28.5 986 11.2 116 8.8 175 69.4 387 28.2 97 19.3 Mortality per cent. Fig. 95 gunshot Hospital. —Result injury. ) of parti (From a al excision of radius for patient in the Episcopal Comparing these figures, when the number of cases is sufficiently large to justify their being used for statistical purposes, with the re- sults of amputations of the same parts, as given in previous chap- ters, we may conclude that—(1) excision in the continuity of the bones of the forearm is permissible in favorable cases ; (2) excision in the continuity of the humerus irf more fatal than amputation of the corresponding parts, and is so often followed by non-union as to be in most cases an undesirable opera- tion ; (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 amputa- tion, and may, therefore, be re- sorted to in selected cases; (5) ex- cision in the hand or foot is not an operation to be recommended. Judging from my individual ex- perience,which is, of course, limited, 1 In 164 cases bony union did not occur. REMOTE CONSEQUENCES OF GUNSHOT INJURY. 191 I should say that, except in the case of the radius or ulna separately, and perhaps of the fibula, excision in the continuty 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 necrosis or ununited fracture, and I believe there is as yet no instance on record of useful reproduction of bone in a case of excision in continuity for gunshot or other traumatic injury. In the case of the separate bones of the forearm, however, most excellent results may be obtained by excision. I have myself twice excised considerable por- tions of the radius, in cases of gunshot fracture, one being a primary (Fig. 95) and the other a secondary operation ; both patients made good recoveries. Of 7888 completed cases of gunshot fracture of the humerus, recorded in Dr. Otis's Surgical History 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, conservation may be attempted in suitable cases, but in gunshot fractures involving the knee-joint ampu- tation is safer. These points will appear from the following table, con- densed from two in the third volume of the Surgical History:— Mortality per cent. Statistics of Gunshot Fractures. Amputation. Expectation. Upper third of femur Middle Lower " Knee-joint In gunshot fracture of the leg great, and if the vessels and nerv 77.4 46.0 65.8 40.6 45.0 38.2 50.8 60.6 if the splintering of the bones be not very *es 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. Bu'nes—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 coutused wounds of bone were ably investi- gated by the late Dr. Lidell, who 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; those are : 1. Eechymosis of the osseous tissue; 2. Eechymosis of the medullary tissue; 3. Simple osteo myelitis (attended with the production of new bone, both from the periosteum and from the medulla) ; 4. Necrotic osteitis, or an inflammation of bone so severe in character as to terminate in necrosis; 5. Suppurative osteo- myelitis; 6. Gangrenous or septic osteo-myelitis (both this and the last- named condition are almost certain to terminate fatally); and 7. Necrosis produced directly by contusion of bone, without the intervention of either eechymosis or inflammatory irritation. If the bone which is contused be in the neighborhood of an articulation, 192 INJURIES OF BLOODVESSELS. the latter may undergo serious or fatal disorganization ; or if an important organ, such as the brain, be adjacent, secondarv 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. Nerves.—Very curious nervous affections are occasionally observed a> consequences of gunshot wounds. These affections may consist of paralysis of either motion or sensation, or both, of hyperaesthesia, 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.' Encysted Balls__Balls sometimes become encysted, that is, sur- rounded by a layer of dense cellular tissue, within which they may remain without producing any irritation, for a very long period. There are well- attested cases on record in which encysted balls have remained harmlessly in the tissues for forty or even fifty years; in other cases, again, after a variable interval, they excite inflammation by acting as foreign bodies, and may produce serious or even fatal consequences. Especially when lodged in the lung or pleural cavity is this apt to be the case, so that it is given as a rule by many authorities, that any gunshot wound of the thoracic cavity, in which the ball remains lodged, will sooner or later cause death. CHAPTER X. 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 few days; or the blood may coagulate, the clot subsequently exciting suppuration, or possibly becoming organized, as pointed out in Chapter VIII. More rarely, the blood may become encysted in a fluid state, constitutinir what is sometimes called a venous aneurism. Open Wounds of Veins are not unfrequently met with in civil prac- tice, and occasionally give ri-e to most serious consequences. Hemorrhage from a Wounded Vein is marked bv the even and rapid flow, and the dark' 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 extremelv fatal accidents, eighty-five cases collected by S. W. Gross having been fol- 1 See also remarkable eases reported by Dr. J. II. Brinton (Am. Journ. of Mnl. Sciences, Oct. 1870, p. 435), and by Dr. B. Kliett (Ibid., Jan. Ib73, p. 90). 8 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. HEMORRHAGE FROM A WOUNDED VEIN. 193 lowed by death in no less than thirty-seven instances.1 Hemorrhage from superficial veins can usually be readily controlled by pressure, or even bv position. Thus the most profuse bleeding, from the 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 atone 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 pyemia, 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 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 apt to be followed bv secondary hemorrhage, so that it is now generally abandoned, the vein, if of moderate size, being tied as an artery, above and below the bleeding point.2 In the case of very large veins, the practice is more doubtful, and here suture of the wound with a continuous stitch of fine catgut is often safer than ligature, which is apt to be followed by gangrene. I have myself occasionally resorted to this mode of treatment with advantage, and Schede reports a large number of cases thus successfully dealt with, including one of so large a vessel as the inferior vena cava. It is usually recommended that in any case in which it is found necessary to tie the principal vein at the root of a limb, the artery should also be tied so as to equalize the circulation ; Pilcher 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 stagnation. 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 ligature, which gradually cuts its way through, as in the case of an artery, though in a shorter time in proportion to the size of the vessel. Phlebitis may follow a wound of a vein, and was formerly supposed to be the cause of pyaemia, which occasionally occurs and proves fatal after such an injury; this subject will be fully discussed in another part of the volume. 1 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. 2 Braun has collected twenty-seven cases of lateral ligature, of which nine are known to have proved fatal from hemorrhage or pyaemia. 194 INJURIES OF BLOODVESSELS. Entrance of Air into Veins—The most frightful and fatal conse- quence of venous wounds, though fortunately one" which is rare, is the entrance of atmospheric air and" its transfer to the heart. This accident is principally met with in cases of wound of the internal jugular, or of the other large veins situated at the root of the neck or in the axilla, and this part of the body is accordingly often spoken of by surgeons as the " 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 jaw, while this accident occurring in the femoral vein is supposed to have been the cause of death in a case of thigh amputation during the Crimean war. 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 la- the natural connections of the part, by the position of the patient, or\y 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 anv 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 state" moaning and perhaps struggling ; the pulse is almost imperceptible, the action of the heart tu- multuous but feeble, and the respiration difficult and oppressed. Death may occur immediately, but more commonly after an interval varying from a few minutes to an hour or more; or,'if the quantity of air 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 bv svneope. Sir Charles Bell believed that death was caused bv the direct transference of air to the base of the brain, and in confirmation of this view Gross's observation may be referred to, viz. : that animals may be rapidly killed bv the injec- tion of air into the carotid artery. Cormack attributed the fatal result directly to paralysis of the right side of the heart from gaseous distention, while Moore maintained that death was due to the entrance of air to the heart impeding the action of the cardiac valves and thus stopping the circulation, a view which has received experimental confirmation from M. ?u){lH' (1° f experiments also, by Kowalewskv and Wyssotsky, show that frothy blood accumulates in the right side of the heart, mechauicallv hmdenng the normal circulation, and thus causing death by anaemia of the aortic system. Finally, Hare denies the fact of the entrance of air REMOTE CONSEQUENCES OF INJURIES OF VEINS. 195 into veins, and maintains that the symptoms attributed to this cause are due to clot-formation. Treatment.—As a preventive measure, the surgeon should exercise extreme caution in all operations about the root of the neck, or deep in the axilla, using as much as possible the handle instead of the blade of his knife. It might also be desirable to have the large veins compressed by an assistant, or protected by serre-fines, between the seat of 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 below the aperture. When this alarming accident has actually occurred, the first indication for treatment is obviously to prevent any further ingress of air, by 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 endeav- oring to keep up the action of the heart by appropriate means. Of these, the most promising appear to me to be artificial respiration and the administration of stimulants. The patient should be in the 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 respiration may be practised with suitable bellows, or simply by the surgeon's mouth. Sylvester's or Hall's method would scarcely be applicable in these cases, on account of the situation of the wound. 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 men- tioned—(1) an attempt to suck out the air by means of a canula intro- duced into the wounded vein, into the right jugular vein, or even into the heart itself; (2) bleeding from the right jugular vein or from the temporal artery; (3) tracheotomy; and (4) the injection of warm water into the heart. 1 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 196 INJURIES OF BLOODVESSELS. violence, 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 hemor- rhage or extravasation ; if the violence have been less, the vessel may undergo obliteration, or in very slight cases may recover without evil consequences. The obliteration of an artery, occurring some hours or days after the reception of an injury, is usually attributed to the effect of inflammation; I believe, however, that it is more commonly due to the plugging of the vessel, either by embolism (fragments of clot being carried from another part of the circulation), or more rarely to an actual thrombosis in situ, clotting taking place in the injured vessel itself. As a result of this obliteration, or infarctus as it is called by French writers, gangrene or serious visceral degeneration may occur according to the size and situation of the vessel. Thus, in two cases of injury in the lumbar region, Moxon found complete thrombosis of the renal arteries, with corresponding incipient degeneration of the kidneys. Rupture or Laceration of an Artery may be either partial or complete; partial laceration generally occurs without external wound, Fig. 96.—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. 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 HEMORRHAGE FROM A WOUNDED ARTERY. 197 for the development of an aneurism at a subsequent period; or the torn inner coats of the vessel, curling upon themselves, may furnish a nidus for the occurrence of coagulation, which, as in the case of contusion, may cause gangrene of the part below the seat of injury ; or, again, the lacerated inner coats may turn downwards, and by their mechanical valvular action produce gangrene, by directly interfering with the circulation. Finally, a partial 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. 96.) Complete, rupture may occur subcutaneously, or in an open wound. In the latter case, the nature of the accident may be obvious from the profuse arterial bleeding, though in other instances, if the coats of the vessel are twisted up^n themselves, there may be scarcely any hemorrhage, the artery, perhaps, hanging out of the wound and pulsating, and yet no blood escaping. When an artery is torn across subcutaneously, there may be wide-spread 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 asceuding aorta, occur- rintr 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, when fatal bleeding may ensue. Hence, a partially divided artery should always be ligated as a precautionary measure Penetrating wounds of arteries, if very small (consisting of a mere 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 the bottom of a narrow and tortuous passage through muscular or other tissue, approaches in its nature to 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, how- ever, 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 198 INJURIES OF BLOODVESSELS. to a main trunk, may bleed more furiously than a larger vessel divided at a more distant point, and, in general terms, the nearer a cut vessel is to the centre of circulation, the more profusely will it bleed. As the pulsa- tions 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. Ex- travasation 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 in- creased 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 spontaneoualy 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 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 irrita- tion, with extreme restlessness and delirium, to which the name of "hemor- rhagic 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 Periodic Hemorrltage 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 PROCESS OF NATURE IN ARRESTING HEMORRHAGE. 199 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 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 Hamophilie or Bluterkrankhe.il. 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. Kidd 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- 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 were experimentally and very thoroughly investigated by Dr. J. F. D. Jones, whose monograph on the subject was published over 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 effects 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- 200 INJURIES OF BLOODVESSELS. 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 173B, 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 interna] 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 ; Beale and Lee con- sider the union to be due to the development of germinal matter, derived from the white corpuscles of the blood; while Billroth (practically return- ing 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. 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 protective, and as furnishing a suitable medium in which the new tissue may germinate; Senn, too, re- gards the clot as an accidental formation, which never undergoes organiza- tion ; and Ballance and Edmunds maintain that its function is merelv to furnish a temporary barrier to the blood-stream, and to afford a ladder-like support and nutriment for the plasma cells of the arterial wall, to the activ- ity of which they believe that the ultimate occlusion of the vessel is alto- gether due. Without entering into a discussion of this question, which must be con- sidered to a great degree one of purely theoretical interest, I mav sav that, whatever be the method by which injuries of other tissues are repaired, bv the same method, in all probability, are wounds of arteries united; and this method, as I have endeavored to show in other 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, derive this practical lesson : that as the repair of an artery after injury appears to require the co-operation both of the walls of the vessel and of the contained blood, no means of arresting hemorrhage can be looked upon as philoso- phical which ignores the efficiency and attempts to dispense with the aid of either of these agents. The application of this remark will be seen directlv, when I come to speak of the local means of treating arterial hemorrhage. TREATMENT OF ARTERIAL HEMORRHAGE. 201 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 which has long been recognized by surgeons, that secondary hemorrhage usually occurs from the distal extremity of a wounded vessel. In the case of partially divided arteries the process is essentially the same; a clot forms between the sheath and the vessel itself, and com- presses the latter ; this pressure may likewise be aided by the formation of a clot in the external wound. The permanent closure of the arterial incision is effected as in the case of complete division, by the inflammatory process. Very slight wounds, especially if longitudinal, may close with- out the calibre of the artery being obliterated ; if, however, the size of the wound be equal to one-fourth of the circumference of the vessel, the latter will almost inevitably be converted into an impervious cord at the seat of injury, and it is probable that, in these cases, the healing process is assisted by the formation of an internal, as well as an external, coagulum. When such a wound heals without the obliteration of the calibre of the artery, the inner coats of the latter do not unite very firmly, and an aneurism is apt to be subsequently developed. In an artery as large as the axillary or femoral, it may be stated, in general terms, that a wound of one-fourth of the circumference of the vessel will, if untreated, either cause death by hemorrhage, or give rise to a traumatic aneurism ; in the rare instances in which neither of these consequences ensues, the vessel will, in healing, be converted into an impervious fibrous cord. Treatment of Arterial Hemorrhage. The treatment of arterial hemorrhage should be both local and constitu- tional. The constitutional treatment consists in keeping the patient quiet in a recumbent position, and in avoiding any sudden elevation of the head or of the arms, which might induce fatal syncope. Food and 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 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 be administered, or ergot may be used, and may be conveniently combined with opium and digitalis. As a last resort transfusion of blood, or one of its modifications, may be tried in the manner and with the precautions recommended in Chapter V. The statistics of this operation in cases of hemorrhage, as given by Landois, are very favorable, 99 cases having afforded not less than 65 recoveries, while in 11 of the 31 fatal cases (the result in 3 was doubtful) the patients were moribund at the time transfusion was practised. Strieker recom- mends vigorous kneading of the abdomen, so a.s 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, while, on the other hand, in cases of internal hemorrhage, advantage may be derived from keeping the blood in the limbs, as suggested by Dawbarn, by the use 202 INJURIES OF BLOODVESSELS. of the Spanish windlass (p. 109). For the anaemia left after recovery from the primary effects of hemorrhage, a lony course of tonics, and espe- cially 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 hemorrhage may act as a predisposing cause for the occurrence of tuberculosis or other morbid conditions. The local treatment of arterial bleeding consists in the adoption of various meas- ures, which may be either of a temporary 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 instrument have been sufficiently described in a previous chapter. In dealing with certain arteries, as the subclavian, to which a tourniquet cannot be applied, effectual pressure may be made with the handle of a large key (previously wrapped, so as to protect the skin), or other suitable implement; or if the clavicle be much displaced—as by an aneurismal tumor—Syme's plan might be employed, which consists in making an incision in the line of the artery, upon which direct pressure is then made by introducing a finger through the wound. For the perma- nent arrest of arterial hemorrhage, the surgeon may have recourse to the use of—1, cold; 2, position ; 3, pressure; 4, styptics; 5, cauterization ; 6, torsion; 7, ligation; or 8, acupressure. 1. Cold is an efficient means of arresting hemorrhage from many 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 away the clots and exposing the wound to the air the hemorrhage ceases spon- taneously. Hemorrhage from small vessels may often be arrested by pouring a stream of cold water over the part, or if the bleeding come from one of the mucous outlets of the body, as the mouth, nostrils, rectum, or vagina, by introducing small pieces of ice. Care must be taken, however, in the use of cold, not to continue its application too long, lest injurious depression or even sloughing should ensue. The application of hot water has been successfully employed in cases of capillary hemorrhage by Keet- lev, 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, 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 STYPTICS AND CAUTERIZATION. 203 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, which 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 artery, this will be found a very efficient mode of controlling hemorrhage. 4. Styptics—These agents, when employed alone, are not of much use, except in checking capillary oozing or the bleeding from very small vessels. The simplest and most convenient is ordinary alcohol,"pure or diluted, the employment of which in operations has already been adverted to. The styptic 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. AVright and Bicknell advise the employment of " fibrin ferment," obtained from fresh blood, or from the thymus gland of the calf, to which a small quantity of chloride of calcium is added. Among the more powerful styptics may be especially mentioned the perchloride of iron, in substance, in solution, or in the form of the muriated tincture, and the persulphate, or Monsel's salt. The latter, in particular, is undoubt- edly a very powerful agent, and, when properly used, capable of serving a very good end; its indiscriminate employment in all cases of surgical hemorrhage has, however, been productive*^" 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. Holloway advocated the employment of styptics, with pressure, in cases of consecutive hemorrhage from gunshot wounds, as often preferable to the use of the ligature; and though, of course, a practice founded on uni- versal experience is not to be revolutionized by the record of a few excep- tional cases met with by any individual, still the instances mentioned by this surgeon 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 204 INJDRIES OF BLOODVESSELS. learn from the writings of Sharpe, two hundred years subsequently, that even in his time the cautery and styptics were still preferred to the liga- ture by many surgeons, both on the Continent and in some parts of Eng- land. 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 figured in the chapter on Minor Surgery, and it will be sufficient to add here that when used for hemorrhage, as it is the coagulant and not the de- structive effect that is needed, the temperature of the iron should not be raised above a black heat. 6. Torsion, as a means of controlling the 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 spe- cially named Amussat, Velpeau, and Fricke. After- wards torsion was occasionally used by surgeons, generally in dealing with small arteries; but the practice received a fresh impulse some years since, and was strongly advocated by several writers as a mode of treatment applicable to vessels of all sizes; this movement was most actively participated in by Syme, Humphrey, Bryant, and Forster. Torsion may be practised in several ways: Syme, Hum- phrey, and Tillaux, following Amussat, draw the extremity of the artery out from its sheath, and twist it until it is twisted off; the surgeons of Guy's Hospital, on the other hand, adopt Velpeau's plan of leaving the twisted end attached, that it may give additional security by acting as a mechanical plug. Free torsion (that is, with a single pair of forceps) is recommended by Bryant for vessels of moderate size, and for all vessels in the extremities; limited torsion (in which the vessel is grasped with one pair of forceps and twisted with another) for such arteries as are large and loosely connected. Ingenious forms of torsion-forceps have been devised by Hewson and Briggs. (Fig. 97.) When it is not intended to twist off the end of the vessel, the num- ber of turns should vary from six to eight, according to the size of the artery. The mechanism of torsion is as follows: the inner and middle coats are lace- rated and curl upon themselves, forming a nidus for the coagulation of blood, just as after ligation, or in the ordinary natural process of repair already de- scribed ; the external coat is twisted into a cord, which serves temporarily as a mechanical plug, and is eventually sur- rounded by lymph and incorporated with the adjoining tissues or more Fig. 97.—Hewson's tor- sion-forceps. LIGATION. 205 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 applicable 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 suggested bv Dr. Speir, of New York, who employs an instrument which he calls the "artery con- Fig. 98.—Speir's artery constrictor. stridor" (Fig. 98); 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 corru- gated but not divided. The instrument is removed as soon as this has been accomplished. 7. Ligation—The use of the ligature, though apparently known to the ancients, was afterwards completely forgotten, so that its 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, when applicable, the very best method of checking arterial hemorrhage. The form and structure of the ligature, and its mode of application to the open ends of vessels, have already been described (page 111), 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 aneuris- mal needle (Fig. 99), or even an ordinary curved needle, or an eyed probe. The mechanism of the ligature in controlling hemorrhage is now well understood (thanks to the investigations of Dr. Jones), and the rules for Its application are thor- FlG_ 99_Aneurismal needle, armed with a ligature. oughly 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 206 INJURIES OF BLOODVESSELS. 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 tying the larger vessels, the giving way of the inner tunics of the artery is sometimes dis- tinctly perceptible to the surgeon. The divided inner coats curl upon themselves, and assist the formation of an internal coagulum, while the artery is permanently sealed by the occurrence of inflammatory changes, just as in the natural haemostatic process already described. The noose of the ligature, if this be of silk, is gradually loosened b}T the process of granu- lation, and finally cuts its way through, or comes out bringing with it the constricted portion of the external arterial coat, while the catgut or other form of absorbable ligature gradually disappears and, as pointed out by Lister, is replaced by a ring of fibrous tissue. 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. B. Howard published some experiments to show that it was 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 was sufficient sometimes to secure obliteration of the vessel, and the more recent experiments of Ballance and Edmunds lead them to declare that simple approximation of the arterial wall is suf- ficient, and that rupture of the inner coats increases the risk of secondary bleeding. The sufficiency of contact without rupture, long since advocated by Scarpa, was indeed known from the cases of Hunter, who, as we have seen, did not tighten his ligatures in operating for aneurism ; but I am not aware of any clinical facts which show that a loose ligature is superior to a tight one, while the almost universal experience of sur- geons is that it is less safe, and that, when of silk, 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 fine whip-cord or silk. Various attempts have been made from time to time to substitute other materials which it has been supposed would produce less irritation and might become encysted or absorbed. Thus Sir Astley Cooper and Dr. Physick made use of animal ligatures, catgut or some'similar substance, and this practice was afterwards occasionally adopted by others.1 Car- bolized 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 dis- appears without dividing the external coat of the artery, and thus does not securely occlude the vessel—in this respect being open to the same ob- jection as acupressure; hence, for ligations in continuity, I believe that 1 Eve employed ligatures made from the sinews of a deer, and Barwell recommends those taken from the middle coat of the ox's aorta. T. Smith, Croft, Pollock, and Morrant Baker have used carbolized ligatures made from the tendon of the kangaroo, as sug- gested by Girdlestone, and VVyeth has successfully tied the carotid with the sciatic nerve of a calf. Ishiguro suggests ligatures made from the sinews of a whale. Bal- lance and Edmunds recommend ox peritoneum, kangaroo tendon, or boiled floss silk, and if these cannot be obtained, boiled Chinese twist, chromicized catgut or silk- worm-gut. LIGATION. 207 well-prepared chromicized gut is preferable. Metallic ligatures were em- ployed in a series of experiments on the lower animals by Levert of Alabama, more than sixty years ago, and since then have been occasion- ally used in operations on the human subject. Levert found that wire ligatures tightly secured around the arteries of dogs produced obliteration of the vessels, and that, when both ends of the ligature were cut short, the loop became encysted, and remained in the wound an indefinite time without producing irritation. Similar results have been since obtained bv Sir J. Y. Simpson and others. Howard, on the other hand, finds that wire ligatures, if drawn tight, produce marked inflammation and suppura- tion around, the seat of ligation, and therefore recommends the use of loose wire ligatures. Metallic ligature threads have now been used a suf- ficient 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; but I see no reason to believe that they are any better than catgut ligatures in ordinary wounds, or than those of silk or silkworm- gut for abdominal cases, in which a ligature which will be readily en- cysted is more desirable than one which will be absorbed. Rules for Ligating Wounded Arteries.—In the application of ligatures to wounded arteries, there are certain rules which 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 wounded vessel, that it might be secured by a ligature. Uud^r any circumstances the patient should be constantly watched, and if the wound were in an extremity, it would be right to apply a provisional tourniquet, so that, in case of secondary hemorrhage, all unnecessary loss of blood might be prevented. 2. In applying a ligature to a wounded artery, the surgeon should cut down upon it directly at the point from which it bleeds,'and secure the 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 ruleshould 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 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 208 INJURIES OF BLOODVESSELS. 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, which was directly connected with the operation, and entirely independent of the original injury. For these reasons, then, viz , that by this method only can the actual source of hemorrhage be determined; that thus only can probable security be afforded against secondary bleeding; that if 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 doivn upon, and tied where it bleeds. In doing this, the surgeon should usually take the original wound as the guide for his inci- sions; should, however, the wound be very deep, it may be more con- venient 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 pressure 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 accumu- lation of recorded experience on the subject from both civil and military practice, to persist in cases of arterial hemorrhage in tving the mam 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 con- sidered 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 mav serve to check the hemorrhage for a short time, as soon as the collateral circulation LIGATION. 209 is fully established, bleeding will again begin from the distal end of the vessel. When the artery is only partially severed, Savory's plan may be properly adopted, the vessel being completely divided between the liga- tures. 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 may 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;' 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 mani- festly impossible to reach the seat of the wound, and the surgeon's only resource is to tie the main trunk. Again, in cases of secondary hemor- rhage from wounds of the palmar arches, it mav be necessary to deviate from the ordinary 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 corre- Fig. 100.—Grooved director. spond with the general course of the vessel. If there be a wound, that should, of course, be the starting-point for the incision, but in other cases the operator must rely upon the pulsation of the vessel, if that can be felt, and if not, upon his general anatomical knowledge as to the course of the l 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 « Ogston, of Aberdeen, has successfully tied the deep palmar arch by separating the abductor indicia from the radial side of the metacarpal bone of the index finger, through a dorsal incision. 6 ' H 210 INJURIES OF BLOODVESSELS. Fig. 101.—A. Opening the sheatb. B. Drawing ligature around the artery. C. Tying artery. (Bryant.) artery. It is well, especially when the arterv lies deep, to make the incision, as recommended by Hargrave and Skev, somewhat obliquely to the course of the vessel, which can thus be more readily found than if "the incision be directly in its line. The skin and superficial fascia may be divided bv the first stroke of the knife, but afterwards the surgeon should pro- ceed with great caution, taking up each successive layer of tissue with delicate fcrceps, 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. 101, A), and makes an opening just suffi- cient to allow the passage of the needle which 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 except the vessel itself. The point of the needle, which must be well 7 , , , ground down and rounded, is then teazed through the opening in the sheath (Fig. 101, B), a process which may be facilitated by a gentle touch with the knife, one end of the ligature drawn out, and the other drawn backwards with the needle, which must be withdrawn as gently as it was introduced. The operation is completed by tying the artery firmly and tightly with the reef-knot (VW 101 C) and bringing both ends of the ligature out of the wound, whicli is closed T ^UutUreS/nd !ight,y dressed- If catgut be used for the ligature, this should be tied with a surgeon's knot and reef-knot combined (Fi«- 44) and both ends cut short. Savory and some other surgeons advise that in every case two ligatures should be applied, and that the arterv should be divided between them ; but while I consider the double ligature indis- pensable in cases of wounded arteries, a single ligature is I think safer 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 while ligature of the nerve would at least give unnecLarv pain, and might possibly expose the patient to the risk of tetanus. It would ZZIT* Pf ^ °f thG partS bel0W' Wh,'ch in some situations might shTld hJ 1 ^rT conse. 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 fracture is seen as a cause of deformity in the projection of the inner frag- ment of a fractured clavicle, when, as pointed out by Anger, the weight of the arm being taken off by the fracture, the inner end of the clavicle is jerked upwards by the normal resiliency of its ligamentous and other attachments. Direction of Displacement.—The displacement in cases of fracture may take place in various directions; thus, there 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 muscular action. Thus, in fracture of the thigh there is often an angular displacement outwards and forwards, due to the fact that the most power- ful 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" frae- 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 ol injury inflicted on the "spongy layer"—no longer cartilage, but not yet bone— whieli unites the epiphyseal cartilage to the diaphysis. If this spongy layer, as usually happens, he torn off with the cartilage, and accurate reduction be not promptly ellected, 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. MOBILITY. 215 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. 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 bv 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 thi"h to several inches. Another form of shortening is due to impaction ; this is often seen in fracture of the cervix femoris, the shortening beino- 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 Ion»i- 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 fractu'res 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 bein"- twisted upon its own axis; this form of displacement mav 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 brevis. Displacement in cases of fracture may be confused with deformity from other causes; thus a periosteal node or an exostosis may closely simulate angular displacement; shortening may result from old joint-disease or from contracted tendons; the position which a joint'assumes when the seat of sprain 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, uot 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 svmptom of fracture ; he part which gives support to the limb is broken, and the limb can be cent in any direction. In fractures, however, of the leg or forearm, when >ut one of the two bones is broken, the other acts as a splint, and hinders ne manifestation of this symptom ; again, in serrated, and especially in impacted fractures, there will often be no undue mobility ; or the swelling 246 FRACTURES. 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, dis- location, 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- bility, 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. Velpeau, however, showed that a fractured clavicle interfered with raising the arm to the head, merely by the pain caused by the act; and Gouget, a French army surgeon, has shown the same thing as regards the power of walking after fracture of the patella. 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 Eechymosis, to a greater or less extent, occur in almost every case of fracture: the degree of eechymosis 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 com plica- DIAGNOSIS OF FRACTURE. 247 tion of fracture. When the extravasation reaches to the neighboring joints, intra-articular effusion results, as pointed out by Gosselin, from irritation of the outer surface of the synovial capsule ; this symptom is, therefore, usually met with some hours or even days after the occurrence of the fracture. Diagnosis of Fracture. The diagnosis of fracture can usually be made without much difficulty by attending to the symptoms above enumerated, the first three of 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 successively 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 case of suspected fracture that the surgeon should arrive at a correct diagnosis, his examination should always be made deliberately and systematicall}r. The deformity, mobility, impair- ment of function, pain, etc., should be successively noted, before proceeding to the manual examination which is to determine the existence or non- existence of crepitus. In this final part of the investigation, preliminary extension being made by an assistant, if necessary, the surgeon grasps the limb above and below the suspected seat of fracture firmly—so that he controls the bone as well as the flesh, and gently moves his hands in various directions, so that if there be a fracture, the ends of the 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 evi- dence, 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 facili- tated 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 cedema 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 might be tried. This plan con- sists in endeavoring to disperse the swelling by systematic friction and kneading (massage), in the course of which proceeding the fracture, if there be one, will become evident. Under certain circumstances, the use 248 FRACTURES. of an anaesthetic would be justifiable, in order to facilitate the diagnosis (see page 84).1 In any case of doubt, it is safe to presume that the worst has occurred, 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 case of compound comminuted fracture of the humerus, which, though carefully examined by himself and others, was not detecied until the eighth day, and I can myself recall a case in the Pennsylvania Hospital, in which the swelling of the part prevented the recognition of anything further than that the 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 frag- ments. 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 Bones I would respectfully refer the reader for a detailed exposition of the whole subject of bone pathology. Bone grows in length by the development of bone-cells from the epiphyseal cartilages, or cartilages of conjunction, and in thickness by the development of bone-cells from the inner or osteo-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, whether propagated from the bone or from the external soft parts, gives rise (usu- ally) 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 in- creased production of new bone; in the marrow, the irritation, if not ex- cessive, 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 ijf 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.2 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 any doubtful case. 2 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 PROCESS OF UNION IN FRACTURED BONES. 249 Taking now the simplest case of fracture—an intra-periosteal fracture, so called—the process of repair can be seen at a glance. The traumatic irritation propagated from the broken bone causes swelling of the perios- teum, active proliferation, and formation of a sheath of new bone around the seat of fracture ; this is the " enshealhing" or " ring callus" of surgical writers. At the same time the medulla feels the effect of the irritation, becomes hardened and partially ossified ; this constitutes the "interior" or "pin callus." Lastly, the osseous tissue itself undergoes cell 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 enshealhing 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 enshealhing 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 cavitv 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 be so small in amount, and so temporary in duration, as to escape observation ; this is seen in certain serrated, impacted, and partial fractures, and is often spoken of as union by intermediate callus alone. On the other hand, the fragments 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 which will be con- osteo-genetic power, and the formation of callus is due not to proliferation of previ- ously existing cells, but to an accumulation of wandering cells, which, following Cohn- heiin, 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 inflammation and repair in the osseous tissues that has already been noted with regard to those processes in the soft structures of the body. According to Feltz, hone, periosteum, and medulla are all restored by means of an '"embryo-plastic" tissue, which differs from the connective and medullary tissues, but is of an embryonic character analogous to that met frith 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 bone is devel- oped, in cases of fracture, by the medullary structure, but that the change in the periosteum is rather calcification than true ossification. 250 FRACTURES. sidered hereafter, bony union does not take place, and the fragments arc 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 which are observed in the heal- ing of open, as compared with that of subcutaneous wounds. Cartilage is occasionally met with in callus; it is, however, but a temporary con- stituent, due to excess of irritation. Separated epiphyses unite as frac- tured bones: the part usually remains permanently thickened, while, from the injury to the cartilage of conjunction, the growth of the bone in length may be permanently interfered with. (See Fig. 127.) 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 Hewson, but, for practical purposes, I know of nothin-r better than a simple, per- forated, hard mattress, with a pad accurately fitting the perforation, and a pan which slides in a framework beneath a corresponding opening in the bedstead; the latter should be provided with strong wooden or metallic slats, so as to furnish an even surface and secure firmness and rigidity to the whole arrangement. The lower sheet must, of course, be also 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 ordinarv TREATMENT OF SIMPLE FRACTURES. 251 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 corre- sponding part of the opposite side. He then, by'a careful and methodical examination, proceeds to satisfy himself as to the nature and extent of the injury, and then, replacing the limb in an easy position prepares his splints and bandages before attempting to reduce the fracture. 1. Reduction, or Setting the Fracture, consists in replacing the fragments by manipulation as nearly as possible in their normal position as regards each other. I say advisedly "as nearly as possible," for I believe,°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 the evils which would result from continued displacement. Reduction should be effected by the hands alone; no mechanical contrivance should be used to give increased force, lest serious mischief to the already 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 deformitv ; but the tendency to spasm gradually passes off, so that by constant attention and careful dressing during the early stage of the treatment, it is almost always possible to obtain such accurate 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 assimple apparatus as possible; plain and light splints of wood, pasteboard, wires,' or thin metal, such as can be made by any carpenter or blacksmith, are, I think, in every way preferable to the elaborate and complicated appliances which have been,"from time to time, recommended for the treatment of fractures. Straight and angular splints, made of smooth half-inch boards, for the upper extremity, straight splints and plain fracture-boxes with soft pillows for the lower extremity, a roll of 1 Surgeon-Major Porter, of the Medical School at Netlev, suggests that, in military practice, splints might be readily made from abandoned telegraph wire. Mr. Pyle recommends splints made from corrugated paper, and Dr. McBride those of hard 252 FRACTURES. cotton-wadding 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 iu the use of splints and other apparatus mav be stated as follows:— (1) They are to be used as means of retention only, not of reduction or extension ; these are effected by the surgeon's hands, and splints and band- ages are merely to prevent the recurrence of displacement. (2) All splints, etc., should be firmly and evenly padded, so as not to exert injurious pressure on the bony prominences with which they come 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 bv 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 frac- ture 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 >n much pain as to render it probable that displacement has recurred, or that the splints are pressing unevenly, the dressing should not be disturbed more than absolutely necessary. It is a good rule to leave the fingers or toes exposed, so that the surgeon can by them judge of the condition of the circulation in the injured limb; and if they appear undulv 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 watching, and a patient with a broken bone should receive from his surgeon at leasrdaily visits until after the subsidence of all inflammatory symptoms. 3. The third indication for treatment (see p. 250) 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 bandaire is often recommended, but is a somewhat hazardous remedy, and should be used with great caution. Tenotomy also has beeu proposed for this purpose; but I can scarcely conceive of a* case in which 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 bullse form they should he opened with the point of a lancet. The formation of vesicles in more than ordinary abundance, or the presence of cedema in connection with a frac- ture, renders it probable that union of the bone will be delaved If extravasation proceed from the rupture of a large arteru the case will require special treatment, which will be considered under the head of TREATMENT OF SIMPLE FRACTURES. 253 complications. Embolism by particles of fat is an occasional complication of simple fracture, which has been already referred to at page 155. 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 bandage may seem sufficiently loose when applied, and yet in a few hours may become the cause of great constriction from subsequent swelling of the limb; hence the importance of not applying a bandage beneath'the splints; it is, as remarked by Mr. Erichsen, almost invariably to a neglect of this rule that the occurrence of gangrene from the pressure of a bandage is due. Especially is this true in the case of the forearm, in fracture of which part this accident most often occurs. 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 clue, at least in some measure, to causes entirely beyond control. The treatment of gangrene occurring under such circumstances must vary according to its nature and extent"; if it be due to constriction, and the surgeon fortunately discover it in time, he must instantly remove the bandage, when possibly the patient mav escape with superficial sloughing. If complete gangrene have occurred, Fig. 128.—Gangrene from tight bandaging. (Bisll.) 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. 167), immediate removal of the limb must be prac- tised at a point above the farthest limits of the disease. In the former case a favorable result may be anticipated, but under the latter circum- stances 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 mav 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. 254 FRACTURES. 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 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 ]>os- 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, which 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 TREATMENT OF COMPLICATED FRACTURES. 255 the limb gangrene should occur, amputation would be necessary. 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 condition, and when the operation could be done immediately above the knee, than bv running the risk of being compelled to amputate at a higher point with the patient under the depressing influence of gangrene. In the upper 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. Laurent 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 accord- ing to the Hunterian method than by other modes of treatment. Rupture or other Serious Injury of an Important Nerve, as the mus- culo-spiral or median, is a very troublesome and annoying complication of fracture, causing loss of power or permanent impairment of the 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 down in the last chapter in discussing injuries of the nerves in general. A very Severe Flesh-wound, even if not communicating with the seat of fracture and thus rendering it compound, may seriously complicate the progress of the case, and may occasionally necessitate amputation. Unless, however, the injury to the soft tissues were, in such a case, in itself 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 256 FRACTURES. chorea, reported by Dr. Wm. Hunt, 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 readilv induce sloughing. Treatment of Compound Fractures.—The first question to he determined with regard to an}' case of compound fracture is, whether or not amputation is to be performed; if the operation is to be done at all, it should be done as soon as possible, for the reason already given in Chapter VI. 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 which 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 which the wound is made by the fragments perforating the skin, for the reason that in the latter case the soft tissues are comparatively little injured, while in the former they are apt to be greatly torn and bruised, or perhaps completely pulpefied. Hence compound fractures from railway and machinery 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, when, if other circumstances are favorable, an attempt may be made to save the limb. If, however, the wounded vessel cannot easily be secured, and if the part injured be the lower extremity, immediate 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 liga- ture may be appplied to the brachial artery, which has been several times successfully tied under such circumstances. 3. Great comminution of the bones themselves may be a cause for ampu- tation in cases of compound fracture. In the upper extremity much may be done in the way of conservatism, by removing splinters, and then placing the bones in such a position as to favor union. In the lower extremity, if the comminution be so extensive that removal of the primary and secondary sequestra will leave a gap in the continuity of the bone, the resulting limb, even if it could be preserved, would scarcely have sufficient firmness to be useful, and hence in such cases primary amputation is to be recommended. An exception should, perhaps, be made in cases of compound fracture in the upper third of the thigh, in which position primary amputation is so fatal an operation that the surgeon is loath to resort to it under any circum- TREATMENT OF COMPOUND FRACTURES. 257 stances; 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 °-un- 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 surgery, I cannot but believe that in the immense majority of instances the best interests of the patient will be promoted by primary amputation in cases of compound fracture of the knee-joint. 5. A compound fracture, 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 cases are usually such as result from accident by railway or other vehicles, or by machinery, and are apt to be attended with much greater destruction of soft parts than is at first apparent; so that, in most instances, amputation at the highest point of injury will be found the safest mode of treatment. The complication of compound fracture with dislocation at a higher point of the same limb is of less consequence. In such a case the broken bone should be temporarily put up, and the dislocation reduced, the com- pound fracture being afterwards treated on its own merits. Compound epiphyseal separation is sometimes met with in young per- sons, and may be mistaken for compound fracture involving an articula- tion, from which lesion it can, however, always be distinguished by care- ful examination. If, as sometimes happens, the diaphysis project through the wound, reduction is very difficult, and can usually be accomplished only by resecting the projecting portion, an operation which may be best performed with Butcher's or a chain saw. The after-treatment"does not (litter from that of ordinary compound fracture ; the resulting limb, though shortened, is not materially impaired in utility, even in the case of the lower extremity. Treatment of Compound Fractures which do not require Amputation. —Many ingenious forms of special apparatus have been invented for the treatment of compound fractures, but I am not aware that they present any advantages over the ordinary splints and boxes habitually used in the management of simple fractures. The only special precaution to be ob- served is, to so arrange the splints and bandages that free drainage may 258 FRACTURES. be secured from the wound, and that the latter may be readily accessible without removing the entire apparatus. The points to be particularly attended to in the treatment of these in- juries are: 1. Reduction of the fracture; 2. Extraction of splinters; 3. Closure of the wound ; and 4. Management of the consecutive inflamma- tion. 1. Reduction is to be effected, as in the case of simple fracture, by relax- ing the neighboring muscles, and by gentle manipulation. If a fragment project through the skin, the difficulty of reduction is much increased, and in such cases it may be necessary to enlarge the external wound, or even to resect the projecting end of bone. This measure should, however, be resorted to with extreme hesitation, especially in the lower extremity, for the loss of any considerable portion of the continuity of a long bone will be apt to result in the formation of a false joint, requiring subsequent am- putation. This, indeed, has been the ordinary result in cases in which I have seen this operation performed. 2. In the management of splinters or sequestra, the rules which were given in the chapter on Gunshot Wounds, founded on Dupuytren's divi- sion of splinters into primary, secondary, and tertiary, are to be observed. Those fragments which are loose or but slightly connected are to be re- moved, while those which are more firmly attached are to be pushed into place, that they may give solidity to the callus and assist in the repair of the injury. In case of doubt, it is better to err on the side of allowing fragments to remain, as, if they afterwards become necrosed, they will be spontaneously loosened, when they can usually be removed without much difficulty ; though in some cases a dead splinter may become surrounded by callus, requiring division of the latter before the sequestrum can be extracted. 3. If the external wound be small, and unaccompanied with much con- tusion, an attempt should be made to close it, and thus convert the case into one of simple fracture. I have frequently succeeded in doing this; and the effort should always be made when the nature of the case will permit it. For this purpose the wound is to be washed and freed from blood, and then hermetically sealed with gauze and collodion, styptic colloid, Paresi's antiseptic preparation (see page 165), or the compound tincture of benzoin ; or, in the absence of these agents, simply with a piece of lint dipped in blood, as recommended by Sir Astley Cooper. If, however, the wound be a large one, or if it be accompanied with much contusion and laceration, it will be useless to attempt its closure, and it should then be dressed lightly, and in such a way as to allow of free drainage. Even if an attempt have been made to close the wound, the parts should be frequently examined, and if it appear that pus is accumu- lating underneath the dressing, the latter should be immediately removed, and free vent given to the accumulated discharges. 4. The management of the inevitable consecutive inflammation which attends compound fractures, is to be conducted in accordance with the principles enunciated and the rules laid down in the chapters on the Treat- ment of Inflammation, and on Wounds in General. Ice, water-dressing, irrigation, laudanum fomentations, poultices, astringent washes, antiseptic dressings, etc., may each and all be appropriately used in different cases and under different circumstances. The splints employed should be pro- tected by oiled silk from being soiled by the discharges ; and while the fracture should not be unnecessarily disturbed, the utmost care must be taken to keep the parts clean and to preserve the neighboring integument in a healthy condition. Treves advises that compound fractures should TREATMENT OF FRACTURES WITH IMMOVABLE APPARATUS. 259 be freelv exposed, the wound being kept covered by a dry powder such as iodoform or creolin. In compound fractures of the lower extremity, the bran dressing, introduced by Dr J. Rhea Barton, of this city, will be found most serviceable. It affords equal pressure and support to the injured member, restrains hemorrhage, absorbs discharges, and can be daily renewed, as far as necessary, without material disturbance of the limb. Its mode of application will be described in the next chapter. The patient's general condition must also receive attention. The action of the bowels must be regulated, and traumatic fever moderated by the administration of suitable remedies. When suppuration is fairly established, tonics, espe- cially iron, quinia, and cod-liver oil, may be freely exhibited. The diet should be nutritious, but unirritating; and in the later stages, or perhaps from the first, free stimulation may be required. The connection which has now been so often traced as to make it appear causal, between pro- longed suppuration and the peculiar form of visceral degeneration known as albuminous or amyioid, clearly indicates the paramount importance, in these cases, of maintaining the patient's strength and supporting his system in every possible manner. The time required for the cure of a compound fracture may be estimated at from two to three times as long as would be needed in the case of a simple fracture of the same part. Secondary amputation may be required in the treatment of compound fractures, on account of secondary hemorrhage, traumatic gangrene, sloughing following erysipelas, osteo-myelitis, extensive necrosis, general exhaustion of the patient, hectic, etc. The proper period for amputation in cases of traumatic gangrene has already been pointed out in preceding chapters. In the case of the other complications which have been men- tioned, the surgeon must choose his time as best he can, operating at some period when there is a momentary subsidence of constitutional disturbance, and while not hastily condemning a limb without fair trial of conservative measures, yet not delaying interference until the patient has sunk so low that interference will be of no avail. The only general rule that can be given with regard to these cases is, to avoid, if possible, operating during the intermediate stage, which usually ranges from the second to the tenth or twelfth day. After suppuration has been fairly established, the case becomes somewhat assimilated to one of chronic disease, and amputation can then be performed with comparatively fair prospects of success. Treatment of Fractures -with "Immovable Apparatus."— In the later stages of the treatment of fractures, advantage may often be derived from the use of a plaster-of-Paris bandage, or one of the other forms of immovable dressing described in Chapter V. It is right to add that several excellent surgeons, both at home and abroad, recommend the use of these dressings even in the early stage of fractures, and believe that by their employment as good, if not better, results may be obtained than by the ordinary methods. For my own part, I cannot but regard any form of immovable dressing as unsafe when employed before the swelling which always follows a fracture has entirely subsided, and I am not in the habit of applying the plaster bandage until the union of the broken bones has become tolerably firm—usually in the course of the fifth or sixth week. I would invite those who are interested in the further consideration of this subject to refer to Professor Hamilton's excellent treatise, where the comparative advantages of these different modes of treatment are fully, and—as far as I am able to judge—very fairly, set forth. There are two principal ways in which the plaster-of-Paris bandage may he applied; one, and that which I think upon the whole the best, consists in the application of the wetted gypsum roller over a dry roller, in 260 FRACTURES. the way described on page 84, care being taken to keep the limb well extended while the plaster is setting; and the other, or "Bavarian plan," in which two pieces of flannel, stitched together at their middle by a straight seam, are laid beneath the limb, the inner layer being then folded evenly around the part and secured with pins or stitches, when the liquid plaster is spread over it, and the outer layer finally brought up and secured in the same manner as the Fig. 129.—Bavarian immovable splint. (Bryant.) nrs^ > after the plaster has become hard, the pins or stitches are removed, when the splint may be opened and taken off, the seam at the back serving as a hinge. Treatment of Badly United Fractures.—From various causes, over some of which the surgeon may have no control, a fracture may unite with so much deformity as to disfigure the limb, if not to render it useless. If the deformity be in a longitudinal direction, depending on overlapping of the fragments, the case is, I believe, hopeless, for the surrounding mus- cles will have probably become permanently contracted and shortened, and attempts at extension after union has once occurred will prove fruitless. Transverse deformity will be gradually lessened by the processes of nature, superfluous callus being absorbed, and projecting bony prominences rounded off. Angular deformity, if very slight, may be left to nature in the hope that it will be gradually removed by the physiological action of the muscles. If at all marked, however, it will require treatment, and this, if the bony union be comparatively soft, can usually be satisfactorily carried out by careful bandaging and the judicious use of pads and compresses— or the surgeon may by gentle but firm pressure bend the newly formed callus, so as to restore the limb to its proper shape. If the union of the fracture be further advanced, more force may be required, and the surgeon may break the bone over again, with a view of resetting it in a better position. This may be done with the hands, or, at a later period, with a screw clamp, such as those devised for the purpose by Rizzoli, Von Bruns, Butcher, and C. F. Taylor. A remarkable case has been reported by Switzer, in which a large amount of deformed callus disappeared under inunction with compound iodine ointment, and it would certainly he proper to try the sorbefacient effects of this remedy before resorting to the severer measures which will next be described. When the callus is so firm as to resist the application of such an amount of force as the surgeon deems justifiable, he may adopt measures to weaken the bond of union by operative interference. Perhaps the best plan in such a case is that sug- gested by Brainard, which consists in subcutaneously drilling through the uniting medium in various directions, and then rupturing the remainder; or the bone may be partially divided with a saw (Langenbeck) or chisel (Nussbaum, O'Grady), or, as done by Warren and Heath, a wedge-shaped piece may be removed from the apex of the bony angle, the rest of the bond of union being, in either case, broken through, as in Brainard's method; or the deformed callus may be exsected, and the fragments firmly wired together—an operation which I have successfully resorted to in several instances, and which has also succeeded in the hands of Dr. Forbes and others, but which, in addition to its inherent risks, of course, exposes the patient to the chance of recovering with a false joint; or, finally, in an aggravated case, it might be necessary to resort to amputation. UNUNITED FRACTURE AND FALSE JOINT. 261 For further information on this subject, the reader is respectfully referred to Dr. G. W. Norris's excellent paper, in his well-known Contributions to Practical Surgery. Reduction of Deformity in Partial and in Impacted Fractures.—In connection with the subject of Badly United Fractures, I may refer to the question which often arises as to whether or no reduction should be at- tempted in cases of partial and of partially impacted fractures. The answer to this question may be said to depend upon the position of the fractured bone ; thus, while it would be manifestly improper to attempt reduction of an impacted fracture of the neck of the femur, it is, I think, right to re- duce a partial fracture of the clavicle or of the forearm, even at the risk of converting the case into one of complete fracture. In the forearm (and in the clavicle, if the angular projection be outwards), the deformity would be so great as to be very objectionable, while inward angular displacement of the clavicle might endanger the integrity of the important underlying structures by irritation from bony spicula. Tardy or Delayed Union of Bones is occasionally met with, and is, probably, more often dependent on constitutional than on local causes. Sometimes it appears to result from mere debility and depression, without the existence of any positive cachexia; under such circumstances it may be sufficient to get the patient out of bed, with his limb supported in a plaster-of-Paris bandage, letting him recover his health by means of out- door exercise. In some cases the process of union may be assisted by the use of tonics, especially cod-liver oil and the phosphates (which, however, have not been found as practically useful as was anticipated), and by giving an extra allowance of ale or porter. If a syphilitic taint be sus- pected, iodide of potassium or mercury may be cautiously administered. Ununited Fracture and False Joint. Occasionally a broken bone does not unite at all, or unites only through the medium of fibrous or ligamentous bands, or, having been united, be- comes again separated by the absorption and softening of the callus. In some bones, indeed, as in the patella, bony union almost never occurs, but in such cases the want of union cannot be considered abnormal. The terms ununited fracture and false joint are applied only to fractures in those situations in which bony union is habitually met with, as in the various long bones or the lower jaw. The proportion of cases in which non-union occurs is estimated by Hamilton at 1 to 500; it is, therefore, a rare accident. The late Dr. G. W. Norris, whose monograph on this subject is the best that has yet been published, has described four distinct forms under which non-union of fracture may occur. The first is that which has already been referred to under the name of delayed union ; here callus is formed, but does not undergo complete ossification, and hence the union is im- perfect. " In the second class of cases, there is entire want of union of any sort between the fragments, the ends of which seem to be diminished in size, and are extremely movable between the integuments. The limb in these cases is found greatly shrunken, and hangs perfectly useless."1 In the third and most usual form, the ends of bone are rounded off and tapering, and " are connected together by strong ligamentous or fibro- ligamentous bands," passing between the fractured extremities ; there may 1 Dr. C. B. Porter, of Boston, reports a case in which after ununited fracture the humerus was absorbed, and entirely disappeared without exfoliation. 262 FRACTURES. be but one band, or several; "in either case the newly formed substance is firmly adherent to the bones, and, if of any length, is in a high degree pliable." In the fourth variety, to which the name of pseudarthrosis or false joint is properly given, "a dense capsule without opening of any sort, containing a fluid similar to synovia, and resembling closely the com- plete capsular ligaments, is found. In these cases the points of the bony fragments corresponding to each other are rounded, smooth, and polished, in some instances are eburnated, and in others are covered with points or even thin plates of cartilage, and a membrane closely resembling the syno- vial of the natural articulations. It is in this kind of cases that the member affected may still be of some utility to the patient, the fragments being so firmly held together as to be displaced only upon the application of con- siderable force." The diagnosis of ununited fracture is usually sufficiently easy ; I have, however, known great relaxatiou of the ligaments of the wrist-joint to be mistaken for ununited fracture of the extremity of the ulna. Causes of Non-union after Fracture—These may be either constitutional or local. Among the former may be enumerated general im- pairment of health, and various cachectic conditions and diatheses, such as scurvy, phthisis, rickets, syphilis, cancer, and, according to Yerneuil, diabetes. With regard to the influence of cancer in preventing union after fractures, Norris says that when the accident depends upon the presence of a cancerous tumor at the seat of fracture, union will not occur, but when it depends on mere brittleness, resulting from what Curling has called eccentric atrophy, the bones unite readily enough. So with regard to syphilis and rickets; though cases are recorded in which these appear to have acted as causes of non-union, other cases are frequently met with in which the disease is well marked, and yet union readily occurs. Preg- nancy is often regarded as a cause of non-union in fractures, but it is probably thus effective in those cases only in which the pregnant state is accompanied by great debility, as from sympathetic vomiting. The same remark applies to the supposed efficiency of lactation as a cause of ununited fracture Age does not appear to exert any particular influence, fractures in the very young and the very old often uniting quite as well as in those of middle life, and more than one-third of the whole number of cases of ununited fracture occurring in those between twenty and thirty. Among the more prominent local causes may be mentioned deficient vascular or nervous supply, mobility or want of proper apposition of the fragments, the intervention between the fragments of a shred of muscle or other soft tissue, or of a foreign body, necrosis or other disease of the ends of the fragments themselves, injudicious treatment (especially tight bandaging and prolonged use of cooling applications), and too early use of the frac- tured limb. The frequency with which ununited fracture occurs in dif- ferent parts is shown in the following table taken from Norris's paper. Locality. Total Number of cases. 48 33 48 1!) 2 150 Cured. No benefit. Died. 31 9 6 32 1 31 14 3 17 1 1 2 113 25 10 Result unknown. 2 Ununited fracture is also occasionally met with in the clavicle, scapula, ribs, and spine. TREATMENT OF UNUNITED FRACTURES, ETC. 263 Treatment—The treatment of ununited fracture, and of false joint, consists in removing, as far as possible, by constitutional, hygienic, and locai measures, any cause which may seem to hinder the process of union between the broken bones, and in endeavoring to excite in the periosteum, in the medulla, and in the fragments themselves, such activity as will induce those changes which we have seen to be necessary in the natural process of repair after fracture. For this purpose, those remedies should be em- ployed which were spoken of in treating of delayed union, the fragments being accurately adjusted, and rendered perfectly immovable by the use of suitable splints and bandages. Firm and accurately fitting splints of metal, leather, or pasteboard may be employed, or the plaster-of-Paris bandage,* or (in the case of the lower extremity) the ingenious and elegant contri- vances of Prof. Smith, of this city, or of Dr. Hudson, or Dr. Ridlon, of New York. In order to excite renewed activity in the periosteum and other bone-producing tissues, various plans, such as blistering, cauterizing, or galvanizing the skin, have been employed, and when the beneficial effect of transmitted periosteal and medullary irritation is remembered, it can be readily understood that these methods should occasionally have proved successful. Other plans which have sometimes succeeded consist in rubbing together the ends of the fragments themselves, and in " per- cussing" the injured limb with a rubber-protected mallet (Thomas). In the event of these simple remedies failing, severer measures may be employed : of these the most important are the establishment of a seton between the fragments, as recommended by Dr. Physick, or on either side of the un- united fracture, as suggested by Oppenheim; the introduction of stimulat- ing injections, as practised by Hulse, Bourguet, Fitzgerald, Lannelongue, and Menard; acupuncture, as suggested by Malgaigne; the introduction of ivory pegs (Dieffenbach and Hill); electro-puncture (Lente); subcu- taneous scarification (Miller) ; drilling the fragments themselves (Detmold and Brainard); scraping or cauterizing the fragments; holding the frag- ments together by means of sutures or pins (Severinus, Rodgers, Gaillard, and F. Mason); resection (White, Roux, Jordan, and Bigelow); covering in the false-joint with periosteal flaps inverted from the bone above and below (Rydygier), with an ivory or bone cylinder or ferrule (Senn), or with a steel splint fastened to both fragments by screws (Tiffanv); trans- plantation of fragments split off from a neighboring bone (Nussbaum), or from bones of other patients (McEwen, Poncet), of rabbits (Mayo Robson, McGill), or of dogs (Patterson, Phelps); and finally amputation. Of all these, the most promising methods are, I think, those of Brainard, Gaillard, Bigelow, and Tiffany. Before resorting to any of them the suggestion of Oilier may be adopted, to rejuvenate, as it were, the periosteum by the milder forms of irritation, that it may afterwards more readily respond to the severer operation. Brainard's plan consists in drilling the 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 ' Guenther and Nillien have observed that the growth of the nails is arrested during the early stages of a fracture, to be resumed as the process of repair goes on, fh ^'ley ?ugge!it tnis as a m«ans of testing the progress of cure, without disturbing the dressings, in cases of delayed union, or of false joint. It would appear, how- ever, that the growth of the nails may be checked by any cause which interferes with the nutrition of the part, and hence this test might not be universally appli- cable; Mitchell has noticed an arrest of nail-growth in cases of cerebral paralysis, and (ray has observed the same phenomenon as a result of compression of the sub- clavian artery. 264 FRACTURES. 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, Fig. 130.—Improved bone-drill. but not from the skin, its direction changed, and another perforation made, and this operation is repeated as often as may be desired." The late Prof. Gaillard's method consists in pinning together the fragments by means of a gimlet-like instrument, provided with a movable silver sheath, a handle, and a brass nut (Fig. 131): the sheath is introduced through an incision, and held against the bone, while the shaft is passed —EjKS^s^f Fig. 131.—Gaillard's instrument for ununited fracture. 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 fraffments, as practised by Rodgers, Flaubert, N. R Smith, and others. The operation employed by Bigelow is almost identical with that independently suggested by Oilier, and is probably the surest method of treating ununited fracture; it consists in making a subperiosteal resection of the ends of the fragments, the freshened extremities being then held together bv 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 bv other surgeons, including Byrd, of Illinois, Annandale, Packard, and mvself. When anything further is required, a small steel splint fastened'directiv to the bones by screws, as advised by Tiffany, may be employed, the limb being fixed in a plaster-of-Paris bandage with a'trap left for the removal of°the splint when union is complete. Whatever method be employed, the after-treatment must be carefullv 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 FRACTURES OF THE FACE. 265 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 XIII. 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; 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 treat- ment, 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 vertebrae, are principally inter- esting on account of their involving respectively the brain and spinal cord ; hence their consideration will be postponed till we come to speak of in- juries of those parts of the body. Fractures of the Face. Any of the facial bones may be broken by direct violence, and especially by gunshot wound; the nature of the injury is usually recognized 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 treat- ment 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, 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 preserved by plugging the nostrils, if necessary. Occasionally the whole nose is split off, as it were, from the face, hanging by the alae in front of the mouth. In such a case, in which the injury was produced by a blow from an iron pan, I kept the nose in place by numerous sutures, the patient making a good recovery. Sometimes the whole nose is driven inwards, fracturing the ethmoid bone, and involving the brain. Under such circumstances, the nose should be gently drawn forwards with forceps, and the case treated as one of fracture at the base of the skull. Profuse hemorrhage may re- 266 SPECIAL FRACTURES. quire 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 ingenious nasal splint has also been devised by Gamgee. Blaudin and Steele em- ployed cutting instruments to perforate the septum and thus facilitate its replacement. Ingalls excises a wedge-shaped piece of the cartilage, and Bosworth removes the projecting part with a fine saw. I have sometimes effected the same object by using a small gouge. Roberts, when the de- flection 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 may follow whenever the patient blows "his nose. Fracture of the Malar Bone is to be treated by keeping the parts in place by compresses, adhesive strips, and bandages. Fracture of the Zygoma, if comminuted, may interfere with 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 ligation of the external carotid. If the malar bone be thrust in upon the antrum, it should be drawn out with a tirefond, or screw extractor (Fig. 93) aided by pressure from within the mouth. If the upper jaw be broken through the alveolus, the teeth may be held together bv 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. r Lower Maxilla—The lower jaw is more frequently broken than an- 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 beino- how- ever near the symphysis and about the position of the mental foramen. Ine lower jaw is often broken in two or more places at once, and its frac- tures are frequently rendered compound bv laceration of the mucous mem- brane Fractures near the symphysis are more or less transverse while those further back are almost invariably oblique from before backwards a lowing considerable displacement, which is evidenced by shortening of the alveolar border and depression of the chin. In fractures near the angle of the bone, the dental nerve is occasionally involved, an accident which causes temporary paralysis, or more rarely convulsions. The displacement, mobility, and crepitus which accompany fracture of the jaw, render its diagnosis usually easy ; in cases of fracture below the condyle there are, besides, embarrassment in the motions of the jaw, and pain, felt especiallv on opening or shutting the mouth. Fractures of the lower jaw commonly unite without much difficulty and with little deformity Treatment—For the treatment of an ordinary case of broken jaw, nothing is required except a compress to support the chin, and a roller bandage. \ e peau, indeed, during the last years of his life, is said to have abandoned all forms of apparatus in the treatment of these injuries, be- lieving that sufficient rest was insured to the fragments bv the inevitable LOWER MAXILLA. 267 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, with the superaddition of a few occipito-frontal turns of the roller, as in Gibson's bandage. The following description of Barton's bandage is taken from Sargent's Minor Surgery:—" Composition: A roller five yards long, and two inches wide ; suitable compresses. Application: Place the initial extremity of the roller upon the occiput, just below its 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 fig. 132.—Barton's bandage for rejoin the starting-point at the occiput, by tra- fractured jaw. 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, 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 additional security may be furnished by sealing the bandage (as it were) with a few strips of adhesive plaster. Gibson's bandage consists of a compress beneath the chin, with turns of a roller passing from that part to the top of the head, from the occiput to the forehead, and from the nape of the neck to above the mental pro- tuberance, 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 crossed behiud the neck and fastened upon the forehead (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 Hamilton ; wir- ing together the teeth on either side of the fracture is often recommended, but I confess to have seen very little advantage from the practice: a better plan is the application of clasps of ivory, silver, steel, or other material, as practised by Lonsdale, Mutter, N. R. Smith, Nicole. Wales, Bullock, and others, or of interdental splints of gutta-percha or vulcanized India rubber, as ingeniously applied by Dr. Gunning and Dr. Beans. In a case of fracture 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, Hamilton, and Kinloch, 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 necrosis and to consequent non-union, which accident is, in this position, I believe, more apt to result from tight bandaging than from the bandage 268 SPECIAL FRACTURES. being too loose. Gunshot fracture of the lower jaw is sometimes at- tended 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 finsrers, 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 Trunk. Ribs.—The ribs are more frequently broken than any of the other bones of the trunk: these injuries may be produced by direct violence, as from the kick of a horse, or by indirect violence, the front and back of the chest being pressed together, and the ribs giving way like an over-bent bow, at the weakest part.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\vall, 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 sometimes 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 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. FRACTURES of the sternum. 269 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 extractors. 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 which is involved with numerous overlapping broad strips of adhesive plaster, each reaching a little beyond the median line, both behind and before. This mode of treatment, which appears to have originated with Hannay, 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 complications must be met by appropriate treatment, and in any case opium may be freely ad- ministered. The dressing may be removed at the end of three weeks, when union is commonly sufficiently firm to enable the surgeon to discon- tinue 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. 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 270 SPECIAL FRACTURES. 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 evidence 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 diastasis. In cases of injury from indirect violence, if the marks of fracture above given be not present, the diagnosis must be made by noting the presence or absence of haemoptysis, emphysema, etc. The ensiform cartilage is rarely the seat of fracture or dislocation, though well-marked cases have been observed by 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 Hewitt, be aided by noting the occurrence of eechymosis 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 com- press, held in position with adhesive strips or bandages. If there be much displacement, attempts at reduction may be made, by straightening the spine and drawing the shoulders backwards. Opium will usually be re- quired, and any thoracic complications must be met by suitable remedies. Mediastinal abscesses should be opened at the side of the sternum, when pointing occurs; thev 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 ap- peared to be caused by pressure on the stomach from displacement of the ensiform cartilage, and was relieved by reposition of the bone after abdom- inal 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 sacro-iliac symphysis. The ilium, pubis, and ischium may separate in their lines of conjunction, the acetabulum being thus split into three portions; or diastasis may occur at the pubic or sacro-iliac symphyses. Fractures of the pubis and ischium assume a somewhat oblique direction, while those about the sacro-iliac 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 SACRUM AND COCCYX. 271 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 injuries are commonly caused by great violence of a crushing nature, such as the fall of a bank of earth. In one case, which was under my care, the crest of the ilium was knocked off by a sharp blow resulting from the fall of a stove-pipe. The pubis has sometimes been fractured as the result of muscular contraction, as in a remarkable case recorded by Leten- neur, while diastasis of the pubic, and occasionally of the sacro-iliac, sym- physis 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 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 luxa- tion, complicated with fracture of the head of the femur. Fracture of the acetabulum may consist merely in a separation of its posterior lip, or in a destruction of its floor, attended sometimes with impaction of the head of the femur in the pelvic cavity. The latter form of injury is commonly attended with such severe visceral lesions as to prove fatal. Separation of thelipof the acetabulum is marked by the signs of dislocation, the displace- ment being readily reduced with crepitus, but as readily reproduced when extension is discontinued. The great danger in cases of fracture of the pelvis is from rupture or laceration of the bladder or urethra. Hence the surgeon's first step should be to pass a catheter, with a view of ascertaining the condition of those organs; if they are found to have been injured, prompt treatment must be employed, according to the principles which will be laid down in speaking of Injuries of the Pelvic Viscera. The treatment of fractured pelvis consists in the first place in restoring the displaced fragments to their proper position, if this can be done 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 flexed, and supported by pillows. 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 case 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 within the rectum, and in the application of a padded belt. Bernard plugged the rectum with a lithotomy tube, in order to maintain reduction, but I should prefer, with Hamilton, to dispense with such an instrument, and 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 272 SPECIAL FRACTURES. 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 suc- cessfully resorted to by numerous surgeons, including Burnham, Mursick, Morton, and myself. Fractures of the Upper Extremity. Clavicle__The clavicle is peculiarly liable to fracture, not only from its exposed position, but from the fact of its being the sole bond of osseous 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 Fig. 133.—Attachments of outer end of clavicle; showing branches of coraco-clavicular ligament. (Gray.) towards the inner end of the middle third, and is characterized bv slight 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 by Dr. FRACTURES OF THE UPPER EXTREMITY. 273 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 drooping of the outer fragment, which is also rocked inwards and somewhat back- wards by the action of the powerful muscles attached to the scapula, particularly the rhomboidei, trapezius, levator anguli scapulae, pectoralis minor, and some fibres of the serratus magnus. The diagnosis of fractured clavicle can usually be made without diffi- culty; if the middle of the bone be involved, the displacement is in itself sufficiently characteristic, while cre- pitus can readily be elicited in any position of the fracture, on account of the subcutaneous character of the bone in its whole length. In cases of partial or partially impacted frac- ture from direct violence, an acci- dent of not unfrequent occurrence among quite young children, per- sistent tenderness over the point of injury will be found a valuable diagnostic sign. The attitude of the patient, in cases of complete fracture, is peculiar, and often sig- nificant of the nature of the injuiy : the head is bent towards the affected side, so as to relax the muscles, while the elbow and forearm are supported in the opposite hand, so as to diminish the dragging sensa- tion produced by the weight of the limb. The prognosis, as regards the life of the patient and the utility of the limb, is very favorable ; I believe, however, that a perfect cure—that is, without deformity— is very rarely obtained, at least in oblique fractures of the middle of the bone. Comminuted fracture of the clavicle is sometimes a serious injury, from concomitant laceration of the subclavian vein or plexus of nerves. Compound 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 18 Fig. 134.—Complete oblique fracture of clavicle near its middle. (Gray.) 274 SPECIAL FRACTURES. became secondarily compound by the occurrence of suppuration ; slight necrosis followed, but the patient eventually made a good recovery. Frac- ture of both clavicles is an accident of rare occurrence, of which Stimson has collected 28 cases, but which presents no peculiarities, except that of course it requires some modification of the apparatus used in treatment. Treatment of Fractured Clavicle.—The treatment of fractured clavicle may be conducted by position alone, or by position aided by various forms of apparatus. The deformity, as we have seen, depends (1) on the tilting up of the inner fragment, by the resiliency of its ligamentous attachments, and the action of the sterno-cleido-mastoid muscle; (2) on the falling of the shoulder with the outer fragment, due to the weight of the arm ; but (3) chiefly on the rocking inwards and backwards of the outer fragment, by the action of the powerful muscles attached to the scapula. Hence the indications for treatment are, (1) to relax the sterno-cleido-mastoid muscle: (2) to prevent the weight of the arm from dragging down the outer 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 not inaptly called the "shoulder-girdle." These indications may all be met by position alone. For this purpose the patient should lie flat on his back, on a firm, hard mattress, with the head slightly elevated, and the arm flexed and carried across the chest, so that the hand rests on the sound shoulder—the position commonly known as the " Velpeau position," from its having been employed by that distinguished surgeon in the treatment of these and other injuries (see Fig. 136). The elevation of the head (by means of a single pillow, which must not touch the shoulders) relaxes the sterno-cleido-mastoid muscle, and thus obviates the tendency to upward tilting of the inner fragment; the position of the arm across the chest makes the weight of the limb act, if at all, in an upward direction, and thus effectually prevents any downward 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 " Velpeau position" by a few strips of the same material. If the patient cannot remain in bed, the same appliances may be used, with the addition of a compress upon the projecting end of the inner fragment, and a broad roller bandage, used in the form of the "third roller of Desault,"1 with additional circular turns to fix the arm in the required position. 1 The application of the third roller of Desault is thus descrihed 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 ami under the elhow, 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 ohliquely across the chest to the axilla of the sound side." These turns are repeated until the roller is exhausted, thus forming two triangles, one in front and the other behind the chest; the firmness of the bandage may be much increased by making additional circular turns, as recom- mended in the text. FRACTURE OF THE CLAVICLE. 275 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 employed by Dr. Staples, broad enough to fix both scapulae, might be made a useful adjuvant to the compresses already described. Vacher has modified the figure-of-8 bandage by applying metallic caps to both shoulders, and draw- ing them backwards by means of a posterior strap and buckle, while O'Connor 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 this city, 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 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.1' Fox's apparatus has undoubtedly produced a great many excellent cures; it has done so, however, I believe, by fixing the scapula more or less perfectly, and not by affording leverage to the humerus, as it was originally intended to do. Indeed, the wedge-shaped pad, if used as a fulcrum, produces so much pain that few patients can endure it for any length of time; so that in practice surgeons generally apply it far back—where it acts merely as a scapular compress—or else reduce its thickness to such a degree that its action as a fulcrum is entirely defeated. Fox's apparatus has been ingeni- ously modified by Levis, Hamilton, and others, and any of these forms of the sling and pad dressing may be used with good re- sults, provided that they are accurately ad- justed and carefully watched by the surgeon ' Moore and Sayre believe that the point of most importance is to render tense the clavic- ular fibres of the pectoralis major muscle, and thus draw the inner fragment downwards; the former surgeon accomplishes this purpose by forcing the entire arm backwards, and fix- ing 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 back- wards by drawing the elbow forwards, at the same time supporting the forearm, as shown in Fig. 135. Dr. Satterthwaite has modified Sayre's See a full and able discussion of the principles of treatment of fractured clavicle, ana ot the comparative merits of different forms of apparatus, by the late Dr. Edward uartshome, in the 2d volume of the Pennsylvania Hospital Reports, pp. 108-142. Fig. 135.—Sayre's dressing for frac- tured clavicle. (Hamilton.) 276 SPECIAL FRACTURES. dressing by adding an axillary pad, and employing elastic bands instead of adhesive plaster, while Dr. Hawes applies an elbow-piece and a shoulder- shield of padded wire gauze. 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 its neck, through the glenoid cavity, or through the acromion or coracoid processes. Fracture of the Body of the Scapula is a rare accident, and is usually due to direct violence, though it is said in one case (Heylen's) to have been produced by muscular action. If the spine of the scapula be in- volved, 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 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-clavicular and coraco-acromial. If these be ruptured, the glenoid cavity and head of the humerus fall into the axilla (where the latter may be 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 comminution of the glenoid cavity Fracture of the Acromion is probably a rarer accident than epiphyseal separation of that process. When the line of fracture is through or behind the acromioclavicular articulation, the shoulder drops forwards, inwards, and downwards, as in cases of fractured clavicle ; if, however, the fracture be in front of the acromioclavicular articulation, there will be little or no displacement, and the diagnosis must be made by the detection of mobility and crepitus. Union occurs without much deformity, though rarely, according to Cooper, except by fibrous tissue. The treatment consists in FRACTURES OF UPPER EXTREMITY OF HUMERUS. 277 fixing the arm and scapula by an axillary pad and bandage, and in sup- porting 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 Vel- peau 's, the application of which can be seen from the accompanying illustration. Fracture of the Coracoid Process, a rare injury of which R. W. Johnson has collected 27 cases, is usually the result of direct violence. There is seldom any displace- ment, and no treatment is re- quired beyond the use of a sling, with perhaps a few turns of a roller around the arm and shoulder. A case of epiphyseal separation of the coracoid is recorded by Ben- nett. Two or more of the various forms of scapular fracture may coexist in the same case, or any one of them may be com- plicated by fracture or disloca- tion of the humerus or clavi- cle; for the treatment of such injuries no general 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, however, 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 Neck of the bone, being chiefly intra-capsular, and ma}r or may not be impacted, ac- cording to circumstances. If the fracture be entirely intra-capsular, bony union cannot well occur, and the detached head of the humerus is apt to become carious or necrosed, requiring an operation for its 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. Fig. 136.—Velpeau's bandage. 278 SPECIAL FRACTURES. (2) Fracture through the Tubercles of the humerus differs from the preceding variety merely in being completely extra-cap>sular. 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 impacted, there may be slight shortening. The signs of this injury are very obscure, and in many cases the diagnosis cannot be positively made during life. (3) Longitudinal Fracture of the Head and Neck, or Splitting off of the Greater Tubercle, produces a marked increase in the antero-posterior diameter of the upper end of the humerus, and, while there is some 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 unim- paired. 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 the line of 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 Fig. 137.—Separation of upper epiphysis of humerus. Fig. 138.—Fracture of the surgical (From a patient in the Episcopal Hospital.) neck of the humerus. (Gray.) epiphysis (Fig. 137) is an accident of early life, but true fracture, though 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 FRACTURE OF SHAFT OF HUMERUS. 279 Fig. 139.—Dressing for fracture of the surgical neck of the humerus (Fergusson.) is characteristic, and which consists in the upper end of the lower frag- ment being drawn upwards, inwards, and forwards, while the upper frag- ment is rotated outwards. Reduction is often difficult and sometimes im- possible 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- ture. The arm is to be securely fastened to the chest with circular turns of a roller, or adhesive strips, and the forearm secured across the chest, somewhat as in the " Velpeau position," or merely supported by a sling, as may be found most convenient. After a few days, when swelling has subsided, a moulded pasteboard or gutta-percha cap may be applied to the shoulder and upper half of the humerus, and will give additional security and firmness to the dressing. This simple mode of treatment, which is very similar to that recommended by Fergusson (Fig 139), 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 also be used in the treatment of the"se injuries. 2. Fracture of the Shaft of the Humerus is an accident of fre- quent occurrence, and may result from either direct or indirect violence. The seat of the fracture is more often below than above the middle of the bone, and its line usually somewhat oblique, from above downwards and outwards. The displacement consists in the drawing upward 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. 280 SPECIAL FRACTURES. 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 pressed 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 in- cluded separation of the lower epiphysis of the humerus. This form of fracture usually results from indirect violence ex- erted upon the extremity of the elbow, and its line is generally oblique, upwards and backwards. This in- jury is frequently confused with dislocation of the elbow backwards, but the diagnosis can be made by observing that in fracture there is increased mobility, change in the relative posi- the deformity, while easily Fig. 140.—Fracture at the hase of the condyles. (Gray.) crepitus, shortening of the humerus, but no tion of the olecranon and condyles, and that reduced, instantly recurs on the removal of extension. In dislocation, on the other band, 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 usually be made by the detection of mobility and crepitus, elicited by grasping the arm firmly with one hand, and moving either condyle successively in various directions, or by pressing and rubbing the condyles together. There is commonly not much displacement, except in case of fracture of the inner epicondyle, when the separated fragment is often displaced down- wards in the direction of the hand. These injuries generally result from direct violence, and after recovery the elbow is often left stiff, if not abso- lutely anchylosed. Fig. 141—Fracture at the hase of and between the condyles. (Erichsen.) FRACTURE OF THE OLECRANON. 281 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. 142), the forearm being in a semi-prone position with the thumb pointing upwards, or by means of an anterior angular splint (Fig. 143), the forearm being supine. The Fig. 142.—Physick's elbow splints. Fig. 143.—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 ex- posed. Several forms of apparatus have been devised for the treatment of these injuries, among the most ingenious of which may be especially men- tioned the splints of Sir A. Cooper, Hamilton, Bond, Welch, and Mayo. I am not aware, however, that they present any advantages over the simple form of dressing above recommended ; whatever plan may be adopted, great care must be taken to avoid undue or uneven pressure, which might produce excoriation or even gangrene. Great difficulty is sometimes ex- perienced 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 mentioned, if the elbow-joint be involved in the fracture, there will always be great risk of anchylosis; hence, it may be proper to resort to passive motion at a comparatively early period in these cases, as soon sometimes as the end of the third or fourth week ; or the patient may be directed to swing a flat-iron, as recommended in the last chapter. Compound frac- ture 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 the latter case, the mechanism of the injury probably consists in the olecranon process \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. Stimson advises permanent extension by means of a weight for the supra-condyloid fracture. 282 SPECIAL FRACTURES. being broken as an overbent lever across the condyles of the humerus, which act as a fulcrum. The symptoms of the accident are sufficiently ob- vious. 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, how- ever (at least according to my own experience), there is little or no sepa- ration, and the diagnosis must then be made by noting the existence of abnormal mobility and of crepitus. Crepitus can commonly be elicited simply by seizing the olecranon and rubbing it laterally against the ex- tremity of the shaft of the ulna, or, if there be any displacement, by grasping the forearm just below the elbow, so that the forefinger rests upon the point of the olecranon, which it draws down in contact with the shaft, when crepitus may be brought out by flexing and extending the forearm with the other hand. Union occasionally takes place by bony deposit, but is more often ligamentous merely. The utility of the arm may, however, be preserved even with considerable retraction of the upper fragment. The treatment consists in fixing the olecranon in apposition with the shaft (which may be conveniently effected by means of a compress and adhesive strips), and keeping the joint at rest in an extended position for four or five weeks, or until union has occurred. Surgeons are divided as to the comparative advantages of complete and of partial extension, many agreeing with Sir Astlev Cooper and Prof. Hamilton in recommending the former, while the majority of French surgeons, Mr. Erichsen, and others prefer the latter. I am myself in the habit of using a simple obtu>e- 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 irksome to the patient, and is at least as effective in obviating deformity as that of complete extension, which sometimes causes an angular depression at the seat of fracture. In cases of compound fracture of the olecranon, or of any compound fracture about the elbow-joint, in which an attempt is made to preserve the limb, the arm should be flexed to an angle of from 100° to 120°, which will be found the most useful position should anchylosis ensue. Wiring the frag- ments of the broken olecranon has been practised by MacCormac, Jessop, Caselli, and other surgeons. Fracture of the Goronoid 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 ca>es in which this lesion has been diagnosticated during life (and in uone of them does the diagnosis seem to have been confirmed by dissection), while only three of nine specimens described by authors appear to give i-atisfao tory evidence as to the existence of fracture. Hence, though the possibility of the accident must be admitted, it mu>t 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__Hotn bones of the forearm are fre- quently broken through their shafts, either by direct, or more frequently by indirect, violence, while by direct violence either the radius or the ulna may be fractured separately. If only one bone be broken, the other acts a> a splint, and prevents the occurrence of much displacement, in spite of the obliquity of the fracture; but if both bones have given way, there is FRACTURE OF LOWER EXTREMITY OF RADIUS. 233 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 pro- nator 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 readh 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 rarely met with except when complicated with other lesions. The diagnostic signs are slight an- terior displacement, with localized pain, mobility, and crepitus. The treat- 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, Goy- rand, Voilleinier, Xelaton, Barton, Gordon, Moore, and Pilcher. There are two varieties of this form of fracture, which are known generally in this country as Colles's and Barton's fractures. Colles's fracture, which is far the more common, is a transverse or slightly oblique fracture, situ- ated at from a quarter of an inch to an inch and a half above the articular extremity of the radius. Barton's fracture is a very oblique fracture, extending from the articulation upwards and backwards, separating and displacing the whole or a portion of the posterior margin of the articu- lating 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-breaking 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 281 SPECIAL FRACTURES. fracture of the styloid process of the ulna, this symptom may not be present. In some cases, according to Moore, the styloid process is dis- located 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. 144). The diagnosis of this Fig. 144.—Fracture of the radius near its lower end. (Liston.) 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, when crepitus will be absent, and reduction very difficult, if not Fig. 145.—Bond's splint. impossible. The treatment consists in effecting reduction by means of extension and manipulation, and in fixing the limb by the use of splints and compresses. Two compresses are required, one over the dorsal projection (lower fragment), and one over the palmar prominence (upper fragment). Two 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. 145) may be used, or one of the ingenious modifi- cations of Drs. Havs, Hamil- ton, 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 Fig. 146.—Gordon's splints for fracture of the lower end of the radius. 16�098 FRACTURES OF THE LOWER EXTREMITY. 285 Fig. 147.—Coover's splints. for use by placing it in a layer of cotton-wadding or folded lint, and ad- justing upon this the palmar compress in such a position that, when the splint is applied, it will press accurately upon the lower end of the upper fragment. The splint is laid on the fractured limb so that the hand folds lightly over the block (which should fit the hollow of the palm), and the dorsal compress is then adjusted to the lower fragment so as to maintain the reduction which has hitherto been kept up by the surgeon's hands. The dressing is completed by the application of a roller bandage, firmly, but not tightly, for fear of gangrene. Another efficient, but, as it seems to me, unnecessarily complicated apparatus, is that emploved by Gordon, of Belfast, which, like the splints devised by Carr, Coover, and Levis, employs a curved instead of a plane surface for the support of the broken bone. The semi-prone position is that usually recommended for the treatment of this injury, but I myself prefer the position of supina- tion, which I have already advised for fractures of both bones of the fore- arm. 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 metacarpus should be treated on a broad palmar splint, which is so padded as to fill up the hol- low of the hand and afford firm support to the injured member; fractures of the phalanges commonly re- quire, in addition, a small pasteboard splint, applied immediately to the injured finger. The use of apparatus may be dispensed with after two or three weeks. In the treatment of all fractures of the upper extremity the limb should (unless fastened to the chest) be supported in a sling, w"hich may, within reasonable limits, be lengthened or shortened according to the patient's preference or fancy. Fig. 148.—Agnew's splint for fracture of metacarpus. Fractures of the Lower Extremity. Femur—Fractures of the thigh-bone may be divided into—1, those of its upper extremity; 2, those of its shaft; and 3, those of its condyles. 1. Fractures of the Upper Extremity of the Femur are usually classified as fractures (1) of the neck within the capsule, (2) of the neck without the capsule, (3) of the neck partly intra- and partly extra- 286 SPECIAL FRACTURES. capsular, (4) through the trochanter major and base of the neck, and (5) of the epiphysis of the trochanter major. The terras intra-capsular 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 fracture. The old classification, however, is at least unobjectionable, and may properly be retained, as being more familiar than any other. 1. Intra-capsular Fracture, of the Neck of the Thigh-bone is an acci- dent of frequent occurrence, being met with principally in those of ad- vanced life, and in women oftener than in men. It is predisposed to by the ordinary senile change in the structure and shape of the cervix femoris, 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 apparently trivial nature, such as slipping from a curbstone, tripping over a loose piece of carpet, or even turning in bed. The symptoms are alteration in the shape of the hip, pain, crepitus, inability to stand or 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. A His has observed that, in the erect posture, the fascia lata is relaxed upon the injured side; and flac- cidity of the tensor vagina? femoris and gluteus medius muscles is re- garded 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 anaesthesia necessary as an aid to diagnosis. Crepitus may sometimes be detected by simply rotating the limb, but is usually not elicted 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 after the accident before falling, probably from the fracture being at first incomplete or partially im- pacted. The attitude of the limb, as shown in the accompanying illustration (Fig. 149), is often char- acteristic, and sometimes almost diagnostic. The shortening, in these cases (as ascertained by measuring both limbs from the anterior iliac spines to the tips of the inner malleoli), is commonly not very marked at first—probably not exceeding" half an inch or an inch ; it subsequently, and often sud- denly, increases by the giving away of ligamentous attachments, by rupture or stretching of the capsule, or by unlocking of fragments, and not unfrequently amounts, under these circumstances, to two inches the neck of the femur. or efen more. (Fergusson.) To determine whether or not the shortening is, in 1 This is denied by Prof. Humphry. FRACTURES OF UPPER EXTREMITY OF FEMUR. 287 any particular case, in the cervix femoris, Mr. Bryant measures the dis- tance 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. "Kelaton'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 shorten- ing, passes below it. Dr. Cleemann has pointed out that from the short- ening of the limb, in these cases, a fold or wrinkle is formed over the ligamentum patellae, 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 re- cumbent 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 Erichsen to paralysis of the external rotator muscles from concomitant injury. Pirrie reports a case in which inversion was accomplished by abduction and great flexion, the deformity thus closely resembling that of dislocation downwards and backwards. (See Chapter XIV.) 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 ob- served by W. J. Conklin. The diagnosis between intra-capsular and extra-capsular fracture will be considered when we come to speak of the latter form of injury. The prognosis of unimpacted intra-capsular fracture must always be guarded. Bony union very rarely takes place in these cases, chiefly on account of the deficient vascular supply to the pelvic fragment, and" the difficulty, often amounting to impossibility, of keeping the fragments in apposition. Many surgeons, indeed, have doubted whether bony 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 impacted intra-capsular fracture, however, bony union may un- H doubtedly 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 inflamma- tion 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-capsular variety. It is, like the latter, usually, though less exclusively, met with in advanced life,' 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 According to Gordon, extra-capaular is more common in extreme old age than intra- capsular fracture. 288 SPECIAL FRACTURES. 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 symptoms are much the same as those of the intra-capsular form of injury, the chief differences being that the trochanter moves in an arc of still shorter radius, that the pain is acuter and more superficial, and that the crepitus is more distinct, the fragments being sometimes felt loose under the skin; the shortening (unless in cases of 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 differential diagnosis between intra-capsular 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 history of the case and the previous condition of the patient. The prognosis of extra-capsular fracture, unless the patient die from shock or general constitutional disturbance, or from some concomitant in- jury, 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-capsular. 4. Fracture through the Trochanter Major and Base of the Neck.—The line of fracture in this injury, which is sufficiently described by its name, separates the femur into two segments, the upper of which 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 ex- tremely 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, any but slight extension is (for reasons already indicated) undesirable, and such cases may be treated by position alone, the joint being fixed by means of the long splint, in any of its varieties, or simply supported by means of heavy sand-bags placed on either side of the injured member, the extension FRACTURES OF UPPER EXTREMITY OF FEMUR. 289 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 cumbrous contrivances of Gross, Hartshorne, or Horner. The simplest mode of treatment, however, and that which I much prefer, is the old- fashioned weight-extension, first popularized in this country by Gurdon Buck, with the addition of sand-bags to either side of the limb. Weight- extension is thus applied: A strip of adhesive plaster (cut lengthwise and well stretched) is prepared, 2^ to 3 inches wide, and 3^ to 4 feet long. On the middle of this is placed a block of wood, of the same width as the adhesive strip, but four inches long and half an inch thick; over this, again, is placed another adhesive strip of the same width, and 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 extension is to be practised, so that it adheres on either side from just below the knee to just above the malleolus, the stirrup remaining as a loop about four inches below the sole of the foot (Fig. 150). The apparatus is fixed by two Fig. 150.—Adhesive-plaster stirrup for making extension in cases of fracture of the lower extremity, etc. or three broad strips passed circularly around the limb, which is finally surrounded with an ordinary spiral bandage. The malleoli should be pro- tected 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 extending weight, which, for fractures of the neck of the femur, need not usually ex- ceed 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-capsular fracture in old persons, in which, no apparatus 290 SPECIAL FRACTURES. 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. Senn advises a plaster-of- Paris dressing with screw-pressure over the trochanter to keep the sepa- rated fragments in apposition. CoUes, of Dublin, employs a modification of Sayre's apparatus for hip-disease. 2. Fracture of the Shaft of the Femur.—This injury may be met with at any age, and in any part of the bone ; it is most frequent, however, in the middle third. The accident commonly results from direct violence, and the direction of the fracture is almost invariably oblique. The fracture is marked by mobility, shortening, eversion, and crepitus, which are so manifest that the nature of the injury can scarcely be mis- taken. Effusion into the knee-joint, coming on some time after the injury, is due, as pointed out by Gosselin, to a subacute synovitis caused by blood leaking down from the seat of fracture to the outside of the synovial membrane. 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 con- sideration of which question I would respectfully refer the reader to Prof. Hamilton's excellent 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 satisfactory result in adults.1 It is to be observed, how- ever, 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 frac- tures 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 con- sideration in the management of these injuries. (Fig. 151.) 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 seen an anterior angular pro- jection, 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 sev- eral specimens described by Mr. Butcher. Whatever 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 1 The question of shortening in fractured thigh has lost much of its significance since Drs. Cox and Roberts and Dr. Wight have ascertained by measurement that an ine- quality in the length of the lower limbs is often congenital. FRACTURE OF THE SHAFT OF THE FEMUR. 291 continued as before, or, instead of the pasteboards, the plaster-of-Paris bandage may be substituted. This is the mode of treatment which I am Fig. 151.—Weight-extension with long splints for treatment of fractured thigh ; counter-extension made by raising foot of bed. in the habit of employing in cases of fractured thigh, and I have found it to be as efficient as it is simple. Excellent cures may, however, doubtless Fig. 152.—N. R. Smith's anterior splint, applied to a fracture of the thigh. be obtained by the use of other means, such as the various forms of appa- ratus already mentioned (page 289), or the "suspension splints" of N. R. Smith, of Baltimore (Fig. 152), and J. T. Hodgen and G. W. Broome, of I.—Compound fracture of shaft of thigh-bone; treatment b y bracketed long splint. (Erichsen.) |- Louis. Compound Fractures of the Thigh may be conveniently Jated with the weight-extension apparatus, with the bracketed long splint 292 SPECIAL FRACTURES. (Fig. 153), with a simple long fracture-box (particular^ useful when the bran dressing is to be employed), or, in some rare cases, with the old- fashioned double-inclined plane, which was so popular at the end of the last and the beginning of this century.1 3. Fracture of the Condyles of the Femur—Either condyle may be broken off separately, or there may be a splitting fracture 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 suppu- rative disorganization, endangering either the limb or the life of the pa- tient. 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, involv- ing 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 complete 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- verse fracture there is almost always some displacement, which is increased by flexing the knee ;2 while in comminuted or longitudinal fractures the nature of the case is rendered evident by the mobility and crepitus, which, under such circumstances, are very distinct. Inability to walk or stand, which is often spoken of as a sign of fractured patella, is, as remarked by Gouget, more apparent than real, the patient being able, though not will- ing, to walk, on account of the pain which attends the effort. The prog- nosis is favorable; though bony union is rarely obtained, especially in the case of transverse fracture, the utility of the limb is not materially im- 1 I will merely mention, without in any degree commending, the plan proposed by Dr. Hennequin, in an essay which received the Barbier prize, that " in fractures of the thigh the limb should be placed in the 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. 2 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 he 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. FRACTURES OF THE PATELLA. 293 paired, and instances are on record in which patients, after recovery, have engaged in duties requiring great activity and strength of limb, although with a separation of several inches between the fragments of the patella. The treatment consists in placing the limb in a straight po- sition, with the leg somewhat elevated, so as to relax the fibres of the quadriceps femoris muscle.1 The upper fragment of the patella, being drawn downwards, is held in place by means of a firm compress, which is secured by strips of adhesive plaster fastened to a broad posterior splint, provided for the pur- pose with notches or cross-pieces. The whole limb and splint are then surrounded With a roller, which, by figure-of-8 turns FlG-^.-Fracture of patella; frag- ■1.11 ■ jj-T- i ., nients separated by flexing the knee. around the knee, gives additional security and firmness to the part. The limb should be raised, simply by pillows or by an inclined plane, the relaxation of the quadriceps femoris muscle being further assisted, if thought necessary, 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, which is essentially the same as that recommended by Hamil- ton, is quite as efficient as the more complicated plans devised by Lonsdale, Amesbury, Cooper, Burge, Callender, Beach, and others. Malgaigne's hooks, and their various modifications, introduced by Morton, Levis, J. M. White, 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, Eve, and Blackman, 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 ofVolkmann, who, by means of a curved needle, carried a strong silver wire around and beneath the patella, approximating the fragments by tightening the ring thus formed. Twynam adopts a similar procedure, and Kocher and Butcher operate in much the same way, applying silk instead of wire, while Kbnig employs catgut. T. Curtis Smith enfploys anterior splints curved to fit the patella, and held together with elastic bands, and plaster-of-Paris splints are used in the same wav by J D. Bry- ant, Mayo Robson passes pins transversely above and below the frag- ments, tying the pins together with ligatures, and Myles, of Dublin, inserts the pins through the fragments themselves; a similar procedure has also been employed by Roswell Park. Cameron, Lister, and others, reviving an old plan, wire the fragments together (antiseptic-ally), and have thus obtained good results; but subsequent amputation has been required in several cases, and at least twelve have terminated fatally. The annexed table, borrowed from Dr. Cutter, shows the result of 186 cases. An addi- tional fatal case (Dr. Byrd's) raises the number of deaths to 12. Subcu- 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. Beach, on the other hand, believing that the qnadriceps muscle is mainly in iamt, seeks to control its action by circular compression applied with short splints, held in place by straps and buckles. 294 SPECIAL FRACTURES. taneous suture is employed by Aitken, who has devised a special instru- ment for the purpose. Table showing Results of Wiring Fractures of the Patella. a! CS >. tk . ■«' a Cases. "3 «3 o v h S =3 •« 5R J3 s c ao 0.0 .5"S-~ ■2 S o ~ a — I 0 £ B a O »i a * o ^ V £ =8-5 *a H O 48 fa Pi 0 3 < 'Jl H « Recent . . . 81 15 12 2 13 ! 9 6 2 1 Old .... 53 16 19 12 3 1 18 1 8 1 2 Others 52 11 1 35 5 1 4 3 34 1 3 6 3 Aggregates . . 186 75 24 11 17 14 6 Macnamara divides subcutaneously the quadriceps femoris and ligamen- tum patellas. Many authors advise that no dressings should be employed until all swelling has subsided; but this delay exposes the patient to the risk of permanent shortening of the rectus femoris, and I, therefore, think it better to apply the apparatus at once, though, of course, not too tightly, watching it carefully, and being prepared to loosen it should the exigen- cies of the case so require. After recovery, a pasteboard or leather cap should be worn around the joint for some time, until the ligamentous bands which unite the fragments have attained the necessary degree of firmness to resist any ordinary force to which they may be subjected. The duration of treatment, in cases of fractured patella, should be about six weeks, the joint being still longer protected with a suitable cap, as already directed. In any case in which confinement would be inconve- nient, a plaster-of Paris bandage might be used after the first week or two, the patient being then allowed to go about. Compound Fracture of the Patella, involving, as it usually does, the knee-joint, is commonly considered a case for amputation. The elaborate statistics of Mr. Poland show, however, that this extreme measure is in reality seldom called for; thus, of 68 cases treated without operation, 56 recovered and only 12 died (17.65 per cent.), while of 1 in which amputa- tion was performed, 5 recovered and 2 died (28.57 per cent.), and of 10 treated by excision, only 4 recovered and 6 died (60 per cent.). Of the whole 85 cases, therefore, 65 recovered and 20 died. Suppuration of the joint occurred in 43 of those cases which terminated favorably, and in all of those which proved fatal. 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), 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- FRACTURES OF THE BONES OF THE LEG. 295 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 Stimson, Heuston, and Manby, and the fifth occur- red in my own practice, in a boy eleven years old, who was caught between Figs. 155 and 156.—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 was so great as to require amputation, and the nature of the accident was thus ascer- tained.by dissectiom (Figs. 155, 156.) Dr. Voss 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. 157), 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 down, 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 foot at a right angle with the leg, to prevent eversion of the knee by frequent adjustment,1 to prevent excoria- tion 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 l 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 ate all in the same vertical plane. Fig. 157.—Fracture-box with movable sides. 296 SPECIAL FRACTURES. 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 in- genuity 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 fracture1 may he best treated in the flexed position, and a very good apparatus for this pur- pose is the anterior splint of the late Prof. N. R. Smith (Fig. 152). 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. 158), or the "anterior splint" may be conveniently employed. Fig. 158.—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- 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 1 For the treatment of these oblique fractures, Malgaigne recommends an apparatus provided with a sharp screw to hold the fragments in place; while Laugier, and more recently Mr. Bloxam, recommend division of the tendo Achillis. I have no personal experience with either of these modes of treatment, which, however, I cannot but think unnecessarily severe. FRACTURES OF THE BONES OF THE FOOT. 297 a sheet of oil-cloth, or India-rubber cloth, and on this a layer of fine and clean bran about two inches deep ; the fracture being reduced, the limb is laid in the box, with a pad of cotton beneath the tendo Achillis and around either malleolus, and a layer of the same material around the limb just below the knee ; the sides of the box are then brought up and secured, and more bran is dusted and packed around and over the leg till the box is filled, the fractured limb being thus 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 soiled 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 254). 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 (Pott's fracture), the tibio- fibular ligaments and the internal lateral ligament being ruptured, or the tip of the inner malleolus being torn off as well; or either malleolus may be longitudinally splintered into the ankle-joint (an accident commonly followed by anchylosis); or, finally, the inner malleolus alone may be broken, the fibula es- caping. Any of these forms of injury may be safely and conveniently treated with the fracture- box, the deformity being obviated by frequent and careful adjustment and the judicious use of compresses. In the case of Pott's fracture, one FlG compress should be placed on the inner side ture of the leg. above the inner malleolus, and another on the outer side, below the outer malleolus, so as to press the foot inwards. I 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. 159. In cases of fractured leg occurring in very young children, or in adults suffering from mania a potu, when no restraint can be borne, it is a good plan to surround the broken limb with a soft pillow, which is held in place by means of firm bandages ; the part can then be tossed about without risk of further injury. Fractures of the Bones of the Foot.—The only tarsal bones, the fractures of which require special notice, are the calcaneum and the astragalus. 298 SPECIAL FRACTURES. The Calcaneum may be broken by direct violence, or by muscular action ; the line of fracture may assume any direction, and, when the in- jury results from direct violence, the fracture may be comminuted or im- pacted. If the tuberosity of the bone only be separated, the fragment may be drawn upwards for a considerable distance by the action of the gastro- cnemius 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, which I prefer, the apparatus already recommended for rupture of the tendo Achillis (page 233). 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 1 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 gypsum bandage. If reduction were impracticable, in a case of simple fracture, I should be dis- posed to temporize, reserving excision (which is usually recommended under such circumstances) as a secondary operation, to be employed should sloughing or necrosis ensue; in Dr. Norris's case, the displaced fragment was excised by 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, which 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, amputation will often be required as a primary operation. Fractures of the Metatarsal Bones or Toes are usually pro- duced by direct violence, and, if attended with much laceration, commonly require amputation. In cases of simple fracture, it will be sufficient, after effecting reduction, to apply a plantar splint and to place the limb in a fracture-box, the dressing being changed, after a time, for pasteboard splints or a plaster-of-Paris bandage. CAUSES OF DISLOCATION. 299 CHAPTER XIV. 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; while 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 " amphiarlhrosis" 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 sacro-iliac symphysis. Dislocations are further classified as complete or partial; as simple, compound or complicated; as recent or old ; and as primitive or con- secutive. 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 terms 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 dislo- cation is one in which time has not been afforded for the production of in- flammatory changes in the articulating surfaces and surrounding tissues, or at least not to such a degree as seriously to impede reduction ; an old dislocation being, of course, one in which sufficient time has elapsed to permit such changes to occur. A primitive luxation is one in which the displaced bone remains in the position into which it was first thrown by the luxating force. A consecutive dislocation is one in which the dis- placed bone has secondarily changed its position, either under a con- tinuance of the influence of the luxating force, or as the result of subse- quent muscular contraction, 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 300 DISLOCATIONS. being usually met with in those in active adult life, and much more fre- qu'ently in men than in women. More important predisposing causes are the anatomical relations of the joint, and the condition of the neighboring muscles and ligaments; thus the ball-and-socket joints are more liable to luxation than the ginglymoid, 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. Cases. Jaw . 7 Elbow . . 45 Femur . . 4d Vertebrae . 4 Radius . . 7 Patella . •» Pelvis . 1 Wrist . . 16 Knee . 9 Clavicle . 42 Thumb . . 20 Ankle . 31 Humerus . 370 Fingers . . 7 Metatarsus . 2 Atrophy and p>aralysis 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 producing dislocation by a voluntary effort, and I have myself seen such a case in the person of an epileptic woman, who was in the habit of dis- locating 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 dislocated 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 ex- tensively lacerated, there may be a positive increase instead of diminution of mobility. From a fracture in the neighborhood of a joint, a disloca- tion 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 crack- ling sound, due to effusion or inflammatory changes in the articular struc- tures, or simply to dryness of the joint from rupture of the capsular liga- ment and escape 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 disjdacement does not always recur in cases of fracture, it may recur in a case of dislocation, if there be much laceration of the ligament- ous tissues, or if the articular surfaces themselves have undergone struc- tural changes from inflammatory action ; thus in old luxations of the hip it is often easier to effect than to maintain reduction. Hence, no one of these symptoms can be considered as in itself pathognomonic, and it is found in practice that the most experienced surgeons are occasionally liable to err in the diagnosis between luxation and articular fracture. PROGNOSIS AND TREATMENT OF DISLOCATIONS. 301 Dislocation, like fracture, is commonly accompanied by pain, swelling, and eechymosis; wide-spread extravasation may occur from rupture of vessels, and paralysis (temporary or permanent), or neuralgia, from com- pression or laceration of neighboring nerves. 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. Tn 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 hones 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 new positions, the utility of a limb after dislocation being often much greater than would be thought probable in view of its evident deformity ; so that it is some- times a question, in cases of old dislocation, whether reduction would be desirable, even if 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- sible. Hence, if the nature of the case be not perfectly clear, the surgeon should not hesitate to employ anaesthesia as an aid to diagnosis, more par- 302 DISLOCATIONS. ticularly as the use of the anaesthetic will greatly facilitate reduction, should the existence of a dislocation be determined. The principal obstacles to reduction, in any case of luxation, are mus- cular resistance and the anatomical relations of the joint. There are three distinct elements to be considered in estimating the influence of the muscles in hindering reduction ; these are (1) the passive force which the muscles possess in common with the other soft structures of the body, and which is brought out by the stretching of their tissues across the displaced bony prominences; (2) the active force, whereby the patient voluntarily though unconsciously resists the surgeon's efforts at reduction; and (3) a state of reflex, tonic contraction into which the muscles are thrown as the result of the traumatic irritation produced by the injury itself; this, which is the most important form in which muscular 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 which accompanies the accident, is so great that the displacement can be reduced with the greatest facility, and, indeed, is often so reduced by the bystanders or by the patient himself. The knowledge of this fact led 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- COMPOUND DISLOCATION. 303 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. 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 assis- tant, 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. 160), or by still more pow- erful means, such as the compound pulley (Fig. 182), Fahne- stock's and Gilbert's rope windlass (Fig. 180), Bloxam's tourniquet (Fig. 181), or Jarvis's adjuster. Continuous Elastic Extension, by means of India-rubber bands, has been utilized by H. G. Davis in the treatment of old dis- locations, and by this means Dr. Davis claims to have re- duced 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 loath 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 304 DISLOCATIONS. 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. Complicated Luxations—The complication of dislocation with fracture has already been considered in Chapter XII. 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, Let'eVant, Cras, and Rushton Parker, would be indicated, and in the latter (as a general rule) amputation. The consequence of non-interference would be the formation of a diffused traumatic aneurism, which would prove fatal either by hemorrhage, or by the supervention of gangrene. Extensive ex- travasation 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 wThich 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 GueYin. Hence, while greater force is required in the treatment of these cases than in that of recent luxations, the employment of such force is always attended with considerable risk. Even manipu- lation without extension is not free from danger, for the displaced bone may, in its new position, have acquired adhesions to the main artery or vein, rupture of which, in the action of reduction, wTould 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. Nathan Smith reduced a luxation of the shoulder nearly a year after the accident, and luxations of the hip have been reduced by'Blackman, and by Smyth, of New Orleans, at periods respectively of six and nine months after the reception of the injury. Even if the attempt at reduction fail, the surgeon's manipulations, if practised with caution and gentleness, may be of service in increasing the mobility of the limb, and thus adding to its usefulness in its abnormal position. Hence, in the case of dislocation, even of several months' stand- ing, 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 manipulation and moderate extension then employed, so as to stretch or slowly sever any morbid ad- hesions, and allow the displaced bone to be gradually brought into its OLD DISLOCATIONS. 305 proper position; or the elastic extension recommended by Dr. Davis might be resorted to, and would certainly be worthy of a trial in the event of other means failing. Subcutaneous Division of Muscles, Tendons, and Ligaments was pro- posed by Dieffenbach as a 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 Mears^andlviorton in cases of irreducible dislocation of the shoulder. Volkmann, Mac- Cormac, and Penrose have successfully excised the head of the femur in long-standing cases of hip-dislocation, and partial excision in old disloca- tions of the elbow has been successfully employed by several surgeons, including Stimson, Mayo Robson. and mvself. 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 formation of a traumatic aneurism, is a very grave accident when occurring under these circumstances; it has been chiefly met with in the case of the • 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, ac- cording 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! Ligation 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 four deaths. In a case of supposed dislocation, which afterwards proved to have been a fracture, Blackman tied the axillary artery in its upper portion, 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. Amputation at the shoulder-joint succeeded in the hands of Jung- ken, but proved fatal in cases recorded by Bell, Bellamy, and Le Dentil, 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 m 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 lux- ation the same operation or disarticulation. Avulsion of the, limb, as occurred in GiieYin's case, would, of course, require immediate amputation. Embolism, followed by gangrene of the forearm, is a rare complication, rJ,J-!e 14th CaSe occnrred in the practice of Mr. Holmes. The patient refused to peimit any operation. 20 306 DISLOCATIONS. 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 notasmuch difficulty in effecting, as in maintaining reduction. GueVin, Brodhurst, Barwell, and others have successfully employed subcutaneous ten- otomy and myotomy, followed by con- tinued extension, in the treatment of con- genital 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 opera- tion. Esmarch succeeded by extension alone, and Buckminster Brown, in a very aggravated case, by extension, pressure, and fixation combined. Hoffa divides the shortened tissues attached to the trochan- ter, and deepens the acetabulum with a chisel, and his plan has been followed by Denuce\ Broca, and other surgeons. Rose, Reyher, Heusner, and Margary have suc- cessfully treated cases of congenital hip- luxation by excision, as have Rawdon and Adams those of the pathological variety. Schiissler removed a wedge-shaped piece from the neck of the femur, and Ewens treated successfully a case of spontaneous hip-dislocation following scarlet fever by subcutaneous osteotomy. In cases de- pendent on muscular paralysis, the diffi- culty would be in maintaining reduction, and here exterual support (in the form of carved or moulded splints, elastic band- ages, or some of the ingenious devices which are used in the treatment of deformities) might be usefully employed. Lannelongue injects a 10 per cent, solution of chloride of zinc above the position of the acetabulum, with the hope of causing a new formation of bone which may retain the caput femoris in place. Congenital dislocation of both hips is well shown in Fig. 161. Special Dislocations. Dislocation of the Lower Jaw is a rare accident, occurring chiefly in early adult age, and rather oftener in women than in men. It is usually double or bilateral, though occasionally one side only is displaced. The most common cause of dislocated jaw is muscular action, though it may also result from a blow on the chin while the mouth is open, or from other forms of violence, such as the forcible introduction of a foreign body into the mouth, or the extraction of teeth. When the mouth is opened, the maxillary condyles ride forwards upon the articular eminences of the tem- poral bones, and a very slight degree of force is then necessary to make them slip still further forwards into the zygomatic fossae, thus producing dislocation. The contraction of the external pterygoid muscles, and per- haps of some fibres of the masseters, is sufficient to produce luxation when the mouth is widely opened, the tonic contraction of the same Fig. 161.—Congenital dislocation of both hips. (From apatientin the Children's Hospital.) DISLOCATION OF THE LOWER JAW. 307 muscles, combined with the position of the coronoid processes (which catch against the malar bones), being the principal obstacles to reduction. J. W. Hamilton describes a spontaneous, backward dislocation of the lower jaw. 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 symptom 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 to close 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. 163, 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 disengaging the coronoid pro- cesses from the malar bones, and the condyles from the zygomatic fossae, by pressing the chin upwards, while a fulcrum is placed upon or behind the molar teeth. The surgeon, standing behind the patient, whose head is supported on the ope- rator's chest, may use his thumbs (protected by a piece of leather or folded towel) as a fulcrum, pressing the angles of the jaw downwards, while he elevates the chin with his fingers ; or pieces of cork or wood may be used as a fulcrum, in which case they should be provided with strings to facilitate their withdrawal. 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 re- produce the luxation of the first. Anaesthesia is I^S^ r6(lUired1 in theSe CaSeS> th0U£h there patient under care of Dr. W. K w ouid be no particular objection to its employ- whitehead.) Double dislocation of the inferior maxilla. Fig. 163.—Unreduced disloca- tion of the lower jaw. (From a 308 DISLOCATIONS. ment if it were thought desirable. After reduction, the part should be supported for at least a week or ten days, by means of a four-tailed sling or other suitable bandage. Subluxation of the Jaw.—Under this name, Sir Astley Cooper has described a peculiar condition, met with chiefly in those of relaxed and feeble muscular frame, which is supposed to depend on the condvles slipping in front of the inter-articular cartilages, and thus rendering the jaw temporarily immovable. Annandale believes that the lesion is really a displacement of the inter-articular cartilage itself. Whatever be the true nature of this affection, it is undoubtedly accompanied by relaxation of the articular ligaments, which allow the condyles to slip about during the act of chewing, thus often producing a clacking sound, which is sometimes audible at a distance. The subluxation, if such it be, may be bilateral or unilateral only ; it is sometimes produced by the act of opening the mouth widely, as in gaping or laughing, but, in other cases, occurs without any apparent exciting cause; it may usually be reduced by the patient himself, by pressing the jaw sideways, or by lifting the chin slightly upwards. 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 patient appears to indicate their use, and the recurrence of the displacement may be prevented by wearing a sling, 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 and Dr. Gibb; the treatment consists in throwing back the head, depressing the lower jaw, and pushing the luxated bone into position. Ribs, Sternum, and Pelvis.—Dislocations of the Ribs are described as occurring either at their vertebral articulations, or at the junction of their costal cartilages. The symptoms would be much the same as those of fracture in the same localities, except that, of course, crepitus would be wanting. The treatment would be the same as for fractures. Dislocations, or rather diastases of the Sternum and Pelvis, were referred to in connec- tion with fractures of those parts. Salleron has reported three cases of dislocation of the ilium at the sacro-iliac 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 Hamilton, about four times as often as the latter. Dislocation of the Sternal End of the Clavicle, usually results from indirect violence, and is almost always in a forward direction. Disloca- tion backwards, however, occasionally oc- curs, and sometimes gives rise to trouble- some 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 himself, to which, how- Fig. 164-Dislocation of sternal end of ever. ma.v be adde1, Lucas, 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 hy Erichsen. Dislocations of the Shoulder.—The head of the humerus may be uisiocated downwards, forwards or backwards. Fig. 165.—Dislocation of the clavicle on the acromion. (Bryant.) 310 DISLOCATIONS. Dislocation Downwards, or into the axilla (Subglenoid Dislocation), is usually due to direct violence, such as a blow on the upper and outer part of 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, coraco-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 when the elbow is lifted away from the body. The arm is kept somewhat abducted, and pain is developed by press- ing 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 surgeon should hesitate before criticising another practitioner for a mistake which may have been unavoidable under different circumstances. Dugas 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 at- tempt 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 estab- lished, no other injury of the shoulder being capable of causing this dis- ability. The prognosis should be somewhat guarded ; although reduc- tion is usually effected without difficulty, yet the arm not unfrequently remains permanently weakened, partially anchylosed, or paralysed 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 Fig. 166.—Dislocation of the humerus downwards, iDto the axilla • subglenoid. (Pirrie.) DISLOCATIONS OF THE SHOULDER. 311 anteriorly, probably on account of displacement or rupture of the lono- head of the biceps muscle. The laceration and stretching of the capsular lio-a- 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, Nicolaysen, AJberti, and Linden, 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. 167) and the Subclavicular: the latter may be considered as an ag- gravated condition of the former, which was, indeed, de- scribed by Sir Ast- ley Cooper as a par- tial luxation. As the names imply, the head of the hu- merus, in these in- juries, rests beneath the coracoid process, or beneath the mid- dle of the clavicle. These luxations, which more often result 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 downward luxation, except that the axis of the arm is even more altered, and that the head of the bone can be felt in a different position. The subcoracoid is more often met with than the subclavicular dislocation, and is said by Mr. Flower and others to be the most common form of luxation of the shoulder-joint. Reduction appears to be more difficult in cases of forward than of down- ward 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 forwards, 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 forwards, and over which the skin is tightly stretched. Reduction has usually been effected without much difficulty in these cases, nut in one instance, mentioned by Cooper, it was impossible to maintain the reduction, on account of rupture of the subscapularis muscle. I have Fig. 167.—Subcoracoid luxation of the humerus. (Pirrie.) 312 DISLOCATIONS. seen but one example of this rare form of injury, and in that, in spite of the marked deformity, the nature of the case had not been suspected for six weeks after the occurrence of the dislocation. I succeeded in effecting 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 bodv, 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 Clark 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 coracoid process; while in the subspinous dislocation, extension should be made downwards, outwards, and subsequently forwards. A great many 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 ; 3, by a combination of these methods ; and, 4, by manipulation, in its technical sense (see page 303). 1. Extension may be made (1) more or less downwards, as in Hippo- Fig. 168.—Sir Astley Cooper's method of applying extension with the heel in the axilla. crates's and Cooper's method (Fig. 168), in which counter-extension is made by the heel in the axilla;"2 as in Skey's method, in which the heel id 1 This inward displacement of the biceps tendon, which Soden, J. Wm. White, and others have considered traumatic, is believed by Canton to be due to the existence of chronic: rheumatic arthritis, which mayor may not have been the result of injury. I have myself been in the habit of considering it 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. 313 replaced by an iron knob; as in Hamilton's plan, in which the scapula is fixed by the ball of the foot placed against the acromion process; or as in 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 Fig. 169.—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 Dupuvtren 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 Fergusson and N. R. Smith, 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 his own 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 whom 314 DISLOCATIONS. may be mentioned La Cour and Sir Philip Crampton, but the credit of reducing the plan to a system, and of prominently bringing it to the notice of the profession, in this country at least, is, I believe, due to the late Prof. H. H. Smith, whose method consisted in first converting the luxation (if it be either forwards or backwards) into the ordinary downward or subglenoid variety, and then proceeding as follows: "Elevate 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 subscapularis 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 downward and across the patient's body, and the bone will usually be replaced."1 In cases of old dislocation, Callender recommends, in order to avoid injuring the axillary vessels, to raise the elbow across the chest, and then force the raised arm outwards, rotating and somewhat depressing the arm while so doing. The reduction of shoulder dislocations by manipulation has also been illustrated by Kocher and by Gordon. Kuhn 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 manipulation directly to the former bone. Dwyer has collected 27 cases (including one of his own) of excision of the displaced head of the humerus, for old dis- location, with five deaths. Dr. Mears's successful osteotomy for old luxa- tion 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. In cases of frequently recurring dislocation, Richard advises that the deltoid muscle having been turned backward, the subscap- ularis should be separated from its anterior attachments, and sutures passed through the capsule and muscle in such a way as to tighten and shorten the former. He reports two cases thus treated with good results. 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 swelling, 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 partis 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 pushed into its proper position ; T. Parker recommends flexion of the forearm with firm pronation and direct pressure; the arm should subsequently be fixed on an angular splint, with a compress over the head of the radius. It is always difficult to maintain reduction in these cases, and reduction itself is 1 Packard's Minor Surgery, p. 204. DISLOCATIONS OF THE ELBOW. 315 occasionally impossible; fortunately, the use of the limb does not appear to be materially impaired by the persis- tence 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 angle, and the forearm twisted inwards and pronated. Reduction may be effected by Sir Astley Cooper's method of flexing the elbow over the knee ; by extension and counter-extension, com- bined with direct pressure upon the olecranon ; or (as recently recom- mended by Dr. Waterman) by ex- tending the forearm on the arm beyond a straight line, thus using the ulna as a lever of the second order (the ole- cranon 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 violence, though occasionally by a direct blow, or by muscular action. Fig. 170.—Dislocation of head of radius forwards; external appearance of limb. (Lis- ton.) Not only are the bones displaced backwards, but they are drawn upwards by the powerful action of the Fig. 171.—Dislocation of both bones of the forearm backwards. (Liston.) triceps muscle. The diagnosis, if swelling have not occurred, can usually oe made without difficulty; the arm is held in a slightly flexed position 316 DISLOCATIONS. (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 condyles of the humerus form a hard and broad promi- nence on the front of the arm. The relative position of the olecranon and condyles is markedly altered, this being an important diagnostic mark be- tween dislocation and fracture. Malgaigne, Littre, and Bennett, however, describe an incomplete form of luxation, in which the position of the ole- cranon is not materially changed. Reduction in a recent case is usually easy, though instances are on record in which failure has attended the efforts of the most skilful surgeons ; the prognosis is decidedly unfavorable as regards old dislocations, though reduction has been effected by Hamil- ton, Miner, and others, at as late a period as seven months after the recep- tion 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. 172). Kelly, of Dublin, sits on a table, and, fixing the patient's arm under one thigh, draws the forearm upwards 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-extension against the scapula (as advised by Liston and Miller); or the luxation may be reduced by simple extension (Skey;, or by extension combined with direct pressure on the olecranon, accord- ing to the plan of Pirrie. In a child, or in a person of feeble muscular develop- ment, reduction can usually be effected without the aid of anaesthesia; pro- longed efforts at reduction are, how- ever, so painful, that in any case of difficulty an anaesthetic should be em- ployed. 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, a"s a test for reduction, to flex the elbow to a right angle; if this can be done without much pain, it proves that reduction is complete. 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 condition of the joint. Stimson recommends arthrotomy in old dislo- cations, 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 outward direction.1 t Fig. 172.—Reduction with the knee in the bend of the elbow. 1 Isham has collected 15 oases of complete outward dislocation, recorded in this country, and a 16th has been added by Homaus. DISLOCATIONS AT THE WRIST. 317 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 aitendance 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 Yolker as a means of exposing the joint in cases of irreducible luxation. 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, reduction was effected by simply flexing the forearm, and then pressing it downwards and backwards. If the luxation were incomplete, the forearm making an obtuse angle only with the arm, reduction might be accom- plished by making forcible extension. Dislocations at the Wrist— The Lower End of the Ulna may be dislocated from the radius, either forwards, backwaras, or inwards. These accidents, of which Tillmans 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 pronation. The inward is the rarest form of luxation, Tillmans's figures giving but 9 eases 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 speci- fied. Reduction is easily effected by fixing the radius, and simply pushing the ulna back into place, the limb being then placed between anterior and posterior splints. In connection with 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 con- dition 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, heen found complicated with fracture. The usual cause of either form of dislocation is a fall on the palm, though in a case of backward displacement recorded by Hamilton the injury resulted from a fall on the back of the hand, the wrist 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. Dulividual Bones of the Carpus are occasionally luxated in a backward direction, those bcnes which have been found thus displaced being the os 318 DISLOCATIONS. magnum, semilunare, and pisiform, to which some writers add the cunei- form and unciform. 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. Chisolm reports a case of forward luxation of the semilunare, in which excision of the displaced bone was required. Nancrede has met with a forward subluxation of the scaphoid. Hands___The Metacarpal Bones, especially those of the thumb, index, and middle finger, may be dislocated upon the carpus, the two latter bones backwards, and the metacarpal of the thumb either backwards or forwards. 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. The Fingers may be dislocated at the metacarpo-phalangeal, or, more rarely, at the inter-phalangeal joints. The proximal phalanx of the thumb is not unfrequently dislocated backwards, reduction being sometimes very difficult, owing, probably, to the head of the metacarpal bone being caught Fig. 173.—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 to the interposition of a tendon, or of the external sesa- moid bone. In the treatment of these luxations, extension mav be made with the ordinary clove-hitch, or with Levis's ingenious apparatus, or Fig. 174.—Levis's instrument applied to the first finger. with the " Indian puzzle," as recommended by 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 per- pendicularly 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 resisting liga- ments or muscles may possibly be required. Forward luxation of the DISLOCATIONS OF THE HIP. 319 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 in- ward lateral dislocation of the ungual phalanx of the thumb has been observed by Mr. Pratt. 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. Simultaneous backward luxation of the second and third phalanges of the same finger has been observed by Sayre. Dislocations of the Hip—The subject of dislocation of the hip has been most ably investigated by Prof. Bigelow, of whose excellent mono- culus is known as the ilio-femoral ligament, or Fig. 176.—Backward dislocation of hip; exter- ligament of Bertin. (Bigelow.) nal appearance. anatomy of the joint, and especially of that portion of the capsule which is known as the ilio-femoral ligament, or ligament of Bertin, and for which 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 to the front of the femur, to be inserted fan-shaped into nearly the whole of the oblique | spiral' line which connects the trochanters in front—being about half an inch wide at its upper or iliac origin, and but little less than two inches and a half wide at its fan-like femoral insertion. Here it is bifurcated, having two principal fasciculi, one being inserted into the upper extremity 320 DISLOCATIONS. 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 remain unruptured in the ordinary dis- locations of the hip, and their attachments 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 Iliosciatic Luxation, presents two principal varieties, viz , upwards and backwards, or on the dorsum ilii, and backwards only, the dislocation into the ischiatic notch of Sir Astlev Cooper, or, which is a better name, dorsal below the tendon (of the obtu- rator internus), according to Prof. Bigelow. These two forms of luxa- tion, taken together, probably embrace more than three-fourths of the whole number of cases, Hamilton having found that of 104 cases, 55 were on the dorsum ilii, and 28 into the ischiatic notch. These injuries usually result from indirect violence: thus, the dislocation on the dorsum may be caused by any force which produces great 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 ischiatic form of luxation is much the same, except that it is more apt to occur when the thigh is flexed at a right angle upon the body, the force then driving the head of the bone more directly backwards, than backwards and upwards. The symptoms of these forms of dislocation are usually well marked. There is shortening of the affected limb, varying from about half an inch in the dislocation below the tendon, to one, two, or even three inches in that on the dorsum ilii. In the first-named variety, the shortening is, as pointed out by Allis, much more apparent 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 beinjr unduly prominent, and thrown forwards, while the head of the femur can often be felt rotating in its abnormal position. The axis of the limb is distorted, the thigh of the affected side crossing the other at its lower third in the dorsal dislocation, and just above the knee in the ischiatic variety ;'- 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. It the limb can be readily everted, the case is not one of luxa- tion. From ordinary non-impacted fracture, a dislocation can be dis- 1 Fabbri, 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. * According to Bigelow, m the ischiaiic variety (dorsal below the tendon) the axis of the luxated limb is more changed than in the ordinary dorsal variety, crossing tlie sound limb sometimes at a point as high as the middle of the thigh. The fact appears to be that the distortion varies according to the position of the head of the bone at the moment of examination, these varieties of dislocation being readily interchange- able, and the exact position of the bone differing in different cases. DISLOCATIONS OF THE HIP. 321 tinguished 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 trochanter is unduly prominent, and the head of' the bone can be felt beneath the gluteal muscles. A convenient mode of measure- ment, 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 287. 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 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 Fig. 177.-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. (BlOELOW.) method of treatment consists in flexing the thigh upon the pelvis, so as to relax the iho-femoral or Y ligament. The acknowledged difficulty which attends reduction of the ischiatic variety of this luxation is due (as shown »y tiigelow), not to the head of the bone being lodged in the sciatic notch, nut to its being fixed behind and below the tendon of the obturator internus niu^cle, which separates it from the acetabulum, and which renders reduc- jOQ.,b/,extension in the line of the body al*nost impossible. Bv flexing tie thigh on the pelvis, the head of the femur is unlocked from the grasp "i tne obturator tendon, and the luxation is then as easily reducible as one 322 DISLOCATIONS. 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 Sutton. The Y liga- ment 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 303), which, though practised empirically in these cases for a great many years previously, was first reduced to a system by Nathan Smith and Reid, and has been particularly illustrated, of late years, by Bigelow and Gunn. In the form of dislocation now under consideration, the manipulation 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 ischiatic 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 ; and (3) in finally bringing down the limb into its natural posi- tion. The process, in fact, embraces the three motions of flexion, outward circumduction, 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 consti- tuting a sliding fulcrum by means of which the head of the bone is lifted into the acetabulum. Fig. 178.—External appearance of downward dislocation. In executing this manoeuvre care must be taken not to flex the thigh too much, or the Y ligament will be unduly relaxed, and the effort at reduction will fail; and not to abduct the limb too widely, or the posterior part of Fig. 179.—Reduction of downward dislocation, by rotation and inward circumduction. (Bigki.uw.j DISLOCATIONS OF THE HIP. 323 the capsule will be unnecessarily torn, and the head of the bone may slip below the socket on to the thyroid foramen;1 the angle of extreme flexion should be from 50° to 60°, and that of extreme abduction from 130° to 140°. The first mistake (that of undue flexion) is readily remedied by repeatingthe manoeuvre with the limb somewhat more extended ; to remedy the second error it is necessary, while making abduction, to lift the limb, when the head of the bone will usually slip readily into its socket. 2. Dislocation of the Head of the Femur Downwards, or downwards and forwards into the Thyroid Foramen, is produced by the application of force while the thigh is in a position of abduction, or by a blow on the back of the pelvis while the body is bent and the legs widely apart. The capsular ligament is extensively torn, particularly at its inner and 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 com- monly an elongation of from half an inch to two inches, though, according to Rivington, there may be no lengthening, or even slight shortening ; there is abduction ; the leg is advanced, and the foot straight or slightly everted ; the trochanter is depressed, and, in a thin person, the head of the hone 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 inwards2 in abroad sweep across the abdomen (Fig. 179), 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 tho dorsum ilii. The manipulation may be sometimes assisted by drawing the upper part of the thigh outwards with a towel. 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 walking, 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 prominence of the head of the bone, which 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 impossibility, 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 Bigelow, "by much the same method as in the thyroid dislocation, except that in the pubic luxation the flexed limb should be carried across the sound thigh at a higher point. First, semi-flex the thigh, to relax the Y ligament, at the same time draw- This accident, according to the late Dr. Erskine Mason, occurs only when there Has been rupture of the obturator interims muscle. Dr. Markoe, in one case, succeeded in reducing a thyroid luxation by outward rotation (using, therefore, the outer branch of the Y ligament as a fulcrum), inward ronton having previously thrown the head of the bone on to the sciatic notch, from winch it was immediately returned to its primitive position ; as remarked by Prof. igelow inward rotation with less extreme flexion would, probably, have succeeded in the fust instance. ' 321 DISLOCATIONS. ing the head of the bone down from the pubis. Then semi-abduct and rotate inwards, to disengage the bone completely. Lastly, while rotating inward and still drawing on the thigh, carry the knee inward and down- ward to its place by the side of its fellow." As in the thyroid luxation, Fig. 180.—Application of the rope windlass, for backward dislocation. 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 draw- ing the flexed groin directly outwards with a towel. 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 pulleys 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 Astlev Cooper and other standard au- thorities (Figs. 180, 181| 1S2). Besides the three regular forms of dislocation which have been above described, there are various anomalous forms, as (1) directly upwards (usually consecutive upon the pubic dislocation), (2) directly downwards, between the sciatic notch and the thyroid foramen, (3) downwards and backwards on to the body of the ischium, (4) downwards and backwards into the lesser sciatic notch, and (5) downwards, inwards and forwards into the perineum. These various forms of downward dislocation may be either primitive, or consecutive upon the ordinary thyroid variety. In these irregular forms of dislocation there is usually great laceration of the capsular ligament, with, in some cases, rupture of the external branch, 1 Mr. Kelly, of Dublin, reduces forward dislocation 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. 325 or even both branches of the Y ligament. Reduction may usually be effected by simply flexing the thigh, and then lifting and pushing the dis- placed bone in the direction of its socket; or the luxation may be converted into one of the "regular" varieties, when mani- pulation can be applied according to the methods already described. Ridlon describes a case of upward (supracotyloid) dislocation in which, though reduction was not effected, the patient walked with- out difficulty. 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 such circum- stances the apparatus recom- mended by Prof. Bigelow for effecting angular extension may be usefully employed. The dif- ficulty, however, in these cases, will be often found to be not so much in effecting, as in main- taining reduction, owing to the structural changes which occur in the acetabulum and in the head of the femur. To meet this difficulty 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 iyfeilA Fig. 181.—Bloxam's dislocation tourniquet, applied for downward dislocation. (Erichsen.) Fig. 182.—Mode of reducing upward dislocation with pulleys. there is any tendency to reproduction of the deformity after reduction. > olkmann, MacCormac, Pyle, Penrose, Kammerly, and Tillaux report eases of old dislocation of the hip successfully treated bv excision, and llleneuve one greatly benefited by osteotomy. Lane made a new caput 326 DISLOCATIONS. femoris and acetabulum, and sutured the tendon of the rectus femoris to the anterior ligament of the joint, the patient recovering with a useful limb. The complication of dis- location of the hip with fracture of the thigh should be met by applying firm splints, or Bigelow's "an- gular extension" apparatus, before attempting manipu- lation. Should fracture oc- cur during the effort to re- duce an old dislocation, the attemptsatreduction should be at once abandoned, but advantage might be taken of the accident to obtain union in such a position as would diminish the defor- mity of the limb. After reduction of a hip dislocation, it is usually suf- ficient to tie the knees to- gether with a few turns of a bandage, keeping the pa- tient in bed for a week or ten days. An unreduced dislocation, especially ofthe ischiatic variety, allows, Fig. 183.—Angular extension, in reduction of old dislocation after a time, much more of the hip. (Bigelow.) use of the limb than would at first be supposed possi- ble. Compound Dislocation of the Hip has, according to J. W. Perkins, been observed in nine cases, of which six terminated fatally. 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 Out war a Dislocation is the most common, and may be either partial or complete ; it may be recognized by the undue prominence of the inner condyle, and by the patella being felt in its new position ; the limb is usually slightly flexed. Reduction is effected by extending the leg- on the thigh, and flexing the latter on the pelvis, so as to relax the quadriceps femoris muscle, when the patella can be easily pushed back into its proper place ; Hamilton directs. that the patient should be in a sitting posture, the surgeon sitting or standing in front of him, and raising the affected leg upon his own shoulder. If this manoeuvre fail, reduction may be accomplished by alternately flex- ing and extending the knee, while lateral pressure is simultaneously made upon the patella Dislocation Inwards is very seldom met with; its symptoms and treatment are (mutatis mutandis) the same as those of the outward variety. Dislocation of the Patella, on its Axis is produced by the same causes as lateral dislocation, of which, indeed, it may be looked upon as an aggra- DISLOCATIONS OF THE KNEE. 327 vated form ; either edge of the patella may project anteriorly, or the bone mav be entirely reversed, so that its posterior surface is in front. The leg is usually fully extended, more rarely slightly flexed ; the prominence of the patella is so marked as to render any mistake in diagnosis almost impossible. Reduction may commonly be effected, as in cases of lateral dislocation, by direct pressure, aided by alternate flexion and extension. A case is recorded by W. F. M. 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 patellae and tendon of the quadriceps extensor muscle, with a view of facilitating reduction in these cases, but the operation does not appear to have been productive of any marked benefit, while in one case it caused fatal sup- puration. Dislocation Upwards can only result from rupture of the liga- mentum patella}; the treatment would be the same as for fracture of the patella itself. Dislocations of the Knee.—The Head of the Tibia may be 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 stepping into a hole while walking. The lateral dislocations are always incomplete, while the antero-posterior luxations may be either complete or partial. The symptoms of these injuries are very obvious ; the complete luxations are usually accompanied with shortening. Reduction may be effected by forced flexion of the knee, with direct pressure, aided by 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 reduc- tion, the limb should be placed at rest in a long fracture-box, or on a suit- able splint, until the subsidence of all inflammation of the joint, the part being afterwards protected from sudden motion by the use of an elastic knee-cap or firm bandage. Compound Dislocation of the Knee is usually a case for amputation. Dislocation of the Semilunar Cartilages, or Internal Derangement of the Knee-joint (Subluxation of the Knee), consists, according to Erichsen, in the semilunar cartilages slipping either forwards or backwards from beneath the condyles of the femur, so that the latter come in direct contact with the articular surface of the tibia, pinching the folds of synovial 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, who 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 effected by alternately flexing and extending the knee, combining these movements with slight twisting and rocking of the joint. As the process is painful, ether may appropriately be used in these cases. After reduction, the patient should wear an elastic knee-cap, to prevent recur- rence of the displacement. Annandale, Owen, Cotterill, and H. W. Allingham have effected cures in several cases by opening the joint and pulling the displaced cartilage into its proper place with forceps, and then 328 DISLOCATIONS. securing it with sutures. Brodhurst, Croft, and Annandale have also treated displacements of the semilunar cartilages by 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 effected 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 by Sir Astley Cooper, Malgaigne, and Hamilton, as dislocations of the lower end of the tibia: I think, however, that it is better to speak of them, with Boyer and others, as dislocations of the foot upon the bones of the leg. The displacement occurs between the upper articulating surface of the astragalus and those of the tibia and fibula, and the foot may be dislocated forwards, backwards, to either side, or, as in a case 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 II. W. Smith, always incomplete. These injuries may result from either direct or indirect violence, the particular form of the displacement depending upon the position of the foot at the moment at which the accident occurs. The antero-posterior luxations can be easilv recognized by the characteristic deformity, the foot being lengthened in the forward, and shortened in the backward, dislocation. The true lateral luxation is a less frequent accident than is generally supposed, the majority of the cases which are called dislocation being really instances merely of rotation of the astragalus, without actual separation of that bone from the 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 lauda- num 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 moment at which the accident occurs. In the forward dislocations, the leg is shortened, the astragalus projects in front of one or the other malle- olus, and the foot is somewhat extended and twisted to the opposite side, BURNS AND SCALDS. 329 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 Fitzgerald 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, simjde dis- location, 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 irreduci- ble, the patient notwithstanding recovering with a very useful foot. In a case of compound dislocation, it would be proper (unless reduction were readily accomplished) to excise the astragalus at once, or to amputate, if the concomitant injuries were so severe as to forbid excision. Other dislocations of Tarsal Bones are described, as of the calcaneum and scaphoid upon the astragalus, which remains in place below the arch of the malleoli (subastragaloid dislocation of Malgaigne); of the calcaneum upon the astragalus and cuboid, or upon the astragalus alone; of the scaphoid and cuboid upon the os 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) is advised by H. Lee and Pick in the subastragaloid variety. Even if reduc- tion cannot be effected, the limb will often be serviceable in spite of the deformity. Dislocations of the Metatarsus and Toes are of rare occurrence except as the result of great violence, when amputation will often be re- quired. In cases of simple dislocation reduction may usually be effected simply by traction and direct pressure, the parts being afterwards fixed with suitable spints and bandages. CHAPTER XV. 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, which 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 in every-day life, it is not strictly correct; for, in many eases, 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 330 EFFECTS OF HEAT AND COLD. injuries produced by caustic acids or alkalies are essentially burns, whether the asrent be applied in a liquid or in a solid form. Effects of Burns and Scalds__The effects of the-e 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. Dupuv- tren divided burns into six classes or degrees, according to the extent of injury inflicted ; and this classification, which is in some respects convenient, is still adopted by most surgeons. The first class embraces cases of verv superficial burn, marked by redness, and followed by desquamation of the cuticle. In the second class the injury extends more deeplv, and is fol- lowed by the formation of numerous vesicles and bullae. In the third class the whole depth of the skin is involved, and is thrown off in the form of thin superficial sloughs. In the fourth class the destructive effect reaches the subcutaneous areolar tissue, the sloughs are firmer and deeper, and, on separating, leave granulating ulcers. In the fifth class the deeper-seated structures, muscles, tendons, etc., are affected; while in the sixth class of burns, all the constituents of the part, including the bones, are involved in destruction. The various changes which take place in a part that is burnt are those that have already been fully described in the chapter on Inflammation, and the processes of granulation, cicatrization, etc., by which repair is 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 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, loss of animal heat from destruction of the skin, or suppres- sion of the physiological action of that tissue. Thus, of ten patients re- ceived into the Pennsylvania Hospital from a fire at the Continental The- atre, in September, 18(51, six died within twenty-four hours, some with- out any reaction, and others having reacted very imperfectly. The second stage is marked by the occurrence of inflammatory fever", accompanied often by violent traumatic delirium ; the duration of this stage is usually from the second to the tenth or twelfth day, and during this period death may occur from internal congestion, or from inflammation of the brain, air-passages, kidneys, or alimentary canal; the locality of the burn in- fluences 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, though fortunately rare, complication of this stage, which has been particularly insisted on by Long and Curling, is perfor- ating ulcer of the duodenum. This, according to Curling, results from the irritation due to the vicarious action of Brunner's glands in attempt- ing to replace the deficient action of the skin, but is, iu common with the other visceral complications of burns, directly traceable, according to Feltz and Wertheim, to the occurrence of capillary embolism, or, according to Silbermann, to thrombosis, due to changes in the red blood-corpuscles. W. Hunter suggests that it may be due to an irritant poison excreted through the bile. The duodenal ulcer usually proves fatal, either from hemorrhage SYMPTOMS AND PROGNOSIS OF BURNS. 331 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 widespread ulceration, without regard to the particular cause of the injury ; death may occur from simple exhaus- tion, from secondary visceral degeneration (probably of the so-called amy- loid or albuminoid variety), or from pyaemia, According to Ponfick and Lesser, one of the chief causes of death in cases of severe burn is disin- tegration of the red blood-corpuscles, with secondary parenchymatous in- flammation of the kidneys and uraemic poisoning. Salvioli believes that death results from blood-stasis, due partly to thrombosis and embolism, partly to arterial contraction, and partly to a change in the red corpuscles themselves. 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, partly from the accumulation of blood in the cen- tral organs of the body, and partly from increased radiation of heat due to destruction of the skin. 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 the development of the second stage, thirst becomes the most distressing symptom ; there is an insatiable craving for liquids, which are rejected by vomiting as soon as they are 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 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 fame; it is, perhaps, scarcely necessary to say that such an occur- rence 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 cedema of the glottis, and consequent suf- focation. Hot steam may be inhaled (as is sometimes done bv 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 Holmes, how- ever (and this corresponds with my own experience), most deaths from 332 EFFECTS OF HEAT AND COLD. 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 freelv, 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, is 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 at- tending 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 super- vene 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 admin- istration 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 complica- tions 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 long postponed, on account of the risk, already referred to, of the occurrence of visceral degeneration, probably of the so-called amyloid or albuminoid variety. With regard to Local Applications to burns, I do not believe that it makes a great deal of difference what article is used, provided that the surface is thoroughly excluded from the air, and that the process of dress- ing is neatly and properly attended to. The application which I myself prefer in cases of recent burn, is the old-fashioned carron oil, made by stirring linseed oil and lime-water into a thick paste, which is then spread upon old linen or muslin, and covered with oiled silk. It is customary to speak of this as a filthy dressing, but I cannot see that it is any less clean than other applications, while it is certainly, according to mv experience, extremely soothing and agreeable to the patient. Wertheimer makes it aseptic by adding thymol. 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 potas- OPERATIONS FOR CONTRACTED CICATRICES. 333 sium, thiol, or any other of the host of substances which have been recommended. More important than the particular article used is the mode of usin«- it. Only a small portion of the surface should be uncovered at once, andTthe burn, if extensive, should thus be dressed, as it were, in detachments. Vesications, if there be any, should be punctured with the point of a sharp knife, the contained serum being allowed to drain away of itself, so as to preserve the cuticle as a covering for the parts beneath. The dressings should be covered with oiled silk or waxed paper, to prevent, evaporation, and should be held in place with roller bandages, the injured parts bein^ Fig. 184.—Deformity of foot following severe burn. (From a patient in the Pennsylvania Hospital.) 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, zinc or resin cerate, or boric-acid ointment, as in the case of any other granulating surface. While the dressing is to be conducted with all gentleness, it must be neat and thorough; especial care should be taken to wipe clean the newly formed skin around the healing ulcer, which may be advantageously stimulated from time to time by light touches with lunar caustic or bluestone. During the healing process, care must be taken to guard against undue contrac- tion 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 bv operative interference. Operations for Contracted Cicatrices__In the early stages, before healing is completed, or afterwards if the cicatrix be still soft and pliable, it may be 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- 334 EFFECTS OF HEAT AND COLD. Fig. 185.—Contraction of arm following a burn. (From a patient in the Episcopal Hospital.) 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 healthv tissue on both sides of, and beneath, the scar; the after-treatment consists in making extension by means of screw- apparatus, or, which I think better, the ordinary weight-extension, applied to the limb 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. There- suit of such an operation is shown in Figs. 185 and 18(5, from pho- tographs of a patient under mv care some time 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 practi.-ed by Mutter, Buck, and others, to rem- edy the deformity, which is both annoying and painful. Xo 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 bv 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 clone by Butcher, whose operation,'which has for its object the restoration of the elasticity of the cicatricial flap, con- sists in scoring sub-utaneously the hardened tissue with numerous inci- sions made with a long, narrow-bladed knife. The surgeon is thus enabled to unfold, as it were, the matted cicatrix, and render it available for auto- plastic purposes. When the deformity is limited to dragging down and eversion of the lower lip, Teale's modification of Buchanan's cheiloplastic operation will be found very useful; this consists in dissecting up flaps from the side of the lower lip (Fig. 187, a), and then joining these flaps together and to the freshened edge of the central portion (b), which Fig. 186.—Result of plastic operation for contrac- tion of arm following burn. (From the same patient as Fig. 185.) EFFECTS OF COLD. 335 Fig. 187.—Teale's operation ; the flaps in place. (Erichsen.) affords a firm basis for their support; the triangular spaces (c) which are left are allowed to heal by granulation. James, of Exeter has supplemented the use of the knife, in these cases, by the employment of a screw-collar, which gradually pushes the chin away from the ster- num. In the case of the upper lip, Teale makes a crucial incision, of which the point of inter- section is immediately below the septum of the nose. The incision involves the whole thick- ness of the part, and the operation is completed by dovetailing together the resulting lateral tri- angles, so as to increase the depth of the lip at the expense of its breadth. W. Adams has in- troduced 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 harelip pins for three davs. This mode of treatment is mani- festly inapplicable to large scars, and is indeed particularly recommended by its author forthe 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 Savre in the case of the hip-joint, have been proposed by Carnoehin, 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 bv excising a wedge-shaped portion of bone, three-quarters of an inch wide at it's upper part and an inch below; but in a case thus operated on by Gurdon Buck (for cicatricial contraction resulting from cancrum oris), though an inch and a half of bone was removed, the parts became re-approximated, and the operation seems to have been only partially successful: a better plan is, 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 -2(5 cases of the former gave 13 permanent recoveries and 3 deaths, while 40 cases of the latter gave 15 permanent recoveries and 2 deaths. Ihe 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 remedv ; the itching may be relieved, according to Erichsen, by the internal administration of liquor potassaB. 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 ot 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- 336 EFFECTS OF HEAT AND COLD. ceptibilitv 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 cold 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 ancenlia; (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 congelation, usually from congestion, but sometimes from anaemia, in either case due to capillary embolism by clots originating in the injured part. Tourraine, Granjux, Pugibet, and other French military surgeons have recorded curious cases of syncope preceded by intense redness of the whole surface of the body, as the result of cold baths. Hemiplegia was, 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 with snow, or with flannel wrung out of tincture of camphor or dilute alcohol, together with a resort to artificial respiration. These means should be continued until reaction is well established, when the body may be wrapped in blankets, stimulating draughts administered, and the temperature of the room gradually raised. Efforts at resuscitation in such cases should not be prematurely discontinued, as patients have occasionally been saved even when apparently dead for several hours. Tedenat refers to a case in which 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 7fi.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 XXVIII.) 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 alterations 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 stimu- lants, 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 fg j), frequentlypainted upon the part, which is then wrapped in raw cotton. The nitrate of silver seems to obtundthe local sensibility, and certainly 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 chilblain require stimulating applications, such as resin cerate, or dilute citrine ointment. T. Smith has called attention to the periodicity with which the paroxysms of itching in chilblain are developed, and which he is disposed to attribute to the time at which the patient's principal meal is FROST-BITE. 337 taken. The daily paroxysm may be anticipated, if the patient's conven- ience 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 41)4 cases, that in 333 the 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 6, 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 incon- venience. 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 rec- ommends 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 be 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, tneir 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 me 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. 338 INJURIES OF THE HEAD. CHAPTER XVI. 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 eases, but the surgeon should encourage absorption by the use of evaporating lotions, or of moderate pressure. If, however, suppuration occur, the pus must be evacuated by a free incision. Cephalhsematoma, or Caput Succedaneum, is a bloody tumor of the scalp in new-born children, resulting from pressure during birth. The blood is usually effused between the scalp and pericranium, though more rarely beneath the latter. The treatment is the same as for similar ex- travasations resulting from other causes. _ Wounds of the Scalp.—Scalp-wounds do not differ materially from similar injuries in other parts of the body as regards their pathology and treatment. The tissues of the scalp are extremely vascular,1 hence the hemorrhage in these cases is often profuse; on the other band, the vascu- larity of the scalp is of advantage in enabling the parts to preserve their vitality after injuries which, in other tissues, would 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, which is better, with the gauze and collodion dressing, or one of its modifications (see page 165). 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 necessarv. 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, usuallv 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 simplv to support the flaps with adhesive strips, and apply to the wound some warm 1 W. J. Tyson has recorded a remarkable case of traumatic aneurism of the scalp. INJURIES OF THE SCALP. 339 and soothing application, such as moist antiseptic gauze, olive oil or di- luted alcohol. ' As in every case of scalp-wound there is at least a possibility of some concomitant injury to the brain, a patient with such an injury should be carefully watched during the entire course of treatment; the diet should be regulated (all irritating or indigestible substances being avoided while at the same time easily assimilable nutriment is provided in sufficient quantities), and attention should be given to the condition of the various secretions and excretions of the body. Erysipelas and Diffuse Inflammation of the Subcutaneous Areolar Tissue are usually said to be especially apt to follow upon wounds of the scalp. Such has not been my own experience, though I can readily under- stand that a patient should be predisposed to these affections when treated by the plan of excessive depletion formerly in vogue in the manao-ement of these cases. The proper course to be pursued in the event of such com- plications arising would be to remove all pressure or sources of tension by reopening the lips of the wound, and making counter-incisions if neces- sary, for the evacuation of pus or sloughs. ' Necrosis of the outer table of the skull usually, though not necessarily follows in cases of scalp-wound in which the bone is denuded of pericra- nium. Such a case should be treated upon ordinary principles the seques- trum being removed as soon as it has become loose. The formation of granulations over the exposed bone may be hastened by cautiously drill- ing the external table—a mode of treatment said to have been practised in eases where patients were scalped in Indian warfare The accompanying cuts (Figs. 188, 189) 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 Figs. 188 and 189.-SeYere scalp wound. (From a patient in the Episcopal Hospital.) being thus as it were, squeezed off from her head and forming a large fhfe" ,1°t8!iaped flaP> which was thrown backwards, like the lid of a box, IV " ? denuded of its pericranium for a space of two and a half incnes by one inch in extent. A considerable portion of the wound healed /n„fer,o;» an(i ^he patient was discharged cured after fifty-four days. ^0 exfoliation of bone occurred. 340 INJURIES OF THE HEAD. Cerebral Complications of Head Injuries. The principal risk attending all injuries of the head is from simulta- neous or subsequent implication of the brain, and I shall, therefore, before speaking of fractures and other lesions of the skull, consider the various cerebral complications which are met with in these injuries, and which may be classified, as a matter of convenience, under the heads of concus- sion, compression, and inflammation. Concussion of the Brain—It is a rather mortifying confession, that the ideas of surgeons of the present day, as to this condition, are much less definite than those of their predecessors. We have, however, ad- vanced so far that we are now enabled to say pretty clearly what concus- sion is not, and thus to separate it from other conditions with which it was formerly habitually confused. Thus, we now know that cerebral concus- sion is not shock (see page 150), and that it is not a purely functional, apart from an organic, condition. The older writers had no hesitation in declaring that a man might die from concussion of the brain without the existence of any physical lesion whatever; but the fallacy of this opinion has been ably exposed by modern authors, among whom should be spe- cially mentioned Sir Prescott Hewett. In fact, while there is no evidence that cerebral concussion is ever a cause of instant death, there are inva- riably found after death from this cause signs of contusion, compression, extravasation, laceration, or inflammation. Concussion of the brain, as its name implies, consists in a shaking or, to use a Johnsonian word, a trenief action of the cerebral mass, and it is easy to understand that such a trembling might be attended by a more or less temporary arrest of cell-action, by capillary stasis, and by functional inactivity, without any persisting lesion or permanent ill result. Such, indeed, is probably the condition of affairs in the slight cases of concussion, or stunning, which are not unfrequently met with, especially among children ; though, these ca^es not proving fatal, our knowledge of their morbid anatomy must, of course, be purely conjectural. According to Fischer, the phenomena of concussion are due to reflex paralysis of the intra-cranial vessels; but, from experiments on the lower animals, Duret concludes that they depend on increased tension of cerebro-spinal fluid—a conclusion, however, which is strenuously rejected by Bochefontaine. Miles has furnished experimental confirmation of Duret's views, and main- tains that the symptoms of concussion are due to anaemia of the brain, caused by reflex stimulation of the restiform bodies and other centres in the region of the bulb. A more violent concussion of the brain may cause contusion or lacera- tion of the cerebral structure itself, or rupture of the cerebral vessels, giving rise to extravasation, with or without compression, and more remotely followed by inflammation, suppuration, or softening. Contusion and Laceration of the brain, like the same conditions in other organs, may vary from the slightest bruising or separation of fibres, to the most extensive crushing and tearing, sometimes amounting to complete pulpefaction and disorganization of the whole cerebral mass. The symp- toms and prognosis of these injuries depend upon their extent, and upon the particular part of the brain which is affected; thus, Callender has shown that pain is especially connected with lesions of the outer gray matter of the brain, and convulsions with lesions in the neighborhood of the middle cerebral arteries, and particularly in that portion of the right hemisphere which is above the corpus striatum. A laceration involving concussion of the brain. 341 the medulla oblongata would, of course, be more apt to prove fatal than one of similar extent in a less vital part.1 The extravasation which invariably accompanies cerebral contusion presents various appearances in different cases; thus, there may be nume- rous points or specks of extravasation, each not larger than a millet-seed (miliary extravasation), or the blood may be poured out in larger masses, forming collections the size of a split pea. The latter form of extravasation is easily recognized, but the former may be mistaken for the appearance presented by the cut surface of the cerebral vessels—from which, however, it maybe distinguished by the fact that the points of extravasation are not easily wiped away, and, if picked out, leave behind them small but distinct cavities. The occurrence of these miliary extravasations is accounted for by Duret by the diffusion of the force of the injury by means of the cere- brospinal fluid. Contusion of the brain, with its attendant extravasation, may be circum- scribed or diffused ; the former condition is frequent, and the latter rare. Certain parts of the brain are more exposed to contusion than others ; thus, the base of the brain is more often affected than the upper part; the middle and anterior, than the posterior lobes; the cerebellum, than the pons and medulla. The reason for this difference is, doubtless, as pointed out by Brodie, the greater or less irregularity of the surface of the various por- tions of the skull. When extravasation takes place on the surface of the brain, or into its ventricles, or even (in large amount) into its substance, the characteristic symptoms of compression are developed — a condition which will be presently considered. Causes of Cerebral Concussion.—Concussion of the brain may be caused by various forms of external violence, such as a direct blow or fall, by violence resulting from counter-stroke, as a fall on the loins, buttocks, or feet, or even by sudden and violent agitation of the surrounding air, as by an explosion in a patient's immediate vicinity. Symptoms of Cerebral Concussion.—Every case of concussion is, I be- lieve, accompanied by shock, and in many instances the symptoms of the latter condition alone can be recognized. The patient, after a blow on the head, becomes pale and somewhat collapsed, with a cool surface, small and feeble pulse, diminished power of sensation and motion, and partial uncon- sciousness ; after a variable period these symptoms pass off; vomiting may or may not occur, and the patient is apparently quite as well as before the accident. The symptoms here are evidently those of shock (with the ex- ception of unconsciousness), and cannot be considered as in any degree characteristic of the brain-lesion. So, again, in cases in which death fol- lows in a few minutes or hours after an injury to the head, the patient lying meanwhile senseless and collapsed, the fatal result may be due to shock, or to intra-cranial hemorrhage, or to laceration of a vital part of the brain ; but there is no symptom which we can point out as pathognomonic of concussion, apart from other conditions. Even in the intermediate cases, which are often spoken of as typical instances of concussion, though, as a According to Brown-Sequard, lacerations of the brain are followed by pleural eechymosis or pulmonary apoplexy on the side opposite to that of the cerebral lesion. rleischman and Ollivier have observed a similar con lition of affairs in cases of non- traumatic disease of the brain. Extravasation has also been noted, in connection with brain lesions, in the heart, kidneys, and other organs. On the other hand, cerebral abscess appears sometimes to result from embolism following pulmonary dis- ease, as in cases recorded by (lull and Sutton, Huguenin, and J. H. Hutchinson, or trom congenital communication between the right and left cavities of the heart, as in cases recorded by Ballet, Gintrac, and others. 342 INJURIES OF THE HEAD. matter of convenience, we may trace their clinical history and divide it into stages, we cannot point to any symptoms which definitely charac- terize the lesions of concussion, apart from those of other cerebral injuries. Indeed, it would be better, I think, if we could dispense altogether with the term concussion as denoting a condition, and look upon it as merely indicating the cause of what have been described as concussion-lesions, viz., cerebral contusion, laceration, extravasation, etc. With this explanation and reservation, the clinical history of a typical case of so-called concussion of the brain may be said to present three stages, the symptoms of which are as follows :— In the first stage the patient lies motionless, senseless, nearly pulseless, pale and cold, breathing feebly but naturally, the pupils dilated or con- tracted, fixed or acting freely (according to the particular seat and form of lesion),1 with perhaps involuntary discharge of feces and urine. From this first stage, which may last many days, the patient may recover without any further trouble, or he may gradually sink and die without reaction; or the first stage may be very evanescent, so that when the surgeon first sees the patient he has already passed into the second stage, which Mr. Erichsen regards as an entirely independent condition, and graphically describes under the name of Cerebral Irritation. The disappearance of the first stage, whether by passing into the second or by direct recovery, is commonly marked by the occurrence of vomiting. In the second stage the patient is no longer unconscious, though much indisposed to speak or pay attention to surrounding objects. If roused by a question, he will answer, but peevishly or angrily, turning away as* if displeased at the interruption. The posture of the patient is peculiar ; he habitually lies on one or other side, curled up, with all his joints more or less flexed, and, if a limb be touched, draws it away with an air of annoyance. The eyelids are kept firmly closed. The pulse during this stage, at first small and weak, becomes gradually fuller and more frequent, while the breathing is easier, and the surface regains its natural warmth and color. The symp- toms now may be masked by those of the second stage of shock (see page 153), and thus, instead of being morose and taciturn, the patient, though still irritable, may be voluble and loquacious. The condition of cerebral irritation which marks the second stage of concussion gradually subsides, after having lasted several hours or days, the patient almost invariably complaining of severe headache as he regains ability and willingness to communicate with those around him. The third stage varies in different cases ; in some, there is positive inflammation of the brain and its mem- branes; in others, as irritability subsides, fatuity takes its place, and a state of weak-mindedness supervenes, which may end in recovery, or in cerebral softening and death. Prognosis.—From what has been said, it is evident that the prognosis in any case of cerebral concussion or contusion should be very guarded; the patient may die, as we have seen, in the first stage, from the shock of the injury; or, if he escape this risk, from intra-cranial congestion or in- flammation ; or, at a still later period, from softening of the brain or cere- bral abscess. As a rule, however, if the first stage be slight, we may expect the others to be so likewise, and, numerically, the proportion of deaths to the number of cases of slight concussion, or stunning, is very small ; still, it is not always possible to be sure that the amount of brain- lesion is as slight as it at first appears, and every case of concussion must be, therefore, a subject of grave interest to the surgeon. 1 Cerebral compression appears to be marked by fixed or slowly moving pupils; mere laceration does not affect their free action. CONCUSSION OF THE BRAIN. 343 Treatment of Cerebral Concussion and Contusion.—There is a popular notion that a person who has received a stunning blow on the head should not be allowed to sleep, or even to lie quietly in bed; need I say that this is as unreasonable as it is cruel ? The first indication for treatment is certainly to place the injured organ at rest, and it would be no more un- philosophical to insist that a man should walk with a contused foot, or write with a lacerated hand, than to expect him to exert the mental faculties when suffering from concussion of the brain. A patient thus affected should be placed at rest, in bed, in a cool and moderately darkened room, and should be disturbed as little as possible. If the state of shock be so great as to threaten death from asthenia, the patient must be stimulated, preferably, however, as far as possible, by external applications, such as sinapisms or hot bottles, and by those internal remedies which are most evanescent in their effect, such as the spirit of hartshorn or carbonate of ammonium. As a matter of fact, it is very seldom indeed that a case of concussion requires any stimulus at all. Reaction usually begins in the course of an hour, or two or three hours, sometimes much earlier, and, as the pulse rises, the stimulants, if any have been given, must be discon- tinued. The risk now is from congestion, or extravasation, with subse- quent inflammation, and the treatment must be directed accordingly. It is in this stage that cold, and especially dry cold, is particularly useful as a local application. In the first stage it would have added to the existing depression, but it is now eminently indicated, and is a most valuable remedy. Esmarch's ice-bag or Petitgand's apparatus may be employed. or, in the absence of these, cloths rung out of cold water should be assidu- ously applied. The secretions and excretions should be regulated, the bowels being opened with enemata, or occasional mercurial or saline purges, and the bladder relieved by catheterization, if necessary. The diet should be very light, and administered in small quantities at a time ; there is no article of food better, under these circumstances, than milk, to which lime- water should be added if there be vomiting. Rest, both mechanical and physiological, should still be enforced ; and if the patient be restless, the surgeon need not fear to give opium. I am aware that there is a good deal of difference of opinion as to the propriety of administering opium in injuries of the head, but surely there is nothing to contraindicate it in what we know of the pathology of these cases, while its soothing and calming effect is exactly what is required. Metaphorically speaking, it puts the brain in splints and thus places it in the most favorable position for the repair of its injuries. Of course, opium in these, as in all'other cases, should be used with discretion, and if there be any threatening of coma, should not be given ; but in such a case the restlessness which calls for it would not be present. With opium may be given small doses of mercury, to obtain what the older writers would'have called its " anticipatory anti- plastic" effect; I am in the habit of ordering a sixth of a grain of calomel, with two or three grains of Dover's powder, every four hours, and this may often be continued for many weeks. By perseverance in this plan," the patient will, in most cases, be tided over the second stage, and may then be allowed gradually, and with great ?Jutl°n'.toresume his usual mode of life. For a long time, however, he should live by rule, guarding against all sources of irritation, eating and drinking very moderately, and in fact remaining, if not under treatment, at least under surgical supervision. If, on the other hand, the case pro- gresses less favorably, and the contused and lacerated brain becomes inflamed, the chances of recovery are much diminished ; traumatic enceph- alitis is, however, of such importance as to demand separate consideration. 344 INJURIES OF THE HEAD. Compression of the Brain.—It is not my purpose to enter into a theoretical discussion as to whether the brain is susceptible of being actu- ally compressed, or whether, in the condition known as compression, it merely changes its form, expanding at other parts to compensate for its apparent contraction at the seat of lesion. The term cerebral compression is so universal^ employed by surgeons, and is in many respects so con- venient, that I shall not hesitate to use it, although it may not exactlv describe the condition which it is meant to represent. Causes.—Compression of the brain may be caused by various circum- stances: thus, it may be due to the pressure produced by a foreign bodv, as a bullet or piece of shell; by a portion of displaced bone ; by effusion of blood, either on the surface of the encephalon or within its mass; or by what are ordinarily called the products of inflammation—lymph, serum, and pus. Symptoms.—The symptoms of compression are as follows: The patient lies unconscious and comatose ; the breathing is slow, and accompanied by stertor, and by a peculiar blowing motion or whiff at the corners of the mouth ; this sign, which is very striking, appears to be due to paralysis of the cheeks, and is compared by the French writers to the act of a man smoking a pipe. The pulse is full and rather slow, the decubitus dorsal, and the skin usually cool, though sometimes hot and moist. There is re- tention of urine, and the feces are passed unconsciously. The pupils are fixed and immovable, usually midway between contraction and dilatation, sometimes widely dilated, and rarely contracted; or one pupil may be con- tracted, while the other is dilated ; the difference in different cases depend- ing, as shown by Callender, upon the part of the brain involved. There is paralysis of motion, usually affecting the side opposite to the seat of in- jury. The period at which the symptoms of compression are developed depends on the particular source of the pressure: if this result from de- pressed bone or a bullet, the symptoms will be instantly manifested, and the patient will probably continue in a completely comatose condition from the moment of injury, either till the pressure is removed or till the case ends in death ; this, it will be remembered, was the course of events in the case of President Lincoln. If, however compression be caused by extrav- asation, it will begin gradually, and slowly increase during several hours, until the intra-cranial bleeding has spontaneously ceased, or has been arti- ficially arrested ; while compression from lymph, serum, or pus comes on at a still later period of the case. Diagnosis.—I regret that I cannot agree with those surgeons who con- sider the diagnostic marks between compression and concussion to be plain and easily recognizable. Unfortunately, as our knowledge of the pathol- ogy of concussion has increased, the several symptoms which we formerly regarded as pathognomonic are shown to be often common to both condi- tions ; and this is not surprising when we remember that extravasation is an almost constant lesion of concussion, and a frequent cause of compres- sion, thus rendering the difference between the two conditions, in many cases, one of degree only. Bouchut has recently asserted his ability to dis- tinguish concussion from compression of the brain by the use of "the oph- thalmoscope, the optic nerve and retina presenting a normal appearance in the former condition, and evidence of intra-cranial pressure (" choked disk") in the latter ; but it is evident that if the views advanced in these pages as to the pathology of "concussion" be correct, this test could only serve to distinguish those slight cases in respect to which no confusion would be likely to exist. It used to be said that the symptoms of concussion were immediate and temporary ; those of compression, often not immediate, but COMPRESSION OF THE BRAIN. 345 permanent. We have, however, seen that the first stage of concussion presents no definite symptoms; none, in fact, which might not be due to shock and syncope (conditions which might equally complicate compres- sion)—while, if concussion be attended with much extravasation, com- pression itself may result. Again, if compression be caused by a foreign body, or by displaced bone, the symptoms will be immediate—while in many cases of slight compression, the brain in a short time becomes habit- uated to the source of pressure, when the symptoms may pass off without surgical interference. And so with the other symptoms which used to be considered diagnostic, there is not one, I believe, which can be implicitly relied upon. A man was brought into the Episcopal Hospital with a com- pound, comminuted, and depressed fracture of the frontal bone, with rup- ture of the membranes, and escape of brain substance. When I saw him he was comatose, and evidently suffering from compression of the brain ; I removed those fragments of bone that were loose, and elevated the re- mainder; the patient breathed somewhat less stertorously, and turned on his side; the next day he was conscious, and rapidly recovered. Here there was manifestly compression from an obvious cause—depressed bone ; and yet the only change in symptoms produced by relieving this compres- sion (the accompanying concussion remaining) was a diminution in ster- tor and the substitution of lateral for dorsal decubitus. Hence, though in certain cases we can say without hesitation, in view of the one-sided paralysis, profound coma, and other symptoms mentioned, this is compres- sion or that is concussion, there are other cases in which it is impossible to draw such a distinction ; compression may disappear spontaneously, leaving concussion, while concussion, by a continuance of intra-cranial hemorrhage, may end in fatal compression. Prognosis.—Compression in itself is not a very fatal condition ; in many cases, in which the pressure is not very great, the brain accustoms itself to the new state of affairs, and the patient regains consciousness and goes on to recovery. In other cases it is possible by surgical interference to re- lieve the compression, and then, if the brain itself be not structurally altered, there is a good prospect of recovery. The gravest forms of compression are those which result from intra-cranial hemorrhage or suppuration, the latter condition being particularly dangerous, and proving almost always, sooner or later, fatal. Duret has shown experimentally that as soon as the compression becomes so excessive as to surpass the arterial tension, death supervenes. Treatment of Cerebral Compression.—When the cause of compression is recognizable, an attempt should obviously be made to remove it. Thus, if compression be due to a fragment of bone, this should be elevated or re- moved, provided that it can be done with safety ; or if to hemorrhage, in a situation which can be reached, the surgeon may make an effort to evacu- ate the effused blood and secure the vessel; if, however, the cause of the compression be uncertain, and still more if the existence of compression itself be doubtful, it will, I think, be usually wiser to abstain from opera- tive interference, and to treat the case on the general principles which have been laid down in speaking of the management of the second stage of cere- bral contusion (page 343). Spencer and Horsley recommend that for hem- orrhage from the middle cerebral artery, the common carotid should be compressed against the vertebrae, or, if necessary, Heated. Purgatives may be employed in these cases pretty freely ; and, if the patient cannot swallow, a drop of croton oil in mucilage may be placed on the tongue, while the bowels are solicited by turpentine enemata. The question of trephining in these cases will be'considered hereafter. 346 INJURIES OF THE HEAD. Traumatic Encephalitis, or inflammation of the cranial contents as the result of injury, is a very serious complication both of fractured skull and of the severer forms of cerebral concussion and contusion. The brain substance itself may be affected, or the meninges, or both together; the arachnoid membrane is perhaps more commonly involved than any other part of the cranial contents The meninges are injected with blood, while yellowish, or greenish, and sometimes puriform, lymph occupies the cavity of the arachnoid and the meshes of the pia mater, the arachnoid itself becoming thickened and assuming an opalescent appearance. Ac- cording to Hewett, in cases of meningitis originating from injuries of the skull, lymph will be chiefly found on the dura mater and in the cavity of the arachnoid; while in those cases which originate from injury of the brain (as after concussion), the pia mater is chiefly affected, the arachnoid cavity often escaping. Inflammation of the brain substance itself chiefly affects the gray matter and superficial white substance ; and is marked by great congestion, a dusky leaden hue, and softening, which comparatively seldom affects the central white parts, such as the fornix. Traumatic en- cephalitis may end in suppuration, cerebral abscesses not unfrequently fol- lowing upon seemingly slight injuries, and occurring after long intervals of apparent health. Symptoms of Traumatic Intra-cranial Inflammation.—These are pain (especially referred to the seat of injury), heat of head, fever, contraction of pupils, photophobia, and intolerance of sound ; at a later period there are added vomiting, jactitation, delirium, convulsions, stupor, subsultus, paralysis, and coma. The occurrence of suppuration is frequently marked by repeated rigors. The period at which encephalitis is developed varies in different cases: thus, after general and wide-spread concussion, inflammation may come on in a few hours; after limited laceration, probably not for several days— while inflammation resulting from contusion or fracture of the skull may occur at a still later period. No very trustworthy information as to the precise seat of inflammation can be derived from the symptoms. The researches of Callender would seem to show that pain is especially connected with lesion of the gray matter, and convulsions with disease about the track or distribution of the great vessels, especially the middle cerebral arteries. Solly, however, looked upon convulsions as characteristic of inflammation of the tubular portion of the hemispheres, and Sir T. Watson, of the pia mater or arach- noid; while Brodie and Hewett have seen convulsions follow injuries of the head when there was no evidence of any inflammation at all. Death may result from pressure of lymph or pus on the surface of the brain (in cases of arachnitis), from softening of the brain tissue, from the occurrence of intra-cranial hemorrhage, or from an abscess bursting into the ventricles; or it may result secondarily from thrombosis and pyaemia. Intra-cranial Suppuration may occur between the skull and dura mater (subcranial), in the cavity of the arachnoid and the meshes of the pia mater (inter-meningeal), and in the substance of the brain itself (intra- cerebral). Subcranial suppuration results from lesion of the bone, and is only met with at the seat of injury ; the other varieties may also result from counter-stroke, and may therefore be found at a distance from the point at which the violence was applied. The first and third forms of intra-cranial suppuration are circumscribed, the latter constituting the ordinary cerebral abscess, which may last for an indefinite time without producing any marked symptoms. Inter-meningeal suppuration is com- monly widely diffused, occupying the region of the vertex, usually on the side of the external injury, but occasionally opposite to it. INJURIES OF THE SKULL. 347 The symptoms of intra-cranial suppuration are those of cerebral irrita- tion and compression ; but I do not know of any signs which will enable the surgeon positively to distinguish the presence of suppuration from that of arachnitis. The prognosis in all these cases is very unfavorable; pus has, however, been often evacuated from beneath the cranium, the patient recovering ■ and incisions have been made through the dura mater, and even into the brain substance, in search of pus. Operations of this kind have been re- corded by La Peyronie, Dupuytren, Guthrie, Detmold, Noyes, and many other surgeons, including myself, 155 cases to which I have references having given 82 recoveries and 73 deaths, a mortality therefore of over 47 per cent. Drainage-tubes have been introduced into cerebral abscesses by Burchard, Fluhrer, Fenger and Lee, Hunt, and myself. Tassi records a case in which a cerebral abscess was spontaneously evacuated through the nose, the patient recovering. Treatment of Traumatic Encephalitis.—Intra-cranial inflammation is to be treated on the general principles laid down in Chapter II. Bleeding was formerly considered absolutely necessary in these cases, and is still resorted to by some surgeons. I have already expressed my views so fully as to the employment of venesection in the management of inflammation, that I shall not revert to the subject here, further than to say that I have never had occasion to bleed for encephalitis, though I have with advantage drawn blood, locally, by cupping. Purging is doubtless a most valuable means of treatment in these cases, but should be employed with due cau- tion, and not pushed so far as unnecessarily to weaken the patient. De- sault derived advantage from the use of large doses of tartar emetic, but the remedy is a dangerous one, and is now seldom employed. Calomel and opium are, I think, of great service in the treatment of these cases, and may be given in doses of a quarter of a grain of the former, with a sixth of a grain of the latter, every three hours, till the gums are slightly touched, when the mercurial should be suspended, and iodide of potassium may be substituted. Cold to the head is a valuable remedy, and is very grateful to the patient, as relieving the headache, which is one of the most painful symptoms of intra-cranial inflammation. In the later stages, a blister to the nape of the neck, or even to the entire scalp, is recommended by some authorities. The diet should consist of fluids, and should be light and unirritating; if the general condition of the patient require it, how- ever, the surgeon must not hesitate to administer concentrated nutriment, or even stimulus. After injuries of the head, the brain often appears to be left in an irrita- ble condition, the patient suffering from headache, vertigo, insomnia, etc. Under these circumstances, I have derived benefit from the use of the bichloride of mercury (in very small doses), or the bromide of potassium, which may be given freely, and seems to act well as a hypnotic. The state of the bowels should always be looked to in these cases, care being taken to avoid constipation. The question of trephining, for intra-cranial suppuration, will be discussed in its proper place. Injuries of the Skull. Contusion.—Contusion of the skull, without fracture, is a very serious injury, being commonly accompanied with grave lesions of the brain ; the part of the skull which is bruised may become necrosed, and eventually exfoliate; or, from separation of the dura mater, subcranial suppuration may occur and prove fatal. These injuries are chiefly met with as the 348 INJURIES OF THE HEAD. result of gunshot wounds, though occasionally resulting likewise from the accidents of civil life. The treatment consists in combating cerebral irrita- tion, by the means already described, and in removing sequestra, in case of exfoliation. If a patient with contused skull become comatose, it is usually recommended to apply a trephine, with the hope of being able to evacuate pus from beneath the skull ; the facts already referred to, viz., that it is impossible to distinguish intra-cranial suppuration from arach- nitis, and that, even if the existence of pus were certain, its locality could not be determined, are, however, sufficient to show how slight would he the prospect of benefit from such an operation. Thus, in a case of gunshot contusion of the left parietal bone, which proved fatal at Cuvler Hospital, there were found after death arachnitis of the right side, and abscess of the left hemisphere of the brain, at a point corresponding to the seat of injury—showing that trephining on either side would have been utterly useless. The operation was, according to Dr. Otis, resorted to in twelve cases of gunshot contusion of the skull, during the late war, but in every instance unsuccessfully. Fracture of the Skull.—Fractures of the skull may be simple or compound, comminuted, etc. They may be conveniently classified as frac- tures without displacement (fissured fractures), and fractures with dis- placement (depressed fractures), the latter class being again subdivided into impacted and non-impacted depressed fractures.1 In some rare cases the fracture may be limited to the outer table, which is depressed upon the inner; in other instances the inner or vitreous table is alone broken, the outer escaping. As a rule, the inner table is more extensively shattered than the outer, the exception being when the force is applied from within, as in the discharge of a pistol into the mouth. The cause of this difference is to be found, as pointed out by Teevan.in the well-known fact in mechanics, that fracture begins uniformly in the line of extension, and spreads further in this than in the line of compression, and that (in the case of gunshot fracture) the bulk of the fracturing body is absolutely augmented in its passage through the bone. Any part of the skull may be broken by either direct or indirect vio- lence, the parietal and frontal bones being most often affected in fracture> of the vault, and the temporal and sphenoid bones in those of the base of the skull. Fracture, of the base of the skull is the most fatal form of simple fracture, usually resulting from indirect violence, such as a blow on the top or side of the head, or a fall from a height on the feet or hips; it is generally, if not (as believed by Aran and Hewett) universally, complicated by one or more fissures extending- upwards into the vault. Depressed fracture of the skull is very rarely met with except in the vault, and results from direct violence C. B. Ball has, however, collected several cases in which the base of the skull was driven in, and the condyle of the jaw impacted in the opening, by force transmitted through the lower maxilla. Symptoms of Fractured. Skull.—A Simple Fissured Fracture of the vault of the skull presents no symptoms which can be considered diag- nostic. If there be an external wound, the line of fracture can be usually recognized, though a mistake has arisen, even under these circumstances, from an abnormal position of one of the cranial sutures. Fissured fracture may be followed by the effusion of cerebro-spinal fluid, forming a fluctu- ating tumor beneath the scalp, known as traumatic ccphalliydrocele. Dr. Conner has collected 22 cases of this rare complication, including two ob- 1 Other subdivisions are sometimes made, such as the starred fracture, and the earneratedfracture (a form of the depressed variety). FRACTURE OF THE SKULL. 349 served by himself, and other examples have since been recorded by Bris- towe (three), T. Smith (two), Godlee, Morrant Baker, and Southam. Fracture with Displacement, if compound, is readily recognized ; but if unaccompanied by an external wound, may, as already mentioned, be confounded with a simple scalp-contusion (p. 338). In some rare instances the displacement is outwards, but much more commonly inwards, consti- tuting the ordinary depressed fracture of the skull. The displacement in the impacted fracture is slight, the depression being less than the thickness of the skull; in the non-impacted variety it is usually much greater, frag- ments being often deeply imbedded in the substance of the brain itself. Fracture of the Base of the Skull may be suspected in any obscure case of injury to the head which presents marked brain symptoms ; and there are two signs in particular which, though they cannot perhaps be con- sidered pathognomonic, are unquestionably very significant, and render the existence of fracture at least extremely probable. These signs are the occurrence of intra-orbital eechymosis and of bloody and watery discharges from the ear. 1. Fracture, involving the anterior fossa of the base of the skull, mav cause hemorrhage from the nose, or into the deep parts of the orbit. The blood may flow backwards through the posterior nares into the mouth, and, being swallowed, may subsequently cause baematemesis, giving rise to a suspicion that some lesion of the abdominal viscera may have occurred. Hemorrhage into the orbit and areolar tissue of the eyelids, constituting in the former position what is known as Intra-orbital Eechymosis, is commonly considered as presumptive evidence of the existence of fracture of the anterior fossa, though this symptom may, of course, be due to the giving away of a bloodvessel, without lesion of the bony structures, and may even, as pointed out by Lucas, result from a superficial injury, the blood passing backwards from the eyelids to the conjunctival ocular tis- sues. This form of eechymosis may, however, be distinguished from the subconjunctival and subcutaneous palpebral eechymosis which constitutes the ordinary "black eye," by the fact that it is unaccompanied by contu- sion of the superficial structures, and that it is not a primary phenomenon ; it is, indeed, caused by the gradual leakage of blood from within (the sub- conjunctival tissue being involved before the eyelids), and frequently does not reach its point of greatest intensity until several days after the time of injury. The hemorrhage is usually venous, probably resulting from lace- ration of the cavernous sinus, though it may be arterial, going on to the formation of a circumscribed traumatic aneurism, and eventually requiring ligation of the carotid artery—an operation which has been successful!v resorted to under such circumstances by Busk, Scott, and others. 2. Hemorrhage from the Ears cannot, of itself, be considered a sign of much importance, as it may arise from any injury which ruptures the membrane of the tympanum, without necessarily implying the existence of fracture. If, however, it be profuse and long-continued, the blood which remains in the meatus pulsating, and other symptoms of cerebral injury being simultaneously present, it becomes probable that a fracture of the petrous portion of the temporal bone has occurred, and that the blood proceeds from one of the large venous sinuses in that neighborhood. The occurrence of a Discharge of Thin Watery Fluid from the ear or nose or through a wound of the scalp, is very significant of fracture ; this discharge appears, in most cases, to be due to the escape of cerebro-spinal fluid, though instances have occurred in Avhich the secretion of the tym- panic cavity, and even saliva (leaking backwards through a perforation of the meatus, produced by the fragment of a broken jaw), have been mis- 350 INJURIES OF THE HEAD. taken for the characteristic discharge of fracture at the base of the skull. If, however, a profuse watery discharge occur from the ear immediately after the accident, or if it follow a profuse and continued aural hemorrhage, there can be little doubt that the cerebro-spinal fluid is indeed escaping, and that a fracture, therefore, is necessarily present, though Roser believes that, if the meninges be ruptured, cerebro-spinal fluid may leak through the pores of the cranial bones without these being broken. Watery discharge from the nose is, of course, much less significant, and as an accompaniment of fracture is less often met with than that from the ear. Compound fracture of any part of the cranial vault may be attended by a discharge of cerebro-spinal fluid, provided that there be a communication between the external wound and the sub-arachnoid cavity. It is stated by Robert, who has given much attention to this subject, that cases of fracture accompanied with discharge of cerebro-spinal fluid are always fatal; this is probably a mistake, for several well-authenticated cases are on record in which recovery has taken place in spite of the occurrence of these discharges, though, of course, in any case which does well there is always the possibility of an error having been made in the diagnosis. A sudden cessation of the watery discharge is apt to be quickly followed by fatal coma. Prognosis.—As far as the injury to the bone is concerned, there is very little risk from fracture of the skull; osseous union commonly occurs without difficulty, unless there has been loss of substance, in which case the gap is filled by means of a firm and dense membrane, as shown in Fig. 190, from a photograph kindly sent ine by Dr. Charles E. Slocum, of Defiance, Ohio. If necrosis takes place, the sequestrum is thrown off by a process of exfoliation, and if both tables of the skull are involved, the dura mater may be seen covered with healthy granulations, and pulsating at the bottom of the wound. Very large portions of the skull may be lost, either at the time of the accident, or at a later period by necrosis, with- out injury to the patient; and, in- deed (paradoxical as it may seem), those cases often appear to do best in which the skull has suffered most extensively, the force of the blow or other injury spending itself, as it were, upon the bone, and the brain escaping with comparatively little harm. The danger in any case of fractured skull depends upon the amount of injury done to the cranial contents, this injury consisting in con- tusion, laceration, and subsequent inflammation, conditions which have already been considered. Treatment.—The treatment of a fracture of the skull must have refer- ence to the condition of the cranial contents. The question of trephining in these cases will be most conveniently considered hereafter; after the operation, if it be resorted to, or in cases in which operative measures are Fig. 190.—Fracture of skull with great loss of substance. (From a patient under the care of Dr. Chaeles E. Slocum.) INJURIES OF THE CRANIAL CONTENTS. 351 not required, the treatment should be conducted on the principles already laid down for the management of cerebral contusion and laceration, and traumatic encephalitis. Cold to the head, opium and calomel, liquid food, enemata, with perhaps blisters or local bloodletting if coma be threatened, will be found the most useful remedies in the majority of these cases. In cases of compound fracture, loose fragments and foreign bodies should be removed, if possible, and depressed but adherent portions of skull elevated, provided that this can be effected without too much disturbance. The danger is, however, less from compression than from inflammation, and hence rough handling or careless probing of the brain must be rigorously avoided. Dr. Fulton suggests that a narrow glass test-tube should be employed instead of a probe, so that the parts touched may be seen as well as felt. Dr. Wharton's and Dr. Luhn's statistics both show very clearly that the prognosis is much better when foreign bodies are removed than when they are allowed to remain; but then the cases in which it is possible to remove them are those in which the injury is com- paratively slight and superficial. In fractures at the base of the skull, art attempt should be made to prevent septic infection through the pharynx, ear, or nostril, by the use of appropriate applications to those parts. Injuries of the Cranial Contents. Wounds of the Brain and Meninges__The brain or its mem- branes may be wounded, and portions of the cerebral mass itself driven out of the skull in cases of fracture, recovery yet ensuing; it is indeed surprising to see what serious wounds may occasionally be inflicted upon the brain and its membranes, without a fatal result. I saw, at Cuyler IT. S. A. Hospital, a soldier who had survived a perforating gunshot frac- ture of the skull, and Dr. O'Callaghan gives the case of an officer who lived seven years with the breech of a fowling-piece within his cranium ; perhaps, however, the most remarkable cases on record, of recovery after wound of the brain, are those narrated by Dr. Harlow and Prof. Bigelow, and by Dr. Jewett; in the former case an iron bar, three and a half feet long, and weighing thirteen pounds, passed through the head, and in the latter, a somewhat similar injury was produced by a gas-pipe The symptoms and prognosis of brain wounds will of course vary with the particular part involved. Lesion of the optic tract may cause blind- ness; or a wound in the neighborhood of the fourth ventricle, saccharine diabetes. Wounds of the base of the brain are more dangerous, and more quickly fatal, than those of its convexity. The treatment of brain wounds consists in the adoption of the measures which have already been so often referred to as appropriate in all cases of injury to the contents of the cranium. Keen suggests that any gap in the dura mater should be closed by transplanting a flap of inverted pericranium, and reports a case in which this was successfully effected. Hernia Cerebri—Under this name have been included several distinct conditions, which have merely in common the protrusion of a fungous- looking mass through an opening in the skull. This mass may be merely a collection of coagulated blood, or may consist of exuberant granulations, proceeding from the dura mater or from the wounded brain itself; but the true hernia cerebri consists of softened and disintegrated brain matter, mixed with lymph, pus, and blood. The mass projects through the dura mater and skull, and the superficial portions, which slough and are cast off, are usually replaced by fresh protrusions, until the patient dies exhausted. More rarely the patient may recover, the whole projecting mass being disintegrated and removed, or slowly shrinking without the occurrence of 352 INJURIES OF THE HEAD. sloughing. It was taught by Guthrie that hernia cerebri was more likely to occur through small openings in the skull than through large apertures. This view, however, is not confirmed by the experience of all observers, and the occurrence of the affection appears to depend more upon the condi- tion of the brain than upon that of the skull. Hernia cerebri usually manifests itself in the course of the first or second week of the injury, the period varying with that of the development of cerebritis. The treatment is that of encephalitis in general. I doubt if advantage can be obtained from any local treatment, though it is said that iu the early stages slight pressure has proved useful. Avulsion, excision, and ligation are all to be reprobated, as more apt to add fresh irritation than to be productive of benefit. As the affection seems often to result from the imbedding of spicula of bone in the brain, we should be careful to remove all loose frag- ments that can be detected; while, on the other hand, as hernia cerebri cannot occur without wound of the dura mater, this membrane should be scrupulously respected in all our operations upon the skull. Trephining in Injuries of the Head. The objects sought to be gained by the use of the trephine are the re- moval of compression, whether caused by extravasation, by displaced bone, or by the presence of pus, and the prevention of inflammation, hy the removal of foreign bodies, such as sharp spicula of bone, musket-balls, etc. Trephining is also occasionally employed in the treatment of epilepsy, when it appears probable that the disease is caused by a morbid condition of the skull. SeMillot recommends trephining as a prophylactic in many cases of fractured skull, but his views are not shared by surgeons generally. Trephining for Extravasation__If it were possible to be sure that the seat of extravasation was between the brain and dura mater, and that there were no other lesions, operative interference might be employed with some hope of benefit. When it is remembered, however, that the seat of extravasation can very rarely be determined, and that these cases are almost invariably complicated with grave injury of the brain substance, it ceases to be a matter of surprise that Mr. Hutchinson was able to de- clare, a few years since, that the modern annals of surgery did not con- tain any cases in which life had been saved by trephining for this state of things. There are, indeed, a few cases on record, in which blood has been evacuated from between the dura mater and skull, or even from the cavity of the arachnoid, the patients recovering, and Krbnlein and Rochet have recorded cases of successful trephining for depressed fracture with rupture of the middle meningeal artery ; but, in the majority of instances, the operation has been useless, or has even hastened death.1 Hence, I cannot but think that, as a rule, the surgeon will do wisely to abstain from the use of the trephine in these cases, relying upon medical treatment, as in dealing with ordinary apoplexy. If the trephine be employed, a large circle of bone should be removed, in order to give room for the evacuation of coagula, and to afford a fair opportunity to secure any vessel that may be found bleeding. Powers recommends trephining in two places, so as to afford a counter-opening for through-drainage. 1 Successful cases have, however, been recorded by Stoker and Warren, and several surgeons, including Ball, H. Allingham, Perkins, Lanphear, and Homans, have suc- cessfully trephined for clots below the dura mater, the hemorrhage in the last-men- tioned surgeon's case being the result of counter-stroke. Ligation of the common carotid for bleeding from the middle meningeal artery has been practised by Bentley, Alexander, Gamgee, and Ransohoff, Alexander's case being the only one which ter- minated favorably. The external carotid has been unsuccessfully tied by Mr. Howse. TREPHINING FOR DEPRESSED BONE. 353 Trephining for Depressed Bone—Probably few surgeons, at the present day, would think of operating in a case of Simple Depressed Fracture, without symptoms of compression. Even if there be such symptoms, the advantages to be derived from trephining are, at least, very problematical, for (1) the symptoms, if due to the depressed bone, will probably pass off by the brain accustoming itself to the pressure ; and (2) if the compression persist, it will, most probably, be found to be due to ex- travasation from laceration of the brain itself, a condition which evidently would not be benefited by trephining. Indeed, Hutchinson goes so far as to consider compression of the brain as the result of depressed fracture "an imaginary state," and declares that he has "never seen a case in which there seemed definite reason to think that depression produced symptoms." Although the rule is still given, in most of our surgical works, that trephining is indicated in simple fracture accompanied with marked symptoms, there can be no doubt that most surgeons of large ex- perience are averse to operating in these cases; and for my own part, I can only say that I have never seen a case of this kind in which I thought the use of the trephine justifiable, nor an autopsy which showed that the operation could possibly have saved life. With regard to Compound Depressed Fractures, it seems to me that the course to be pursued should vary, according as they are or are not im- pacted. In an impacted fracture, the depression is necessarily inconsider- able, and if symptoms of compression are present in such a case, they are due to extravasation or laceration, and not to the depression ; moreover, the impaction prevents the access of air to the cranial contents, and thus lessens the risk of disorganizing inflammation following the injury. Hence, in impacted fracture, though compound and depressed, I would not advise an operation, even if symptoms of compression were present. For one case like Keate's, in which by a happy accident the operator might dis- cover a wound of a large artery, and thus relieve the compression, there are many cases in which trephining could be productive of no benefit, but would, by admitting the atmosphere, seriously complicate the prospects of recovery. If, however, in a case of compound impacted fracture, convulsions or other symp- toms of cerebral irritation should come on at a later period, the surgeon should explore the wound, and, if it should ap- pear that suppuration had occurred beneath the seat of frac- ture, might properly apply the trephine, as I have myself done with advantage under these circumstances. In th.e case of non-impacted fracture, the rule has already been given to remove the loose fragments, and elevate the remainder. In many cases this can readily be done by means of the ele- vator and forceps, without enlarging the opening in the skull. If, however, the aperture be too small to admit of safe man- ipulation, there can be no objection to enlarging it, either with a Hey's saw, with cutting pliers, or with a small tre- phine. The risks of atmospheric contact are unavoidable in such a case as this, and the best that the surgeon can do is to clear the wound as well as possible, by the removal of osse- ous spicula and foreign bodies. It will thus be seen that I would restrict the use of the trephine within very narrow limits; it is not to be used with the idea of relieving com- pression, nor with the idea that there is any special virtue in the operation to prevent encephalitis. The trephine should be used merely as Hev's saw is used, mechanically, to enlarge an opening 23 Fig. 191. — Hey's saw. 354 INJURIES OF THE HEAD. which would be otherwise too small to allow the surgeon to carry out plain therapeutic indications. The surgeon should cautiously explore every compound non-impacted fracture, and if there be loose spicula, re- move them, whether there be symptoms of compression or not. As the inner table is often more extensively involved than the outer table (espe- cially in punctured fractures), it may be necessary slightly to enlarge the opening in the skull in order to remove these spicula, and this enlargement may be done with or without the trephine, according to the nature of the case. All this must be accomplished, however, with the utmost caution and gentleness; and I believe, with Brodie, that it is better to leave, im- bedded in the brain, a foreign body, or even a fragment of bone, than to add to existing irritation by reckless attempts at its removal. Trephining for Intra-cranial Suppuration.—Some years ago, under the influence of the teaching and example of the celebrated Percival Pott, this operation was more frequently resorted to than it is at the pre- sent day. As we have already seen, there is, in the large majority of cases, no symptom which renders it certain that pus is present; and, as Hutchinson remarks, if we adopt the rule of trephining in all cases in which, after bruise or fracture of the skull, the patient has become hemi- plegic or comatose, with inflammatory symptoms, we will operate in twenty cases of arachnitis for one in which we will find any pus to be evacuated; while even if pus be found, and can be removed, in the immense majority of cases arachnitis will coexist, and cause death in spite of the operation. " I have repeatedly," says Hewett, "seen the trephine applied under such circumstances, and matter evacuated, but without any permanent benefit. Indeed, the successful issue of a case of trephining for matter between the bone and dura mater is, I believe, all but unknown to surgeons of our own time." When the chances of a successful issue are so slight there is not much encouragement to resort to an operation ;' more especially as these cases will occasionally recover, at least temporarily, under expectant treat- ment. Even if pus be present, it is impossible to know that it is within reach, and cerebral abscess may continue for many years, producing little or no disturbance; while, though recovery has in a number of cases followed trephining under these circumstances,2 the operation has in other instances but superadded a new injury to those already existing. Chassaignac has proposed to trephine as a prophylactic against pyaemia, in cases of contused skull; but the operation is surely not justified, either by experience, or by what we know of the etiology of the affection meant to be prevented. Trephining for Epilepsy—With regard to trephining for epilepsy, I can only say that 1 consider the operation usually unadvisable,3 and have myself met with but three cases in which I have thought it right to adopt this mode of treatment. Its risks are not inconsiderable, 16 out of 72 cases collected by Billings, and 28 out of 145 collected by Echeverria, having proved fatal ;4 and when we remember the well-known fact that epilepsy is apparently and temporarily curable by very various remedies, which have at least the merit of being harmless", we should pause before 1 Unless, as in cases successfully trephined by P. H. Watson, N. R. Smith, and Cras, an orifice in the skull should plainly communicate with an intra-cranial abscess, when, if the opening were insufficient, the operation would be indicated, as it would also in cases of intra-cranial abscess following suppuration of the middle ear. 2 See page 347. 3 According to Broca, in epilepsy from cranial injury, the temperature is raised upon the affected side ; hence, if the temperature be highest on the uninjured side, the epilepsy is not due to traumatic causes, and will not be relieved by an operation. 4 Dr. W. T. Briggs claims remarkable success in trephining for epilepsy, having cured 25 and lost but 1 case among 30. • CEREBRAL LOCALIZATION. 355 recommending an operation which may not improbably itself cause death and of which the prospective benefits, as regards permanence, are certainly doubtful.1 My own patients, I should add, recovered from the operation and two of them appeared to have been benefited bv it as long as thev remained under observation. I have also trephined in one case for melan- cholia following head-injury; the patient recovered from the operation and his mental condition appeared to have undergone slight improvement' Cripps reports two cases of successful trephining for general paralysis of the insane, and Lanphear recommends the operation for cerebral softenino- Mr. Horsley has supplemented the operation of trephining for traumatic epilepsy by dissecting out a cicatrix from the brain itself. The patient recovered from the operation, and had had no return of convulsions three weeks afterwards. Similar operations have been successfully performed by Keen, Nancrede, and other surgeons. Cerebral Localization—Broca, Lucas-Championniere, Sequin Nancrede, Mills, and others, have given rules for selecting the point of tre- phining, in cerebral injuries, by " localizing" the seat of lesion. Without going into all the details of the subject (which may be found well worked out in Dr. Xancrede's article on Injuries of the Head, in the fifth volume of the International Encyclopaedia of Surgery), I may say that the cerebral centres of interest to surgeons in regard to operative measures are those m the immediate neighborhood of the sulcus which separates the frontal from the parietal lobe of the cerebrum—the sulcus of Rolando. If there be paralysis of both lower limbs, the trephine should be applied over the uppermost portion of this sulcus (of course, on the side of injury) ; in case of hemiplegia, over the upper and middle portions, on the side opposite to that which is paralyzed; when the palsy involves the face and upper extremity, over the lower third of the sulcus and a little in front- in paralysis of the arm with aphasia, below and in front of the sulcus ■ and in palsy limited to the face, with aphasia, clearly in front of the sulcus and below its lowest point. In order to mark the line of the sulcus of Rolando on the scalp, the first point is to determine the position of the bregma or point of junction of the frontal and two parietal bones. This can often be felt through the skin, but if not, it can be found by applying Broca's "flexible square," as in Fig. 192, taking care that the head is so placed as to make the line joining the alveolus of the upper jaw and the condyle of the lower jaw horizontal. The square is provided with a plug, just behind the junction of its limbs, to be introduced into the external auditory mea- tus, and the horizontal limb then passing below the columna nasi, the bregma will be found in the median line of the skull, at the posterior edge of the vertical limb. Measuring back- wards from this point 5.5 centimetres (or only 5, if the patient be a woman), the surgeon has «* Position of the upper end of the sulcus of Kolando; to find the lower end he draws a line horizontally backwards 1 centimetres from the external angular process of the frontal bone, allr1^1?1* te™1in,ated cases reported by Gerster and Sachs, one patient was materi- operation th°an befo/ ted' four were not imProved, and one was worse after the Fig. 192.—Flexible square applied. (After Lucas-Championniere.) 356 INJURIES OF THE HEAD. at the beginning of the temporal ridge, and then another line at right angles to this, and at its posterior "extremity, 3 centimetres upwards Joining the two points thus found, the course of the sulcus of Rolando is indicated with sufficient accuracy for all operative purposes. An easier method of finding the upper end of the sulcus is suggested by A. W. Hare, who from experiments on eleven heads finds that the distance from the glabella to the upper extremity of the sulcus of Rolando is just55.7 per cent, of the entire distance from the glabella to the external occipital protuberance. Chiene finds it sufficiently accurate to take at the upper end a spot half aii inch behind the mid-point between glabella and inion, and then to draw a line four inches downwards and forwards at an angle of 67.5° (three- fourths of a right angle) with a vertical line dropped from the starting- point. The fixed points needed should be marked on the skull with~a sharp instrument penetrating the scalp, so that they may readily be found when this is reflected. I hope that I may be pardoned for still holding the opinion that, although guided by " cerebral localization," numerous brilliant operations have been performed by Macewen, Godlee, Nancrede, Horsley, Weir, Keen, Mc- Burney, and other surgeons, yet, upon the whole, these interesting inves- tigations have thus far not proved as practically useful as was°at first anticipated As candidly pointed out by Dr. Nancrede himself, the chief gain derived from them hitherto has been in showing that in certain cases operations should be avoided ; but operations would not be likely to he undertaken in these cases by surgeons holding the conservative views which 1 have endeavored to inculcate; and, it must be added, encouraged by misinterpreted indications, not a few operations on the brain have been performed, which post-mortem examination has shown had better not have been attempted. Operation of Trephining—The form of trephine ordinarily em- ployed is shown in the accompanying illustration (Fig. 193). It is" to be applied evenly on the surface of the skull, with the centre-pin1 slightly projected, and is to be worked cautiously by light turns of the wrist from left to right'and from right to left, until a groove is formed, when the centre-pin must be withdrawn, le.-t it puncture the skull and wound the dura mater. The surgeon then Fig. 193.-Common trephine. Fn;. 194.-Different forms of elevator. proceeds slowly and gently, brushing away the bone-dust, from time to time, and testing the progress made by means of a fine probe or toothpick. When the diploe is reached (if there be any), the trephine works more freely, and blood escapes with the bone-dust. As the inner table is ap- 1 If the use of the centre-pin be undesirable, the crown of the trephine may be steadied by applying it through a piece of perforated pasteboard, as suggested by Dr. P. H. Watson, of Edinburgh. 06/ OPERATION OF TREPHINING. 357 proached, the surgeon must renew his precautions, lest undue pressure, or an accidental slip of the instrument, should wound the dura mater, an occur- rence which would be very apt to prove fatal. The disk of bone which has been separated will often come away in the crown of the trephine, or may otherwise be readily removed with the elevator (Fig. 194) and forceps. If the external wound be not large enough to allow the application of the tre- phine, more room may be afforded by means of a crucial, "J", or curved incision, the flaps of the scalp being held out of the way, and carefully replaced when the operation is completed. Macewen and St. George re- commended that the disk of bone itself should be replaced, but decalcified bone is preferred by Prof Senn. Frankel, Weinlechner, Eiselsberg, and Hinterstoisser apply a plate of celluloid, and Konig adjusts a flap in- volving the scalp and outer table of the skull. Keen has tried (unsuccess- fully) the insertion of a plate of sheep's bone. If it be necessary to enlarge the opening made by the trephine, this may be conveniently done with Dr. Hopkins's modification of the gouge forceps (Fig. 105). The wound should be lightly dressed, and the constitutional treatment of the patient carried out in accordance with the principles already laid down for the management of cerebral injuries. There are certain regions of the skull to which the trephine should not be applied, if it can be avoided ; these are the various sutures, the lines of the large venous sinuses, the anterior inferior angle of the parietal bone (where there would be risk of wounding the middle meningeal artery), and the frontal sinus; if it should be neces- sary to operate in the latter situation, the outer table should be removed with a large trephine, and the inner table with a smaller instrument. Fig. 195.—Hopkins's trephining forceps. Should one of the large sinuses be unfortunately wounded, a compress should be applied, being insinuated, if necessary, between the skull and dura mater; though ligation has been occasionally practised under these circumstances, it is attended with difficulty, and the delay in attempting it has sometimes proved fatal. Fractures at the base of the skull have usually been considered unsuited for the use of the trephine, but that in- strument has been successfully employed in such cases by Hutchinson, Warren, and other surgeons. The Conical Trephine (Fig. 196) is an old instrument, the use of which has been, in modern times, revived by Gait, of Virginia. It has the ad- vantage over the common instrument, to which it is rightly preferred, that its peculiar shape prevents the possibility of its unexpectedly plunging into the brain ; it, however, has the disadvantage that it divides the skull obliquely, and thereby exposes the part to greater risk of necrosis. The results of the operation of trephining are very unfavorable, the pro- portion of recoveries having been in the New York Hospital only about 358 INJURIES OF THE HEAD. 1 in 4, and in University College Hospital (London) 1 in 3, while in Paris almost every case operated on a few years since, according to Nelation, proved fatal. I have myself resorted to trephining in 33 cases, but in only 12 has the operation been followed by permanent recovery. The majority of deaths after trephining are, however, due, not to the operation, but to cerebral lesions on which the operation could have no effect, so that statistics are yet wanting to show the absolute mortality of the operative procedure. In only two of my own thirty-three cases did the operation seem to hasten death, while in three which ultimately proved fatal great relief was afforded, and life was prolonged for several weeks. Twelve cases ended in complete and one in partial re- covery, and in the remaining fifteen the effect of the operation appeared to be entirely indifferent. During our late war, 227 terminated cases of trephining gave 126 deaths and 101 recoveries; 451 cases of removal of splinters or elevation of fragments, without trephining, gave 176 deaths and 275 recoveries; while 3447 cases treated by expectancy 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 opera- tion of trephining. The most elaborate statistics of trephining yet published are those of Dr. Blubm, who has collected 923 cases, with 450 recoveries and 473 deaths, a total mortality of 51.25 per cent. The death-rate varies accord- ing 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). Fig. 196.—Conical trephine. Primary Secondary Late . Period unknown Aggregates Total. Recovered. 51 94 39 266 450 Died. Mortality per cent. 114 158 59 592 63 64 20 326 55.26 39.24 33.90 55.07 923 473 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.G per cent. But even with these comparatively small death-rates, it be- hooves 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 injuries, the probability of benefit from the operation is seen to he limited to an exceedingly small number of cases. INJURIES OF THE SPINAL CORD. 359 CHAPTER XVII. 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 sav with regard to sprains, fractures, and dislocations of the vertebral column. Injuries of the Spinal Cord. Concussion of the Spinal Cord.'—This may vary, like concussion of the brain, from the slightest jarring or shaking, up to complete 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, fatal (except when accompanied by fracture or dislocation), death as a re- sult 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 cases have been recorded by Boyer, Frank, and others, in which such an event has been supposed to occur, it is probable that, with the more accurate means of examination which are now possessed, positive lesions could have been discovered. Death may, of course, occur from shock, which is an oc- casional complication of spinal injuries; or from concomitant lesions of other organs—lesions which may readily escape detection, if attention be directed chiefly to the condition of the spine.2 The post-mortem appear- ances, in fatal cases of spinal concussion, may be classed as (I) extravasa- tion 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) degenera- 1 The term concussion is retained from motives of convenience. It is not, however, scientifically correct, the various conditions which are designated by the term con- cussion being really instances of contusion, partial rupture of the cord-fibres, etc. See remarks on Concussion of the Brain, in Chap. XVI. 2 See, in connection with this subject, an interesting paper, by Dr. W. Moxon, on thrombosis of the renal vessels through injury to the lumbar spine. (Guy's Hosp. Reports, 3d s., vol. xiv. pp. 99-111). 360 INJURIES OF THE BACK. tion of the structure of the cord, without any evidence 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 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 be- tween the latter and the cord ; and it is probably in one of these positions that extravasation usually occurs, when the symptoms are slow and pro- gressive 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 dis- appear. This is the most plausible explanation of the symptoms in the remarkable case recorded by Hughes, 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. The upper limit of paralysis will, of course, indicate clearly the height at which the extravasation has occurred. Laceration or Rupture may occur in the spinal membranes (partic- ularly 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 ea>es 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 con- secutive to meningitis, the white portion may alone be involved. Inflam- mation 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 result of injury to the spine, without the manifestation of any evidence of inflammation, either during life or upon post-mortem inspection. Paral- ysis, both motor and sensory, sometimes accompanied with muscular SYMPTOMS OF SPINAL INJURIES. 361 rigidity, gradually creeps upwards, until death ensues from interference with the respiratory function. The autopsy shows diffused white 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 eve appears perfectly healthy, though marked changes are subsequently dis- covered by careful microscopic inspection. Wounds of the Spinal Cord.—The spinal cord may be wounded by sharp-pointed or cutting instruments, bv 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 maybe 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 paralysis only of the side injured, as in instances recorded by Vigne's, Peniston, and others; or loss of motion on the injured, and loss of sensa- tion on the opposite side, as in cases narrated by Boyer and by Hughlino-s 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 which is not surprising when we reflect that the rational symptoms are the same in the various forms of lesion. I shall adopt the classification of symptoms which I employed in my monograph on Injuries of the Spine, published in 1867, and which is pretty much the same as that used by Brodie, in his classical paper in the Medico-Chirur- gical Transactions, vol. xx. Motor Paralysis.—The most striking, and probably the most constant, symptom in cases of spinal injury, is paralysis of the voluntary muscles 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 usually less complete than in those at a higher point, the cord being protected in this part by the roots of the cauda equina. Paralysis, ordinarily, does not extend to 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- ord, 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 SDinal lesion in a down- ward direction may be determined by means of the electrical test, proposed ■>v M. Landry. This surgeon found, in a case of luxation of the fifth dorsal vertebra, that the muscles of the thigh ceased to respond to electricity, while those of the leg, though equally paralyzed, continued to contract in response to the electrical stimulus. The autopsy showed that the part of tne cord1 which supplied nerves to the femoral muscles was disorganized, while that whence arose the nerves going to the leg was quite healthy. inus the fact that each segment of the cord constitutes a separate nerve- centre aflords a means of accurately determining the extent of.that portion 362 INJURIES OF THE BACK. 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 pro- gressive 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, a 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 Velpeau, 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 Brown- Pe\mard, 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 cases. The value of this symptom for diagnostic purposes is, however, diminished by the fact that the cord is often found compressed, after death, without spasms having been observed during life. The occurrence of con- vulsions at a later period (as already mentioned) may denote the onset of spinal meningitis; while again, in cases which recover, muscular twitch- ings not unfrequently accompany the return of motor power. Loss of Sensation usually accompanies and is coextensive with motor paralysis, in injuries of the spine. So complete was the loss of feeling in a case recorded by Purple, that the patient submitted to amputation of both thighs, without the use of an anaesthetic, and without manifesting any emotion during the operation. Occasionally sensory precedes motor paralysis, while, on the other hand, in favorable cases, the power of feeling is not unfrequently regained wrhile that of motion is still very imperfect. Hyperaesthesia 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 hyperes- 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 he 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. SYMPTOMS OF SPINAL INJURIES. 363 Dyspnoea.—This is a marked and distressing symptom of injuries of the cervical and upper dorsal regions of the spine. It is often said that in lesions of the cervical cord, respiration is performed by the diaphragm alone ; this is not strictly correct, for, as pointed out by Shaw, in many cases the diaphragm is helped by the serratus magnus muscle (supplied bv the external thoracic nerve), which, when the shoulders are fixed, tends to lift and expand the chest. If the spinal cord be destroyed above the origin of the phrenic nerve, death is instantaneous. The occurrence of dyspnoea in dorsa/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 Cosliveness 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- neys, is not unfrequently met with in cases of sprain of the lumbar spine. This symptom is not usually one of serious import, though Shaw reports a case in which the bleeding was so profuse as to render the patient anaemic Ihere 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 urine, from being clear and acid, becomes tur- bid, ammoniacal, and loaded with mucus, and at a later period with phos- phate of hme. This condition may continue indefinitely, or mav disappear, or acidity and alkalinity of the urine may alternate, without any verv 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 madder, though the latter presented no marks of inflammation. C.VS/?,hs is an almost constant sequence of severe spinal lesions; it is prooably due chiefly to the mechanical injury to the bladder from over- 364 INJURIES OF THE HACK. 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 Brown-Se'quard and Lidell, of neuropathic origin, and thus analogous to the cutaneous inflammation which ends in bedsores. Priapism.—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, particularlv when the injury is in the cervical region, priapism may occur spontane- ously, immediately after the accident, and is then due (as pointed out bv 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- neously—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 bypassing the catheter. Tbeexisteuce of priapism is usually evidence of severe and permanent injury to the spinal cord, though that this symptom may occur in connection with simpleconcussion 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 several months. Flushed Face, usually accompanied by Lachrymation, and by Con- tracted or merely Myotic Pujnls, 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 cervico- eephalic 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 Chossat and Brodie.' The temperature of the para- lyzed parts frequently rises much above the normal standard, this symp- tom 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 observed 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 condition of the sympathetic or vaso-motor nerve. Persistent elevation of temperature, in spinal injuries, is a verv 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 tempera- ture, the patient often experiences a distressing sensation of coldness. 1 J. W. Teale has reported a case of spinal injurv in which the temperature is said to have ranged during nearly nine weeks from 108° to 125° Fahr., and in which the patient ultimately recovered ; but, as in cases recorded by Schliep, Sellerbeck, Ma- homed, and S. Mackenzie, deception may have been practised by the patient making friction upon the bulb of the thermometer, or in other ways. Dr. Donkin has collected eight cases of various kinds in which recovery followed, though the temperture ranged from 108° to 117° Fahr. In a case of spinal concussion under Dr. Little's care, in the .Adelaide Hospital, Dublin, the temperature is said to have risen to 133.6° Fahr., without evil result to the patient. 2 Temperatures of 82° Fahr., 81.75° Fahr., and 80.6° Fahr., were observed in fatal CONCUSSION OF THE SPINE FROM INDIRECT CAUSES. 365 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 bedsores 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. Bedsores 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-Se*quard, Charcot, and Lidell, certain of the so-called bedsores 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 than 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 oc- curred three weeks after a blow on the spine, the patient recovering; while in one of seven cases which occurred during our late war, the au- topsy 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 injuries of any portion of the spinal cord, resulting either from direct vio- lence simultaneously inflicted on the head, or from counterstroke. Deli- rium, Coma, and Insomnia have each been occasionally noted in cases of spinal injury ; the latter symptoms, however, I believe, only in instances in which the cervical region has been involved. Cerebral Meningitis, as observed by Ollivier, often complicates inflammation of the spinal membranes. Concussion of the Spine from Indirect Causes; Railway Spine—Under these or similar names, is described by Erichsen and other English surgeons, a peculiar morbid condition characterized by very varied nervous symptoms, both physical and mental, which, according to these authors, are all directly traceable to the state of the spine. This subject has excited a great deal of interest, and a great deal of controversy, chiefly because of the numerous suits for damages which have been brought against railway 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 re- markable perversions of the special senses, double vision, photophobia, tinnitus aurium, loss of tactile sensibility, etc. Hyperaemia of the optic disk has been observed by W. Bruce Clark, and serious intra-ocular changes have also been noticed by Allbutt and 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 cases reported by Van der Kolk, Wagstaffe, and Nieden. Kosiirew has recorded a latal case of cranial injury, in which the temperature ranged from 79.7° Fahr. to 84.2° 366 INJURIES OF THE BACK. that its sensibility is exalted at one, two, or three points. These are usually the upper cervical, the middle dorsal, and the lumbar regions. The exact vertebrae that are affected vary necessarily in different cases; but the exalted sensibility always includes two, and usually three, at each of these points. It is in consequence of the pain that is occasioned by any move- ment of the trunk in the way of flexion or rotation, that the spine loses its natural suppleness, and that the vertebral column moves as a whole, as if cut out of one solid piece, instead of with its usual flexibility." Other writers of eminence are disposed to doubt the necessary connection of these symptoms with any particular morbid condition of the spine, looking upon "these cases of so-called railway spinal concussion as, generally, instances of nervous shock, rather than of special injury to the spinal cord."1 Dr. Clevenger believes that the spinal sympathetic nervous system is the part primarily affected, and that the cord only becomes secondarily involved as the result of vaso-motor disturbances. There is, as far as I know, but one case in which the post-mortem appearances after death from " railway con- cussion" have been recorded, and that is Mr. Gore's case, which has been successively published by J. Lockhart Clarke, Erichsen, Le Gros Clark, Shaw, and H. W. Page. The condition of the cord in this case closely resembled, as pointed out by Le Gros Clark, that which, according to Radcliffe, is found in ordinary cases 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 examinations. Hitherto our experience has been derived almost wholly from litigated cases, deformed by contradictory statements and opinions ; and the verdicts of juries have stood in the place of post-mortem reports." 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 W. Gull and Dr. Bastian. In view of the great obscurity which is thus seen to surround this subject, I think that the surgeon will do wisely to exercise great caution in declaring that a patient is suffering from "concussion of the spine from indirect causes," whether the result of railway, or of other injury ; at the same time, there can be no doubt that grave morbid changes in the spinal cord do result from comparatively slight blows upon the back, and, of course, in a railway collision, it is very possible that an in- jury might be received which would induce such changes. This fact has long been recognized in a general manner, but is clearly proved by a case which Dr. H. Charlton Bastian has published in the fiftieth volume of the Medico-Chirurgical 2'ransactions, and which has been already referred to (see page 361). Injuries of the Vertebral Column. Sprains—When we consider the number of joints in the vertebral column (nearly eighty), it is not surprising that twists and sprains in this part are occasionally met with, but rather that they are not more frequent than experience shows them to be. The part of the spine most exposed to sprains is the lumbar region, next the cervical, and lastly the dorsal, which is rarely affected. Apart from the risk of concomitant lesion of the cord 1 Le Gros Clark, Lectures on the Principles of Surgical Diagnosis, etc., p. 152. FRACTURES AND LUXATIONS OF VERTEBRAL COLUMN. 367 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 mo- tion, etc. In most instances the ligamentous and other affected tissues gradually return to a healthy condition, but, under other circumstances, if great stretching and laceration have occurred, permanent weakening of the part may ensue, requiring the constant employment of artificial means of support. An occasional but more dangerous consequence is the exten- sion 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 occi- pito-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 by nerve-lesion, is essentially that of sprains in other parts of the body. Rest, mechanical support, soothing applications at first, and at a later period stimulating 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 treatment 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 remaining varieties of mechanical injury to the vertebral column. Fractures and Luxations of the Vertebral Column__I shall consider these two forms of spinal injury together, because, in the first place, they are very commonly associated in the same case, and because, secondly, it is often quite impossible to determine whether a given injury of the spine be a fracture or a dislocation, until a post-mortem examination reveals the exact nature of the lesion. The possibility of luxation 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 Bryant says that of seventeen autopsies made at Guy's Hospital in cases of spinal injury, during six years, no less than six showed the lesion to have been pure dislocation. I have not myself met 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 394 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 very various: in most of the instances met with in civil practice, the alleged causes have been falls or blows, acting sometimes by direct, but probably more often by indirect violence. In the cervical region, these injuries have resulted from falls upon the head or the buttocks, from plunging headlong into shallow water, from falls in turning somersaults, from the head being 368 INJURIES OF THE BACK. 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 cases occur among those in early adult life. Maschka has recorded a case of dislocated axis, in a child killed by its mother, when it was only eight days old, while Arnott saw a fracture of the same bone, produced by fall- ing down stairs, in a man aged seventy-four. Symptoms.—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 mo- bility, and crepitus. Local pain and tenderness on pressure, though often present in these cases, are in no wise distinctive, for they are frequently more strongly marked in sprains than in these more serious injuries. (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 indi- cate fracture, which may involve the ver- tebral arches, or merely the spinous pro- cesses themselves. Fracture of the body of a vertebra, by allowing the approxi- mation of the vertebrae above and below, usually causes angular deformity marked by undue prominence of the spinous pro- cess of the affected vertebra, or of that next above. Rotary deformity, or twist- ing of the spinal column upon its long axis, may be considered indicative of lux- ation, which may or may not be accom- panied by fracture; it is seldom recog- nized, I believe, during life, except in the cervical region. Bilateral dislocation, an injury almost exclusively confined to the neck, would be marked by angular deform- ity, and, if in a backward direction, proba- bly could not in most cases be distinguished from fracture of the vertebral body. Though deformity, when present, is prob- ably the most significant of all the physi- cal signs of these varieties of injury, its absence by no means proves that fracture or luxation has not occurred. Indeed, my tables of spinal injuries show that de- formity 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 displace- ment might occur, which yet might not be revealed except by careful postr mortem dissection. Fig. 197.—Bilateral forward dislocation of the fifth cervical vertebra. (Ayres.) INJURIES OF THE VERTEBRAL COLUMN. • 369 (2) Undue Mobility has been occasionally observed in cases of verte- bral injury, chiefly in the cervical region, and, on the other hand, Immo- bility has been noted in about the same number of instances. I do not know that either of these symptoms can be relied upon to distinguish the injury, in any given case, from simple sprain of the vertebral column, and the surgeon should exercise great caution in his tactile investigations upon this point, as very slight force, or even an unwary movement, might in- duce 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 two per cent, only of recorded cases. Diagnosis.—From what has been said, it will be perceived that, as already observed, the differential diagnosis of spinal injuries is always 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 ordinarily represented. Sir Astley Cooper, and more lately Prof. Brown-Se\]uard, surmised that the proportion of recoveries in these cases was 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 78 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 recov- eries being 18 per cent, in the former and 21 per cent, in the latter region. Taking all the regions together, the mortality is 69 percent., the proportion of recoveries 22 per cent., and that of survivals with more or less relief, short of recovery, 7 per cent. The chances of a fatal issue in these cases vary in- versely with the distance of the point of injury from the brain. Lesions above the third cervical vertebra usually prove immediately, or very quickly, fatal, though instances of long survival, or even of complete recovery, after frac- tures of the atlas or axis, have been re- corded by Philips, the elder Cline, Wil- lard Parker, W. Bayard, Stephen Smith, C. S. May, and several other surgeons. The prognosis in cases of gunshot injury of the vertebrae is, also, less un- favorable than has been commonly sup- posed. Many such cases no doubt prove fatal upon the field of battle, but of 642 tabulated by Dr. Otis, as having FlG. 198._Bony union of fractured vertebra. 370 INJURIES OF THE BACK. been treated during our late war, only 349 terminated in death, while 279 ended in more or less perfect recovery. Duration of Life in Fatal Cases.—With regard to this point, it may be said, in general terms, that of cases of fatal injury in the cervical region, two-thirds die during the first week ; in the dorsal region, two-thirds during the first month ; and in the lumbar region, about the same propor- tion during the first year. Condition after Recovery.—Bony union is, according to Rokitansky, rarely met with after fracture of the vertebrae, though instances of its oc- currence have been recorded by Cloquet, Aston Key, and others. The ac- companying cuts (Figs. 198,199, and 200), from photographs given me by I-'n;s. 199 and 200.—Fracture of vertebral body, and unilateral dislocation of a lumbar vertebra, Dr. Cleemann, illustrate very beautifully the occurrence of osseous union after spinal fracture. The specimen, which was derived from the body of a patient whom I saw in consultation with Dr. Cleemann, is one of very great interest, showing, in addition to a fracture of the lumbar vertebrae, unilateral dislocation, which is a rare lesion in this region of the spine. The case illustrates the difficulty of diagnosis in these injuries, for careful examination during life revealed merely prominence of one vertebral spine, with a corresponding depression below it—thus indicating fracture of a vertebral body, but giving no reason to suspect the existence of luxation. With regard to the general condition of patients after recovery from injuries of the vertebral column, the prognosis will, of course, depend chiefly upon the nature and extent of the lesion to the spinal cord. If any portion of the cord be completely divided or disorganized, the parts of the body which derive their nervous supply from below the seat of the injury will necessarily be permanently paralyzed. Eve 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 pro- longed 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 Shaw's case, in which the cord appears at first to have been comparatively slightly injured, its want of continuity, as found at the autopsy, having been due to subsequent disorganization which TREATMENT OF SPINAL INJURIES. 371 produced a return of paraplegia before death. The only case with which I am acquainted, in which complete recovery is supposed to have fol- lowed complete division of the cord, is one reported by Hurd, 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 aware that this advice will be looked upon by man}' 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 net 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 head, 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 spinous process of that which has been injured. S. D. Freeman advises forcible extension by a weight of 75 pounds, and mechanical reposition of the displaced fragments by cutting down and pulling them into place with strong forceps ; this plan might answer in a case of fracture limited to the vertebral arches, but could hardly be applied to a fracture of the bodies of the vertebrae. It is a revival of the suggestion of Fabricius Hilda- nus and Malgaigne, to draw the bones into place with tenacula. 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 em- ployed by Konig, of Gottingen, and by Coskery, of Baltimore. Hadra, of Galveston, secures immobility by wiring together the spinous processes of the injured and adjoining vertebrae. Treatment as regards Spinal Cord.—In every case of spinal injury the patient should be placed in bed and kept at complete rest, both 372 INJURIES OF THE BACK. 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 bedsores. 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 niv 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 stillette. If bedsores 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 viewT 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 con- dition of the patient. Opium may be given at any period to relieve pain or nervous irritation. Mr. McDonnell highly recommends the adminis- tration 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 greater benefit; at the same time, electricity, systematically applied to the para- lyzed parls, 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 but unirritating, with or without stimulus according to the circumstances of each individual case. Trephining or Resection in Injuries of the Spine ; Lamnec- tomy.—This operation has been suggested and described by surgical writers for a very long period, its history reaching back, indeed, to the days of Paulus iEgineta. The first surgeon, however, who actually prac- tised the operation on the living subject was the elder Cline,1 in the early 1 Louis's operation, in 1762, often referred to as an instance of spinal resection, con- sisted merely in the removal of detached fragments in a case of gunshot injury; a RESECTION IN INJURIES OF THE SPINE. 373 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 nearly one hundred and fifty.1 The object, of course, is to remove the vertebral arches at the seat of injury, and thus, if possible, relieve the cord from pressure, which is supposed by the advocates of the operation to be the cause of paralysis in these cases. But, as a matter of fact, post-mortem inspection has shown that compression exists in but a small number—less than one-third—of fatal cases, and that even in these instances the cord is usually so much lacerated or disorganized as to pre- clude any benefit from operative interference; moreover, compression, when it does exist, is almost always due to the pressure exercised by the body of the vertebra, so that all that resection could possiby do would be, as Dr. McDonnell has phrased it, to take away the " counter-pressure." The operation is by no means an easy one,2 and is in itself attended with no small danger to the patient; beside the inevitable risks which 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, this mode of treat- ment entails immediate peril upon the patient, death having occurred in one case (Willett's) before the operation could be completed. Finally, its statistics show that, instead of increasing, the operation somewhat dimin- ishes the chances of recovery. The only cases in which I can think it at all justifiable are the rare instances in which the injury, inflicted by direct violence, is chiefly if not entirely limited to the vertebral laminae. In the fifth edition of this work I tabulated 61 cases of spinal resection for fracture, and the statistics of the operation have since been so largely increased that I have now references to 142, the results in all but 7 of which have been ascertained. Of the 135 determined cases, no less than 84, or 62 per cent., terminated fatally; while in 19 others, or 14 per cent., the operation was productive of no benefit. In 20, or 15 per cent., the patients are said to have been more or less relieved by the treatment; and in only 12, or 9 per cent., can the cases be considered to have ended in recovery, several of these, moreover, being examples of fracture limited to the ver- tebral laminae, the result of direct violence, and therefore presenting analo- gies to Louis's well-known case, already referred to. It will thus be seen that, from the most favorable point of view, resection of the spine can only be claimed to have done good in less than one-fourth of the cases in which it has been performed, while in more than three-fourths it has been useless, if not positively injurious. Considering, therefore, the not unfrequent favorable issue of these cases under expectant treatment, nearly 29 per cent, having received benefit, and only 69 per cent, dying, of all cases taken together, we are surely 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 embraced in my monograph on Injuries of the Spine, already referred to. perfectly legitimate and conservative procedure, which was resorted to twenty-four times during our late war, with fourteen recoveries. Resection of the spine for disease has been performed by various surgeons, includ- ing Heine, Roux, Holscher, Dupuytren, Macewen, Jackson, Southam, Horsley, Dun- can,(Maydl, Wright, Abbe, Deaver. and Jacobi. "I am satisfied," says Prof. Eve, "that this operation, in the dorsal vertebrae, it not almost impracticable, is certainly one of the most difficult in surgery." (Am. Journ. Med. Sciences, July, 1808, p. 100.) 374 INJURIES OF THE FACE AND NECK. 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 which would prove more serviceable, in this position, than either a trephine or Hey's saw; a single arch having been removed, any additional portions of bone may be readily taken away with gouge-forceps, ingenious modifications of which instrument have been designed for use in these cases by Hopkins, Keen, and other surgeons. Dr. McDonnell recommends very highly the internal administration of belladonna or atropia, during the after-treatment, in order to prevent the development of inflammation of the membranes or spinal cord. CHAPTER XVIII. 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, which may always be used with advantage in wounds of the lips, may be employed in any of these cases to control arterial bleeding, the pin being passed under the vessel, which is then compressed above it by means of the twisted suture. No matter how much contused and lacerated any part of the skin of the face may be, it should not be removed, but should be replaced after having been carefully cleansed, in hope that reunion may occur. The deformity 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. 334). 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. INJURIES OF THE ORBIT AND EYEBALL. 375 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 inflam- mation 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 (see Chap. XXXVI.). Wounds of the orbit may cause blindness, without directly involving the eyeballs, either by injury to the optic nerves, or, possibly, by inducing a reflex condition depending upon lesion of other neighboring nerves, as of branches of the fifth pair.1 In a case reported by 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 lach- rymal sac, 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 which has been carefully sterilized (Fig. 201), after the instillation of cocaine ; if, in doing this, the cornea be superficially abraded, it is well, before dismissing the patient, to apply a light pressure bandage, which will effectually protect the surface until the slight breach of continuity has been repaired. The corneal wound should be irrigated with sublimate lotion (1-8000) lest it become inflamed, and from this cause iritis result; it is advisable, if the iris be discolored, to instil a drop of atropia solution after removal of the foreign body. Grandclement has described, under the name of 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 Fig. 201.—Schell's spud for removal of foreign bodies from the cornea. slight injury. A foreigu 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. 202), a second convex lens being used, if necessary, as a magnifier ; or a drop of a tvvo-per-cent. solution of fluorescin may be instilled, which will color green the abraded area and bring out the foreign body in contrast as a dark particle. The conjunctival 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, 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. 376 INJURIES OF THE FACE AND NECK. which may be done either with the forefinger and thumb (Fig. 203), 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 Fig. 202.—Oblique illumination. (Wells.) Fig- 203.—Eversion of upper lid for detection of foreign bodies. (Erichsen.) 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 siniul- taaeously 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 bein<^ 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 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 considerable amblyopia, with contraction of the field of vision, without abnormal ophthalmoscopic appearance. This traumatic anaesthesia of the retina may persist for a long time, often at last terminating in perfect cure, but sometimes leaving the patient with very defective sight. Bruise of the eyeball may be followed, in addition to the localized oedema of the choroid and retina, by a transient myopia or astigmatism, as in a case reported by Jackson. The ordinary "black eye" of pugilists consists in an extrava- sation of blood beneath the conjunctiva, and into the loose areolar tissue of the eyelids. In this situation absorption is often very slow, the sub- conjunctival stain sometimes persisting for several weeks; the best appli- cation 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 Nuel, are usually situated in front of the ciliary body, at the sclero-corneal INJURIES OF THE ORBIT AND EYEBALL. 377 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. 204, Fig. 204.—Dislocation of crystalline lens into anterior chamber. Dr. De Schweinitz.) (From a patient under the care ol 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 be restored, though it is often rendered imperfect by bands of lymph crossing the anterior chamber and the pupil. A dislocated lens usually becomes cataractous, and often causes intense pain and frequent attacks of iritis, by pressing upon the ciliary bodies and iris; in either case, extraction should be promptly resorted to. From the anterior chamber, the lens may be removed by simple corneal section, and from the posterior chamber by a similar operation, a preliminary iridectomy having been first performed. 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 wounding 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 cham- ber, 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 sur- geon. If the dislocation be beneath the conjunctiva, the lens should be removed through a small incision made in this membrane, 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 Wadsworth. If sup- purative disorganization of an eyeball occur, excision may be necessary to prevent the other eye from becoming sympathetically involved. If the 378 INJURIES OF THE FACE AND NECK. 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, which are contracted behind it, is a rare form of injury of which a few cases are recorded. In order to facilitate reduction, Van Dooremaal divided the external commis- sure with blunt-pointed scissors, closing the wound 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 harelip 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 inflamma- tion 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 with vaseline. If suppurative keratitis ensues, the treatment should be the same as for sloughing ulcers. (See Chapter XXXVI.) After powder-burns of the lids and cornea it is difficult to remove the imbedded grains, hence Jackson has suggested that each particle be touched with the point of an electro-cautery, and has him- self successfully carried out the suggestion. 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 has described a case in which the injury resulted in damage to the external eye muscles, the crystalline 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. Non-penetrating Wounds of the Eyeball are not usually of a serious nature. The treatment consists in the removal of foreign bodies, followed by the application of a solution of boric acid and common salt, with the use of cold compresses if the injury be attended with much pain. Penetrating. Wounds are attended with much greater risk, the chief dangers being from prolapse of the iris, escape of vitreous humor, and, at a later period, from inflammation. If the iris protrude, an effort should be made to replace it by means of a fine probe ; if this be impossible, the projecting portion should be snipped off with curved scissors, and, if a staphyloma be subse- quently formed, an iridectomy should be done opposite the most transpar- ent part of the cornea, or the operation for removal of partial staphyloma should be performed. An effort may be made to obtain a flat, or, if possi- ble, a non-adherent cicatrix, by snipping off the prolapsed iris, freeing the edges of the wound, and covering the opening in the cornea with a flap of INJURIES OF THE NOSE AND EAR. 379 bulbar conjunctiva, 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, be 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, or one of the substitutes for this operation. If an attempt be made to save the ball, cold compresses should be applied, atropia being very freely used, and calomel and opium administered internally. It may be necessary at a later stage to make an artificial pupil, to extract the lens (if this have become the seat of traumatic cataract), or to perform excision, if vision be lost and suppurative 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. McKeown has recorded several cases in which fragments of steel were re- moved by the aid of a pointed magnet introduced through the wound, and recommends the use of a large magnet, moved about externally to the eye, as a means of diagnosis. According to Hubbel, the accident wound is not usually the best point at which to introduce the magnet This should be done through a sclerotic incision just in front of the equator of the ball, usually on the outer side, between the external and inferior recti. Magnets have been successfully employed in cases recorded by McHardy, Hirsch- berg, Snell, Kollock, Minor, Hubbel, Knapp, and other surgeons. Con- venient instruments for the purpose have been devised by Hirschberg, Snell, and Gruening. Nose.—Foreign bodies, such as beads, peas, bits of sponge, etc., are often introduced by children into the nostrils, where they occasionally be- come firmly fixed, and, if allowed to remain, cause a troublesome form of ozaena. The foreign body may usually be removed without much diffi- culty, by means of a 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 Thud- ichum's douche, the current being, of course, directed through the opposite nostril. Politzer's air-bag is used for the same purpose by J. 0. Tansley and S. J. Taylor. Displacements of the nasal septum have already been referred to on page 266. Wounds of the nose require careful stitching. 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 provided at the other with a delicate tooth, placed at a right angle, is doubtless very efficient and safe in skilful hands, but the general practitioner 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 380 INJURIES OF THE FACE AND NECK. the ear. The proper mode of applying the syringe is shown in Fig. 2u5. When there is much inflammation, 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 Fig. 205.—The aural syringe in use. foreign body promoted by the use of astringent solutions. Guersant pre- fers to ordinary syringing irrigation, which may be conveniently effected with a Thudichum's douche, or by means of the double hand-ball syringe used for the administration of enemata. Should syringing fail, or should a perforation of the membrana tympani render its employment unadvisable, Lbwenberg's agglutinative method may be properly tried; this, which is a revival of the plan long since taught by Paulus iEgineta, 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 adhe- sion takes place, when 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 XXXVII. Cheek—Wounds of the cheek occasionally result in the formation of troublesome fistulae. If small, a cure may be effected by pressure and the application of nitrate of silver, a red-hot wire, or the eiectric 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 II. 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 INJURIES OF THE NECK. 381 trocar and canula passed in the natural direction of the duct, the external opening being subsequently closed; by turning the fistulous orifice, with or without the surrounding integument, into the mouth, as practised by Van Buren, Langenbeck, J. R. Wood, and E. Mason ; 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 ; by Richelot's plan, which accomplishes the same purpose by the use of an elastic liga- ture; or by Agnew's method of passing a silk thread subcutaneously around the duct, and tying the ligature firmly on the inside of the cheek. As the thread cuts its way through, the natural course of the saliva is restored. 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. Mollie:e advises injecting fatty sub- stances, 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 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 oper- ation 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. Injuries of the Neck. Wounds__These injuries, which are usually of the character of Incised Wounds, are most commonly inflicted in attempts to commit suicide. It is occasionally a matter of some importance, in a medico-legal point of view, to be able to determine whether a given wound of the neck has been self- 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 gen- eral terms, that suicidal wounds commonly begin on the left side of the neck (the person being right-handed), and pass transversely or obliquely downwards across the part, the extent of the wound on the right, being usually less than that of the left, side. They rarely penetrate so deeph* as to divide the great vessels ; hence the prima facie probability with regard to a very deep wound, "penetrating as by a stab perpendicularly towards the spine," and perhaps involving the vertebrae, 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, Penetrating 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, 382 INJURIES OF THE FACE AND NECK. which is usually present in patients who have attempted suicide. Another danger is from the entrance of air into the large veins in this region, which may cause sudden death, or, as in a case recorded by Le Gros Clark, may prove fatal at a later period, by the air becoming gradually mixed with the blood, and thus interfering with the heart's action. The pneumogastric or phrenic nerve may also be wounded in these cases, and either event would of itself almost certainly cause the death of the patient. The treat- ment of non-penetrating wounds of the neck consists in arresting hemor- rhage, and in approximating the edges of the cut, in such a way as to favor union. Every bleeding vessel, whether artery or vein, should be secured by ligatures above and below the opening in its coats, or to either extrem- ity 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 in- stances with 23 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 hemorrhage being, according to the first-named author, 228, with ',14 recoveries. Whenever it is practicable, however, an effort should be made to substitute 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 being brought out at the angles of the wound, so as to secure drainage. The sutures should embrace the skin and superficial fascia only, and the deeper parts of the wound should be approximated by means of broad strips of adhesive plaster, brought obliquely around the neck. The parts should be further relaxed by bending the head forwards, with the chin almost touching the sternum, and by securing it in this position by means of a nightcap, or sling, 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 ox Apncea, in woupds 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 backward- and obstructing the rima glottidis ; or, if the rings of the trachea be widely INJURIES OF THE NECK. 383 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 (esophagus—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 oeso- phageal fistula. Treatment.—After the arrest of hemorrhage, as in cases of non-pene- trating wound, the surgeon may apply a few sutures to either extremity of the incision, leaving, however, the central portion, as a general rule, to heal by granulation ; an exception should be made in those cases in which the air-tube is completely cut across, when, to prevent wide separa- tion, it may be necessary to apply a stitch on either side, so as to hold the parts in apposition. The sutures, which in such a case should be of silk- worm-gut, or fine silk, may be passed through the superincumbent con- nective tissue, or even superficially through the cartilages themselves. In other cases, from the persistence of venous oozing, or from the occurrence of dyspnoea on attempting to close the wound, it may be necessary to introduce, for a time at least, a tracheal tube, as after the operation of tracheotomy, or the trachea may be opened at a lower point and a tube retained until all inflammatory swelling has subsided. If, at any time, apnoea 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 trache- FlG- 206.-Tracheai stricture. (Cohen.) otomy, followed by systematic dilatation, as employed by Schrotter; or even by external division, as in a case re- corded by Trendelenburg ; or by excision of portions of the tracheal rings, or cricoid cartilage, as practised by H. Lee, and by myself, in a case 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. 206.) 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. 384 INJURIES OF THE FACE AND NECK. 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 breathinc 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." Von Hoffmann leports several cases of fracture of the thyroid cartilage by indirect violence, result- ing from falls on the head. The symptoms are local pain and tenderness; Figs. 207 and 208.—Fractures of the larnyx. (After Roe.) swelling of the neck, with an alteration of its form, consisting either of flattening or of undue prominence ; mobility of the cartilages, and occa- sionally crepitus. There are, besides, often dyspnoea and lividity of face, with the ordinary evidence of collapse, emphysema, and expectoration of bloody mucus; the latter symptoms are considered by Hunt particularly unfavorable, as indicating laceration of the laryngeal mucous membrane. The annexed table gives a summary of 80 recorded cases, 52 collected by H(5noque, 17 added by Durham, and 11 by myself.2 1 Mr. Arbuthnot Lane, however, from an examination of numerous dissecting-room specimens, concludes that many cases present very slight symptoms, and end in recovery without their nature having been recognized. 2 A case has been recorded by Treulich, in which both thyroid and cricoid cartilagee were broken—the latter in two places—and the trachea ruptured by the bite of a FRACTURE OR RUPTURE OF THE TRACHEA. 385 Cartilages Fractured. Thyroid only Cricoid only Thyroid and os hyoides " and cricoid " cricoid, and os hyoides " " and trachea Cricoid and trachea " trachea, and os hyoides " Fractures of larynx" Total 80 No. of cases. Deaths. Recoveries. 36 23 13 12 11 1 4 2 2 11 10 1 2 2 4 2 2 3 3 1 1 7 3 4 57 23 The treatment, in cases in which the displacement is slight and in which there is no dyspncea, may consist simply in supporting the parts with compresses 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 tracheotom}', which, under such circum- stances, affords almost the only chance of saving the patient. Fourteen of the twenty-three cases of recovery were saved by operation, while in at least four of the remainder, from the absence of haemoptysis and emphy- sema, there is reason to believe, as remarked by Hunt, that the fractures were in the median line, and did not involve the mucous membrane. After the operation, an attempt may be made to restore the displaced parts to their proper position by manipulation. Panas and Caterinopoulos recom- mend, instead of tracheotomy, a section of the th\>roid cartilage, followed by the introduction of a large tube, so as to keep the fragments in position. Dr. E. Holdeu has recorded a case of dislocation of the inferior cornu of the thyroid cartilage. Luxation of the arytenoid cartilage has been observed in two cases by Stoerk, and a case of dislocated cricoid carti- lage, reduced by extension and manipulation, is referred to in the Lancet for 1886. Fracture or Rupture of the Trachea, without injury of the larynx, and without external wound, is an extremely rare and usually fatal accident. Cases are reported by Lonsdale, Berger, Beck, J. L. Atlee, Jr., Robertson, Corley, Garrard, Bennett, Long, Drummond, Wagner, and Norton—those seen by the four last-mentioned surgeons being the only instances of recovery.1 In Long's case, life was saved by trache- otom}, supplemented by removal of blood from the air-passages by suction, and by artificial respiration. A case was under my care many 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. Lang has reported a remarkable case horse; life was saved by tracheotomy. Another case, involving the thyroid, cricoid, and four tracheal rings, caused by a blow from the cross-bar of a trapeze, and saved by tracheotomy, is reported by Desvernine. Recovery also followed in a case of cricoid tracture reported by Masucci, and in one of fracture involving both thyroid and cri- coid, recorded by Sokolowski and Bukowski. Here, too, the cure was obtained by tracheotomy. Still another case (fatal) of fracture of both thyroid and cricoid is re- corded by Wagner. Cases of fractured thyroid ended in recovery without operation in the bauds of Bauer and W. J. Taylor, and one after tracheotomy in those of Til- laux, while other (fatal) cases are recorded by Landgraf, Barendt, and Fussell. 1 Another fatal case is mentioned in the British Medical Journal oi March 3, 1888, page 50(1. 25 386 INJURIES OF THE FACE AND NECK. of intussusception of the trachea, which proved fatal at the end of ten weeks. Burns and Scalds of the mouth, pharynx, and glottis are occasionally met with, especially among children, the most usual form of the injury resulting from an attempt to drink boiling water from the spout of a teakettle. It is probable that, in some cases, steam may reach the larynx itself, but in the majority of instances the air-passages become second- arily involved by the extension of inflammation from the mouth and glottis. The dangers are those of submucous laryngitis and oedema glottidis, and the treatment consists in the application of leeches and ice to the throat, and in the administration of antimony or of calomel and opium. Free mercurialization is considered by 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 twentv- 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 hist 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 strong mineral acids, or caustic alkalies. The treatment should be the same as in the case of scald of the glottis or larynx. Of three cases men- tioned b}^ Durham, in which tracheotomy was performed for such ;m injury, two died and one recovered. Foreign Bodies in the Air-Passages__A great variety of sub- stances have been met with as foreign bodies in the air-passages, the most common being, according to Gross, grains of corn, beans, melon-seeds, pebbles, and cherry-stones. Several such objects, sometimes of a dissimilar character, have been occasionalhr met with in the same case. In four in- stances leeches have been extracted from the larynx, bv Alarcacci, 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 walls of the chest. Finally, in one case referred to by Gross: a lym- phatic gland passed through an ulcer in one of the bronchi, and caused death by becoming impacted in the rima glottidis. Situation.—A foreign body may be arrested in any portion of the air- passages, or, more rarely, may be movable, changing its position from time to time. The parts in wThich extraneous substances are most apt to become impacted are the larynx and one of the bronchi, usually the right. Symptoms.—The primary symptoms, or those of Obstruction, are similar to those of inflammatory or spasmodic croup, only, if possible, more violent. The patient feels a sense of impending death, and is, indeed, for the time, in most imminent danger. The face becomes livid, the eyes apparently start from their sockets, the patient gasps and utters piercing cries, foams at the mouth, is perhaps convulsed, or falls insensible. The first paroxysm passing off, th^ symptoms of Irritation become prominent. There is a FOREIGN BODIES IN THE AIR-PASSAGES. 387 short, croupy cough, with pain, especially referred to the top of the sternum, and mucous or bloody expectoration. Paroxysms of dyspncea, -with a sense of suffocation, recur from time to time, and are due to the dislodg- ment of the foreign body, and to its being impelled against the larynx by the act of coughing. Auscultation will reveal various signs, according to the position of the foreign body ; if this be loose in any part of the tube, it may be heard moving up and down with a flapping sound, and occa- sionally striking the wall of the trachea ; if fixed in the larynx, there will be a harsh, rough sound in respiration, coinciding with croupy couo-h 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 plumstone, 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 dyspncea 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 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 Durham's essay, shows compendiously the results in 636 cases__ these being, I believe, with the exception of Weist's, to be presently re- ferred to, the most comprehensive statistics which have yet been pub- lished :— 1. Cases in which no operation was performed:— Resclt. T01^1 Eecov- ^ , number eries Deaths. of cases. | 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 102 176 | 161 7 7 13 j 8 102 15 5 Total of cases not operated on ... . 298 : 176 122 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 .... 16 I 15 3 I ... 263 196 32 25 9 9 15 1 15 1 3 67 7 Total of cases operated upon .... 338 | 260 78 Total number of cases operated upon or not 636 ; 436 200 388 INJURIES OF THE FACE AND NECK. 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 (23.0 per 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—38 years in a case recorded by Ravenel; in 68 of 136 cases of spontaneous expulsion with recovery, collected by Mr. Durham, this period was between one and twelve months. Weist has published statistics of 1000 cases, chiefly collected by private correspondence, which show a somewhat different result, as follows:— Cases not submitted to operation .... " submitted to operation other than bronchotomy " " to bronchotomy .... Aggregates ...... Total, j Recov- Died Mortality ered. per cent. 599 63 338 460 62 245 1U00 767 139 1 93 23.20 1 58 27.42 233 23.30 If, for the sake of comparison with 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 English writer. The dis- crepancy 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 per cent., nearly 6 per cent. more than when an operation is resorted to. Treatment.—In a case in Avhich 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 Fig. 209.—Application of the laryngoscope. (Ekichsen.) opening the trachea, and will then be more likely to succeed, as the risk of strangulation is removed. Thorner has succeeded in extracting a FOREIGN BODIES IN THE AIR-PASSAGES. 389 cockleburr from the larynx by passing a probe armed with a small sponge alongside and below the foreign body, and then suddenly drawing it upwards. Yoltolini proposes to search for the foreign body by intro- ducing, 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 dislodged and extracted, the surgeon, if necessary, dividing the thyroid cartilage in the median line (thyrotomy), or this and the cricoid as well (crico-thyrotomy). If the foreign body be in the trachea or bronchi, it may be immediately expelled through the tracheal wound—or more rarely through the mouth—though in other cases it may not 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. Durham's statistics show, I think, conclusively, that such attempts are not only justifiable, but eminently proper, 61 cases, in Fig. 210.—Throat-mirror used in laryngoscopy. which removal was effected by forceps, having given 58 recoveries and but 3 deaths, none of which appear to have been due to the use of the instru- ment. Stickler records a case in which a foreign body was removed with forceps from the left bronchus after dividing the trachea complete^ down to its bifurcation. Among the best forms of tracheal forceps are those de- vised by Prof. Gross (Fig.' 211), 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 delicate as not materially to interfere with the Fig. 211.—Gross's tracheal forceps. passage of air during the necessary manipulations. Another excellent form is that devised by Dr. Cohen (Fig. 212). In cases in which the foreign body is fixed in a bronchus and cannot be dislodged, it has been suggested that a direct incision should be made through an opening in the chest wall; but Willard's conclusion, based upon experiments on dogs, seems to me a just one, that the risks of such an operation are much greater than those of allowing the foreign body to remain. 390 INJURIES OF THE FACE AND NECK. 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 Fig. 212.—Cohen's tracheal forceps. for a few days until this has subsided. Occasionally the foreign bodv causes not only intense congestion and bleeding from the trachea, but the formation of fibrinous casts similar to those found in croup. Fig. 213 shows such a cast removed by Dr. Wharton, with a shawl-pin (Fig. 214), Fig. 213.—Fibrinous cast from trachea Fig. 214.—Brass shawl-pin removed seven hours (actual size). 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 was followed. Subhyoidean pharyngotomy (see Chapter XXXIX.) may in some cases be preferred to either laryngotomy or tracheotomy, and has been successfully resorted to, in a case of foreign body impacted in the larynx, by Lefferts. -Hoffmann succeeded by the same method in removing a foreign body from the pharynx, but the patient died the next day. 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 cedema of the larynx, or the presence of false membrane, of a morbid growth, or of a foreign body in any portion of the air-passages. The surgical operations employed in the treatment of apncea are artificial respiration, intubation, and the various procedures which are included under the general term of bronchotomy. Intubation and bronchotomy 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 bronchotomy. Artificial Respiration—This may be effected in several ways:— 1. Mouth to Mouth Inflation, though objectionable as furnishing air which has already been expired, is occasionally the only method which 1 Apnoea (a privative and moh. Epic moth, Doric moa or moia) is etymologically the more correct term, signifying "absence of breathing ;" asphyxia (aprivative and 3. WOUNDS OF THE PLEURA AND LUNG. 407 ration has been recently recorded by Madelung. If hemorrhage proceed from a wound of the lung itself, the blood may escape at the cutaneous orifice, may be coughed up through the air-passages, or may accumulate in the cavity of the pleura, giving rise to the condition known as haemolhorax. This condition may also arise, though more rarely, from wounds of the intercostal or internal mammary arteries. The "rational symptoms of hemothorax are those which characterize loss of blood in general, such as faintness, dizziness, and pallor, with disturbance of the respiratory func- tion, dyspniea, restlessness, etc. None of these are, however, in any de- gree pathognomonic, and death from hemothorax may take place without the previous occurrence of any symptom certainly indicative of wound of the lung. The physical signs, when present, are more trustworthy ; they consist of enlargement of the injured side of the chest, with bulging of the intercostal spaces; absence of respiratory murmur, and dulness on per- cussion—gradually increasing in extent, and the line of dulness varying with the posture of the patient; the sensation of a wave of fluid, or of splashing, felt by the patient, or transmitted to the hand of the surgeon on succussion; and, finally, according to Valentin and Larrey, cedema and eechymosis in the lumbar region. All of these signs, except the last (which is by no means constant, and is, indeed, looked upon by Fraser and Otis as somewhat apocryphal), may be equally present in cases of serous or of purulent accumulation, and hence it is oulv by their appear- ance immediately after the injury, and in coincidence with other signs of hemorrhage, that the surgeon can satisfy himself as to the nature of the case. The treatment of hemorrhage, from wound of the lung, would con- sist in closing the external wound by means of a firm compress, in the application of ice, and in the administration of opium and ergot, with per- haps digitalis or veratrum viride ; by these means, in a favorable case, coagulation of the effused blood, and subsequent occlusion of the bleeding vessels, may be obtained, the clot being gradually absorbed, and the patient recovering without further trouble ; if, however, the bleeding con- tinue into the pleural sac, as marked by increased dulness on percussion, with dyspnoea and the other symptoms of hemothorax above enumerated^ the original wound must be reopened, or, if it have already healed, para- centesis must be performed, as in the case of empyema. Hulke, in order to check pulmonary hemorrhage (not traumatic)", incised the pleura and produced collapse of the lung; the patient died on the fifth day. Parker advises that, instead of making an incision, the pleura should be merely punctured, and air injected through a canula. (2) Pneumothorax and Emphysema usually coexist in the same case, though either may be present without the other. By the act of inspiration the air is sucked into the pleural cavity, either through a cutaneous wound or from the ruptured air-vesicles of the lung, while in expiration, the orifice by which the air entered being closed by the valve-like action of the surrounding structures, it is pumped into the areolar tissue, pneumo- thorax thus usually preceding emphysema. If, however, there be old pleural adhesions, or if the external wound correspond exactly with that in the lung, the air may pass directly in and out (tromatopncea), without invading either the pleural sac or the planes of connective tissue. Pneu- mothorax alone may result from rupture of the lung, without injury of the costal pleura, while emphysema alone may result from puncture of th<^ lung through an old pleural adhesion, from rupture of an air-cell or bron- chus into the posterior mediastinum (according to Hilton),1 or possibly, as Seven cases of emphysema occurring during parturition are referred to in the uuoim Journal of Medical Science for March, 1881, p. 286. 408 INJURIES OF THE CHEST. taught by Poland and others, from a non-penetrating wound of the chest. Pneumothorax is marked by great resonance on percussion, with nb.-enee of the respiratory murmur, by amphoric respiration, and occasionally bv metallic tinkling ; if excessive, it produces much dyspnoea. Emphysema is characterized by a diffuse, puffy, colorless, perfectly elastic swelling, crackling under pressure; it can scarcely be mistaken for any other con- dition. It is very seldom that either of these complications requires special treatment. Pneumothorax, if existing on both sides, might threaten suffocation, and the proper treatment in such a case would be to evacuate the contained air by puncturing the chest with an aspirator, or very small trocar, closing the wound immediately afterwards with a strip of adhesive plaster. Emphysema, if very extensive, might require the application of a bandage, or even scarification of the most distended parts. (3) Hernia of the Lung.—This rare form of accident, of which Do- fosses has collected twenty examples, six occurring spontaneously and fourteen consecutively, or as the result of injury, may occur as a subcu- taneous lesion, the result of crushing violence to the chest, or even, it is said, of straining efforts during parturition. It may also occur in the site of a cicatrix, as in an instance mentioned by Velpeau. The tumor under these circumstances is soft, somewhat circumscribed, elastic, compressible, in- creasing in expiration and diminishing in inspiration, communicating a distinct impulse on coughing, crepitating when handled, and measurably disappearing when the patient holds his breath ; the tumor is resonant on percussion, and the seat of a loud respiratory murmur; the limits of the aperture through which it has escaped may often be distinguished by pal- pation. The treatment consists in effecting and maintaining reduction, by means of a compress and bandage, if this be possible, and if not, in the application of a concave pad, so as to protect the part from injury, and prevent further protrusion Hernia of the lung sometimes takes place through an open wound, usually in the neighborhood of the nipple; if the projecting lung tissue be healthy, it may be cautiously" pushed back, the orifice through which it escaped being slightly enlarged, if necessary; if gangrene have occurred, however, the protrusion should not be interfered with, the part being left to be removed by sloughing ; or, if thought proper, the mass might be ligated and excised, the stump being fastened in the wound. A case successfully treated in this manner is attributed to Tulpius. Resection of the lung has also succeeded in the hands of Demons. (4) Hydrothorax and Empyema, the former term denoting a collection of serum and the latter one of pus, in the pleural sac, are occasional com- plications of the later stages of wounds of this part. The symptoms are those of chronic pleuritic effusion, from whatever cause (the physical signs being the same as those which were mentioned in speaking of haemotborax), and the diagnosis is to be made, principally, by observing the later period of occurrence and the more gradual increase of the symptoms, and, in the ^case of empyema, the tendency which is sometimes manifested to the for- mation of an external opening. p]mpyema, according to the elder Pepper and other authors, is particularly marked by bulging of the lower inter- costal spaces, and dilatation of the superficial veins: but Bowditch doubts the possibility of more than suspecting the nature of the pleuritic effusion before operation, and founds even this suspicion, mainly, on the previous history of the case. According to Baccelli and Chew, feebleness or absence of the vocal and respiratory sounds is indicative of the presence of pus, dense fluids transmitting vibrations less readily than others. It is doubtful if any advantage is to be obtained in the treatment of these eases, from the use of medicines designed to promote absorption, such as WOUNDS OF THE PLEURA AND LUNG. 409 are employed in the cases of chronic pleuritic effusion which come under the observation of the physician; hence, in any case in which the accu- mulation is so great as to give manifest tokens of its presence, the sur- geon should have recourse to the operation of paracentesis, which should be performed before the lung has become so bound down bv adhesions as to have lost the power of expanding when the source of pressure is removed. Paracentesis Thoracis; Thoracentesis.—Before resorting to this opera- tion, the surgeon should confirm his diagnosis by the use of an exploring trocar and canula, or, which is perhaps better, an aspirator or long-nozzled hypodermic syringe, by which a small portion of the accumulated fluid may readily be obtained for examination. The particular operation to be chosen depends somewhat upon the nature of the effusion ; if this be serous, the opening should be a small one, and it is here important to guard against the admission of air, by using the suction trocar proposed by Wyman and modified by Bowditch, the aspirator of Dieulafoy, Ras- mussen, or Potain, or, if none of these be at hand, a trocar fitted with a stopcock and gum-elastic bag. or with a flexible tube so arranged as to evacuate the fluid under water. For the evacuation of an empyema the same precautions need not be taken, and it is here better to use a full- sized trocar, leaving the canula or an elastic catheter in the wound, or, which is better, introducing a drainage-tube, one end of which projects at the point of tapping, the other being brought out through a counter-open- ing at the lowest part of the cavity. Phelps and Williams employ tubes provided with valves, so as to permit washing out the cavity while pre- venting the admission of air, and thus encouraging the expansion of the lung. Excision of Ribs for Empyema; Estlander's Operation.—Roser, Peltavy, and Estlander recommend that, instead of using a drainage-tube, a free opening should be secured by resecting portions of one or more ribs —a plan which was successfully resorted to by the late Warren Stone, and has since been employed by numerous surgeons : of 26 cases collected by Berger, 10 ended in complete and 5 in partial recovery, and only 4 proved fatal; but a later statistical inquiry by Cormack shows that of 41 patients only 10 were cured, 18 more or less improved, and 3 not benefited, while not less than 10 died as the result of the operation. Amat's figures afford a somewhat more favorable picture, 67 cases giving 23 recoveries, 24 instances of more or less benefit, 6 of no benefit, and 14 deaths. Individual operators have obtained even better results, Thiriar recording 13 cures out of 15 eases, and Boeckel 9 cures out of 12 cases. Two cases in my own hands have both ended successfully. Schneider reports a recovery after excision of portions of five ribs and the clavicle for empyema following a gunshot wound. Subbotin advises that the ribs should not be excised, but divided in two places, so that the intermediate portion may be pressed inward and thus diminish the cavity of the empyema. Schede resects almost the entire, chest wall, raising a very large oval flap of skin which is subsequently applied directly to the exposed pleura. Tillmans has supple- mented an operation of this kind by curetting the pleura, which was affected with tuberculosis. The point at which paracentesis should be performed is a matter of dis- pute; that usually recommended is between the fifth and sixth, or sixth and seventh ribs, in a line nearly corresponding to the insertion of the ser- ratus magnus muscle. Dr. Bowditch usually tapped between the ninth and tenth ribs, while others go as high as the fourth intercostal space; I have usually chosen the sixth or seventh, finding that at a lower point pain may be caused by the diaphragm rising against the instrument, while, if the puncture be made higher, it is difficult to secure full evacuation of the 410 INJURIES OF THE CHEST. cavity. Whatever point be chosen, the intercostal space should be, if not bulging, at least not contracted ; the skin should be incised with a bistoury or lancet, and the trocar thrust in at the upper edge of the lower rib, so as to guard against wounding the intercostal artery—an accident which proved fatal in a case recorded by Gallard. If an ordinary trocar be used (in a case of hydrothorax), the admission of air may be further guarded against by drawing the cutaneous incision to one side before introducing the trocar, thus making a kind of valvular opening; but the calibre of the suction-trocar is so small that, if it be employed, this precaution is unne- cessary. The patient, at the beginning of the operation, should be in a sitting posture, and as the fluid is withdrawn should be gently lowered into a supine position, and slightly turned on the affected side ; an assistant should steadily compress the lower part of the chest, to prevent syncope, and further to guard against the entrance of air. Parker, Potain, and Secretau, however, facilitate the operation by making a counter-opening and introducing carbolized air through another canula. A similar pro- cedure, under the name of perflation, is recommended by Ewart. The after-treatment (as far as the operation is concerned) consists simply in closing the wound with a piece of lint and an adhesive strip. If it be determined (in a case of empyema) to employ a drainage-tube, this is intro- duced as follows: a steel ey^ed-probe, bent like a sound, is passed through the wound of tapping, and made to project at the lowest accessible inter- costal space; upon this, as a guide, a counter-opening is made, and the eye of the probe threaded with a strong ligature carrying the tube, which is thus readily brought into place when the probe is withdrawn ; the ends of the tube are then secured with safety-pins, and the part covered with an antiseptic dressing. The cavity should be thoroughly washed out at least once a day with a dilute solution of iodine or boric acid, so as to prevent putrefaction of the contained pus and consequent septicaemia. I have seen a number of cases in which this plan has been systematically carried out with complete success, the punctures healing readily when the tube was removed, and recovery following without the occurrence of any re-accu- mulation. The statistical results of the operation of tapping the chest are quite satisfactory ; of 526 terminated cases collected by G. H. Evans, no less than 373 ended in recovery, while only 2 of the 153 deaths were attributable to the operation itself. Of 40 cases of thoracotomy, or incision of the chest for empyema, collected by Dr. Eddison, only 9 terminated fatally. In a case of empyema following a gunshot wound, in which there was reason to suspect the presence of a foreign body, the surgeon should carefully explore the cavity with a probe, after evacuating the contained fluid, when, if a ball, or other foreign body, should be discovered, it should be removed with suitable forceps, as was successfully done by Larrey. Pneu.monotomy and Pneumonectomy.—Purulent collections in the lung have been opened by tapping or incision, with or without subsequent injec- tion, by Lawson, (jodlee, Erichsen, Mosler, Pepper, Fenger, Casini. and numerous other surgeons. Of 25 cases referred to by Ricklin, 9 ended in recovery and 10 in death, while more or less improvement followed in the remaining 6 ; for gangrene of the lung the results are less favorable, 13 cases having afforded but 3 recoveries, 4 instances of improvement, and (5 deaths; of 14 tuberculous cases, at least half terminated fatally. Foubet's statistics of operation for pulmonary gangrene are more favorable, 18 eases having given 9 cures, 2 instances of improvement, and only 7 deaths. Still another cure has recently been recorded by Perier. Pneumonotomy for pulmonary hydatid proved successful in 2l"out of 32 cases collected by Taufert. Excisions of diseased portions of lung have been practised by WOUNDS OF THE PERICARDIUM AND HEART. 411 Krdnlein (three cases), Ruggi (two cases), Block, Milton, Delageniere, Lowson, and Weinlechner ; Delageniere's, Lowson's, and one of Kronlein's patients recovered and Milton's survived for four months, but the other six promptly succumbed after the operation. 2. Wounds of the Pericardium and Heart__Wound of the Pericardium alone does not appear to be as fatal an injury as would nat- urally be supposed; at least, 51 cases reported by Fischer gave onlv 29 deaths and as many as 22 recoveries, the diagnosis in three of the latter being subsequently confirmed by post-mortem inspection, when the patients died from other causes. Wounds of the Heart are usually, though not necessarily, fatal; 401 cases, collected by Fischer, afforded as many as 50 recoveries, the diagnosis in 33 of the latter being eventually confirmed by means of an autopsy. The symptoms of these injuries are not very definite ; if the wound be large, there is, of course, profuse hemorrhage, which may prove almost instantly fatal; punctured wounds are, however, often attended with little or no bleeding, owing chiefly to a peculiar arrangement of the muscular fibres of the heart, described by Pettigrew, by which a wound which is transverse to one layer of fibres is in the direction of another layer, and therefore, to a certain extent, necessarily valvular. Syncope is often observed in cases of heart-wound, occurring not unfrequently at the moment of injury. Pain, when present, is, according to Fischer, due to the pericardial lesion. If effusion of blood or serum take place into the cavity of the pericardium, the sounds of the heart and the cardiac impulse are "diminished in inten- sity. A systolic bellows sound is the most usual abnormal murmur ob- served in cases of heart-wound. Precordial anxiely, dyspncea, and other symptoms are not distinctive, and, indeed, are occasionally entirely want- ing. 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, Pournier, Randall, Carnochan, Balch, Hamilton, Hopkins, Gallard] Tillaux, Conner, Peabody, and others, in which patients have survived 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 pericardium, 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 \yould consist in keeping the patient at absolute rest, and in the applica- tion of cold, the administration of opium, digitalis, veratrum viride, etc., and, if death were threatened by pericardial effusion, perhaps the perform- ance of paracentesis. Block 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. Marks, however, reports a case in which a wound of the heart was successfully plugged with gauze, having been rendered accessible by resection of the ninth and tenth costal carti- lages. If death be threatened by hemorrhage into the pericardium (what Kose calls hearf-tamponade), venesection should be resorted to, with abso- lute rest and the local use of ice. Rose recommends laying open the peri- cardium, but does not appear to have put his suggestion in practice. 41*2 INJURIES OF THE CHEST. Paracentesis Pericardii may be performed in the fourth or fifth left inter- costal interspace, with the same precautions that were recommended for the operation of tapping the pleural sac. Rouse, Barlow, and Rotch are disposed to prefer tapping on the right side of the sternum. Of II cases collected by Dr. Roberts, 22 proved fatal, but mostly from causes uncon- nected with the operation, and of 97 cases collected by Grainger Stewart, only 38 terminated favorably. Rosenstein records a case of purulent peri- carditis 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 Hin- denburg, Korte, Stoll, and Partzevsky ; and Gussenbauer has successfully evacuated pus from the pericardium, after exposing the part by the resec- tion of five ribs. Lannelongue has recorded a remarkable case of congen- ital ectcicardia 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, bein r, 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 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 pyasmia. 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 of 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 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 abdom- inal or thoracic viscera, the prognosis is not as unfavorable as might be sup- posed ; 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 Diaphrag- matic Hernia. Wounds of the diaphragm, resulting from stabs, gunshot injuries, etc., are usually complicated with other serious lesions, and it is from these, rather than from the wound of the diaphragm itself, that the danger in these cases chiefly arises. The symptoms of a wound of the diaphragm are very obscure; in most instances there is great dyspnoea, breathing being principally carried on by the subsidiary muscles of respi- ration. C. T. Hunter, however, recorded a case of gunshot wound in which the ball, after perforating the stomach, bowels, and diaphragm, lodged in the thoracic cavity, but in which there was no difficulty of breathing until shortly before death, the dyspncea even then evidently resulting mechanically, from gaseous distention of the intestines. Hie- CONTUSIONS OF THE ABDOMEN. 413 cough occurred in a case which was under my care in the University Hos- pital. The treatment of a wound of the diaphragm is essentially the same as that recommended for penetrating wounds of the chest. Postempski 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, forcing 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 XX 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, by Pollock's researches, to be at least doubtful, though there can be no question that rapid death may follow these injuries, either from concomi- tant shock, or from a condition of the solar plexus analogous to cerebral 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 abdomi- nal 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 rep- resented 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 con- cave 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. Ahonooo «4> +V,« av.j • i -n Fig- 228.—Ventral hernia, following Abscess of the Abdominal Pa- rupturooftheabdorainai nicies. (From netes occasionally follows Contusion of a patient in the Episcopal Hospital.) 414 INJURIES OF THE ABDOMEN AND PELVIS. the part, and mav 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 invariably 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 ;l 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 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 comparatively favorable prognosis; as was mentioned in Chap. XVII., 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 bowel2 are almost invariably fatal: 149 cases collected by Chavasse gave 143 deaths—a mor- tality of 96 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 may be 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- mortem examination ; that recovery is at least possible would, however, appear from a case recorded byr Fergus, in which the patient was con- sidered 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 ; 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. A fifth case (successful) is recorded by Monod. In none of the cases does it appear that peritonitis was present, the urinary ex- travasation having occurred into the cellular tissue behind the peritoneum. 1 Schmorl and Zenker bave recorded curious cases in which ruptures of the liver were followed by venous, cardiac, and pulmonary embolisms of hepatic tissue. 2 Dr. Whitney has pointed out that, in cases of ante-mortem rupture of the intestine, the mucous membrane is invariably found everted; this is not the case as reganis ruptures produced after death. CONTUSIONS OF THE A1SD0MEN. 415 Ruptures of the abdominal bloodvessels, without other injuries, are seldom met with. Legouest has recorded a case of laceration of the aorta ; and 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 Fig. 96). 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 a portion of the peri- toneum which contains large vessels; while the immediate development of peritonitis would indicate rupture of one of the hollow viscera. Pain in the right hypocbondrium, 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; haematuria would indicate lesion of the kidney, though its absence would by no means prove that this organ had escaped ; haemateniesis would be a symptom of ruptured stomach, and bloody stools of ruptured intestine—a lesion, the existence of which might also be suspected, if the abdominal wall were the seat of emphysema, the diagnosis of which from emphyrsema due to thoracic injury, and from gaseous putrefaction, might be made by observ- ing the history of the case, and the coincident symptoms. The history may also serve, sometimes, to distinguish between gastric and intestinal laceration, rupture of the stomach rarely occurring except when that organ is distended by a recent meal. Treatment.—As these injuries are in the majority of instances neces- sarily fatal, their treatment must, of course, be often merely euthanasial. As far as any curative influence can be exerted by remedies, it must be (as Sir Thomas Watson puts it) in obviating the tendency to death. Hence the surgeon's first efforts must be directed to arresting the internal hemor- rhage which is the source of immediate danger, and at a later period to combating the peritonitis which is the common cause of death in those cases which survive the early periods of the injury. The patient should be put to bed, and kept profoundly quiet; if the symptoms of shock be very prominent, cautious efforts may be made to induce reaction, preferably by the application of external warmth, for it must be 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 advantageously 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 byr means of an ice-bag or box (see page 56), 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 he 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 416 INJURIES OF THE ABDOMEN AND PELVIS. 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 >hould be strong reason to. believe that a hollow viscus was injured. Of 28 such cases to which I have references, only six 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. Rupture of the stomach by perforation through a gastric ulcer, if recognized, should be treated by laparotomy and the introduction of sutures. 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 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 a 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 person, however, or in a very young child, I should consider even local bleeding highly improper. The application of a large blister is usually recommended in these cases, and I have myself employed it. I am not sure, however, that a jacket-poultice, enveloping the whole abdo- men, might not be equally efficient, as it would be probably more agree- able to the patient. I have found advantage from the use of the veratrum viride, in doses of :> 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 sus- pected,2 this drug may be suitably combined with small doses of calomel; 1 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. 2 According to Dr. Flint, if there be perforation the peritoneal cavity will contain gas, and the normal liver dulness will be replaced by resonance. The same authority recommends aspiration to evacuate the peritoneal gas and bring the opposing serous surfaces in contact, thus favoring adhesion. WOUNDS OF THE ABDOMEN. 417 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.1 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 eases the unfavorable symptoms, vomiting, tympanites, etc., are due rather to obstruction from forming adhesions than to actual inflammation. The good done by saline cathartics in septic peritonitis is, I believe, due to the drainage which they indirectly effect, and not to the purgation which they causc, and which in itself is objectionable. Milk diet is that which is best adapted to cases of traumatic peritonitis, wine or brandv being added if necessary. If the stomach or bowel be lacerated, nutritive enemata of beef-tea. eggnog, etc., must be substituted. If serous effusion persists 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 be purulent, even incision and drainage, which have proved successful in cases recorded by Schmidt, Treves, Marsh, Walsham, and Tavlor. Lapa- rotomy for peritonitis has likewise succeeded in the hands of Mikulicz,2 Kronlein, Ceppi, Leucke, Heuser, Gay, Roberts, Studenski, Wylie, Jack- son, and Burchard. In Oberst's case,"" relief was afforded by the "operation, but the patient died in nine weeks from pneumonia and bedsores. Laparo- tomy for peritonitis proved unsuccessful in cases recorded by Drs. Shimmel and F. J. Sheppard, and in my own hands in a case which I saw with Dr. Baldwin. Laparotomy for tubercular peritonitis has, according to Ceccherelli, been employed 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 re- covery. The mortality in terminated cases was thus 30 per cent. In children the statistics are more favorable, 46 cases collected by Aldibert having given 42 recoveries and only 4 deaths. Yander Veer advises con- tinuous drainage after laparotomy, and quotes Konig's figures of 140 German cases, which gave 131 recoveries and only 9 deaths. Maurange advises, as a substitute for laparotomy, aspiration,' followed bv antiseptic washing and the injection of iodoform, while Mosetig-Moorhof recom- mends aspiration, followed by insufflation of sterilized air. Retro-peritoneal Suppuration, resulting from rupture of the in- testine between the layers of the mesentery, might require incisions to evacuate the pus; and similar treatment would be indicated in the event of Lrinary Extravasation occurring from laceration of the kidney or ureter. Wounds of the Abdomex, 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 ^ases 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 hemorrhage be greater than mere oozing, the part must be freely ex- A very efficient mode of obtaining the anaplastic effect of mercury in peritonitis s 10 cover the belly with lint spread with mercurial and belladonna ointments and Mi ka?.p y 0ver t,lis a warm Poultice. •liknhcz reports II cases, of which only 2 appear to have been successful. 418 INJURIES OF THE ABDOMEN AND PELVIS. posed (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. 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. This very ingenious aid to diagnosis has been successfully adopted by several surgeons, but has not always been found infallible, and has the disadvantage that the intestinal distention which it causes in itself some- times 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 rendered clear by the detection of several shot in the matter vomited by the patient immediately after the reception of the injury. Senn'.- test, by inflation of fhe bowel with hydrogen gas, has already been referred to. In any case of doubt, and particularly in cases 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 (enterectomy), and bring the ends to the surface" so as to establish temporarily an artificial anus. If, however, the jejunum be the part involved, to do this would render useless PENETRATING WOUNDS. 419 such a large part of the alimentary canal, that it will be better to report to immediate enlerorraphy, 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 rubber 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 followed the protrusion, under such circumstances, of parts of the stomach, liver, spleen, or other viscera. In these cases, the wound being large, there is commonly not much difficulty in reduction, which should always be practised in the case of such organs as have been mentioned. If the bladder protrude, reduction may be much facilitated by the use of the catheter. If, as occasionally happens, a portion of a solid viscus, 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 sloughing mass may be either cut away or allowed to separate spontaneously. Recoveries under these circumstances have been reported by several surgeons, and 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. SC Cases. scuta neous Ruptures. Gunshot Wounds.1 Viscera Affected. Recov-ered. 27 11 1 45 Died. Mortality per cent. Cases. 289 42 6 50 387 Recov-ered. 130 7 1 28 Died. 159 35 5 22 221 Mortality per cent. Liver and gall-bladder Pancreas .... Kidneys .... 189 83 3 90 162 72 2 45 2S1 85.8 86.7 66.6 50.0 55.0 83.3 83.3 44.0 Aggregates . . 365 84 77.0 166 57.0 ___ Punctured and Incise! Died. 42 6 5 53 > Wounds. Cases. 543 160 13 152 Totals. Recov- Died ered. 180 363 47 113 6 7 80 72 313 I 555 i Viscera Affected. Cases. Recov-ered. Mortality per cent. Mortality per cent. Liver and gall-bladder Spleen, . . , Pancreas .... Kidneys .... 65 35 4 12 116 23 29 4 7 63 64.6 17.1 41.6 45.6 66.8 70.6 53.8 47.3 Aggregates . . 868 63.9 According to Seliger, the mortality after gunshot wounds is, for the liver, 27 per cent.; for the spleen, 65 per cent.; and for the kidneys, 44 per cent. Gunshot wounds j>' the stomach are nearly always, and those of the duodenum always, fatal. When both the thoracic and the abdominal cavity are opened, death usually follows. 420 INJURIES OF THE ABDOMEN AND PELVIS. The parts which are liable to protrude through small wounds are the bowels, mesentery-, and omentum. The treatment of such cases sliould 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 draw ing 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 Tatum and others. Storrs recommends that the lips of the wound should be drawn upwards and separated by means of blunt hooks or ligatures, previously 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 he 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 abdominal parietes. If the protruded bowel be gangrenous, it would not be safe to attempt re- duction, 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 disposed to think that it would 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 subse- quently give way, there would be less danger of fecal extravasation. The course to be pursued in case of Omental Protrusion likewise depends upon the state of the part: if this be healthy, it should 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 ab- dominal 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 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.—-If a solid viscus be affected, the treatment would consist in reduction, or in partial excision, according to the rules above laid down. Postenipski PENETRATING WOUNDS. 421 and Dalton have successfully closed wounds of the liver with sutures. Complete excision may be required by extensive injuries of the spleen or kidney. 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 cases of the previous category. The suture employed should, in case of a large wound, be the continued or glover's suture (Fig. 82), applied through all the coats except the mucous ; or, which is preferable, if the wound be transverse, Lembert's, GeTy's, or Appolito's2 modification. These have for their object the inver- i II 10 Fio. 229. Lembert's suture. Fio. 230. (jolv's suture Fig. 2:>1.—Appolito's suture. sion of the edges of the wound, and the consequent coaptation of the serous surfaces (Figs. 229-231), and seem to me, upon the whole, quite as satisfactory as the more complicated methods of Ve'zien. Bouisson, and Berenoer-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 or silkworm-gut) gradually finds its way into the interior of the bowel, and is eventually discharged per anum. For small longitu- dinal wounds the common interrupted suture may suffice, while a mere puncture may be closed by simply throwing around it a ligature, the wounded point being raised for the purpose with tenaculum or urterv- forceps. If, on the other hand, a transverse wound involve the whole cadbre of the bowel, it is probably better to secure the edges of each ex- tremity 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 bowel bv means of sutures, unless the wound involve the upper portion of the small intestine, when enterorraphu 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, pur-atives 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 Successful gastrorraphies in cases of penetrating wound have been recorded bv neiciienbach, 1'rieto, Facilides, Burckhardt, Dalton, Ball, Black, and Jones. Fatal LawgH"*' 'e bee" recorded b^ Billroth (two cases), Mikulicz, Briddon, and 1.o,icCHSl""?.e,mpl0ys acontin»ous suture, somewhat resembling Appolito's, which he tails the-'right-angled" suture. 422 INJURIES OF THE ABDOMEN AND PELVIS. treatment of penetrating wounds of the belly, with suture of stomach or bowels (ga.strorra.phy, enterorraphy), and, if neecssaryr, 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, at least of gun- shot wound, it offers, I believe, the best chance of recovery; but I am by no means sure that a few years hence the consensus of surgical opinion may not change as regards stab-wounds, and tend more strongly in the direction of expectancy in the management of these injuries. Every hos- pital 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 such wounds has proved successful, have been, with rare exceptions, such as might have been expected to recover without opera- tion. The statistical results of laparotomy for abdominal injury have been investigated by several writers, including MacCormac, Barker, Dalton, Coley, Morton, and Kerr ; to the cases collected by these gentle- men I have been able to add a number of others, and the annexed table shows the results of 306 operations :—l Statistics of Laparotomy for Abdominal Injury. Nature of Injury. Rupture of urinary bladder Rupture of bowels or other viscera Punctured, incised, or lacerated wound Gunshot wound . . . . . Ilecov ered. 33 13 28 6 115 76 190 76 Died. Undeter- Mortality mined. per cent. 20 60.6 22 78.6 38 1 33.0 113 1 59.5 193 2 52.7 Aggregates . . . .1 366 | 171 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 388 cases with 199 deaths, or over 51 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 "accident-hospital" of Philadelphia, and he finds that, omitting all doubt- ful cases, there were treated without operation2 in the wards of that insti- tution, during sixteen consecutive years, 55 undoubted examples of pene- trating wound of the abdomen, of which 25, or over 45 per cent., proved fatal. Adding to these the cases reported by T. G. Richardson, from the Charity Hospital, New Orleans, and those reported by Stimson from three hospitals in New York, we have a total of Ul cases of wound of the abdominal cavity treated without operation, the results of which may be seen in the following table :— 1 In the fifth edition of this work 259 cases were tabulated, to which I have since been able to add 107. 2 In a few cases the external wound was slightly enlarged to permit the reduction of protruding viscera, but no exploratory operation was performed. GASTRIC AND BILIARY FISTULA. 423 Table showing Results of Penetrating Wounds of the Abdomen treated without Operation. Punc La ruRKD, Inci :eratkd W< 3KD, AND )UNDS. Gunshot Wounds. Totals. Hospital. t-r. >--s 9 - -d Mortal per ce 6 1* -a 3 3 u 5 S3 Charity Hospital, ■ -" New Orleans . . 31 24 "i 22.5 32 13 19 59.3 63 37 ?,6 41.2 Pennsylvania Hospi- tal, Philadelphia 29 23 6 20.7 26 7 19 73.0 55 30 ?,5 45.4 New York Hospitals 60 47 21.6 23 81 8 28 15 53 65.2 65.4 23 8 15 66 65.2 13 Aggregates . . 141 75 46.8 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 was employed 20 times, with 7 recov- eries 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 o-un- shot wound, with 2 deaths, or 50 per cent. In 16 cases of gunshot wound operated on in three New York hospitals there were 13 deaths or 81 per cent. From these figures it will be seen that the evidence, as far as statistics go, is, in the case of stab-wounds, in favor of expectant measures, and that a resort to laparotomy has, thus far, added to rather than lessened the mortality in these injuries. In gunshot wounds, on the other hand, the statistical evidence is in favor of operation. I am disposed to think moreover, that some of the deaths after abdominal section in these cases' have been attributable to recklessness on the part of the surgeon in unne- cessarily prolonging the operation, and in disregarding the dangers of shock from exposure and chilling of the viscera, and I believe that,°if exe- cuted with skill and care, laparotomy, at least in well-selected cases of penetrating wound of the abdomen, is the proper mode of treatment. When the patient recovers from a penetrating wound of the abdomen without operation, it is often with a gastric, biliary, urinary, or fecal fistula, according to the part injured. Gastric Fistula is a condition by no means incompatible with long life and comfort. If small, an attempt may be made to promote contrac- tion and cicatrization by occasional cauterization of the edges ; but if Iar<»e the surgeon should ordinarily content himself with applying a suitable compress, or obturator. Billroth, however, has successfully resorted to gastrorraphy, splitting the edges of the fistula and closing the gastric opening with sutures, and then covering the external wound with a flap taken from the neighboring integument. Tillmans has recorded a case of ('ongenital protrusion of the gastric mucous membrane through the um- bilicus. ° Biliary Fistula, of which I have seen but one example, usually ad- mits of no treatment, except keeping the parts clean and removing any gall-stones that may become impacted. Should anything further be re- quired, the gall-bladder might be exposed by abdominal section, and suture or that yiscus (cholecystorraphy), excision (cholecystectomy), or the estab- '•'iiment of a communication with the bowel (cholecystenter-ostomy) might »e resorted to, according to the particular circumstances present. * 424 INJURIES OF THE ABDOMEN AND PELVIS. Urinary Fistula, following a wound of the ureter inflicted in ovari- otomy, has been successfully treated by Gussenbauer by a process of ureteroplasty, which consists in dilating the sinus and then establishing an artificial passage between the cut ureter and the bladder. Similar operations are attributed to Nussbaum and Tauffer. Van Hook advises that when the ureter is divided one end should be tied, a longitudinal incision made beyond the ligature, and the other end invaginated into the opening Fecal or Intestinal Fistula, usually called Artificial or False Anus—the latter name is adopted by H. Morris—is more frequently met with after strangulated hernia than after a wound, but the treatment in either case is the same, and I shall, therefore, consider it here. If the opening into the bowel be but small, the greater portion of the fecal mass being evacuated in the natural way, it may be sufficient to keep the parts clean, and to apply a firm compress, which, with occasionally touching the edges with nitrate of silver, will sometimes effect a cure; or the fistula may be carefully laid open, and its sides brought together with deep stitches—a proceeding by which I succeeded in effecting a cure in n case sent to me by Dr. Benjamin, of Camden. If, however, the opening be larger, and still more if the whole calibre of the gut be involved, the condition is different. In such a case the ends of the bowel adhere by their serous surfaces, their position at the bottom of the external wound having been not inaptly compared to that of the tubes of a double-barrelled gun. The lower end of the bowel, being unused, undergoes contraction, while the upper extremity is frequently abnormally dilated. The mesen- teric portion becomes prolonged between the ends of the gut into a kind of spur, which acts as a valve in further occluding the lower opening. In some cases the junction of the two ends of bowel is at a considerable depth from the surface, the fecal contents finding their way to the external wound through a long and perhaps sinuous canal. The treatment consists, if Pesault's plan of continuous compression1 fails, in dividing the " eperon," or spur-like projection between the intes- tinal extremities, so as to restore the continuity of the bowel, and in sub- sequently freshening the edges of the external wound, which is then closed with harelip pins—or in performing a plastic operation, if the simpler pro- cedure does not succeed. The division of the spur may be accomplished in several ways, the best being by means of the enterotome devised by Dupuytren. The enterotome consists of two serrated blades (Fig. 232, a, b), which are introduced, one into each end of the bowel, and which are then approximated, and fixed by means of a screw. This screw is tight- ened day by day, so as to cause the adhesion of the adjoining surfaces of the bowel, and the removal of the septum by sloughing; if this be done too quickly, the peritoneal sac will be opened,"and death will probably occur from fecal extravasation. Another risk is the possibility of pinching a knuckle of healthy intestine between the blades. The tightening of the screw must be very gradually effected, the time required for safe division of the septum being at leasts week. Marsh recommends that if the spur be prominent only a portion of it should be attacked at a time. In a case in which the lower end of the bowel could not be found, Laugier opened the large intestine at another part, and introducing one blade of a modified Dupuytren's enterotome through each wound succeeded in this manner in 1 Mitchell Banks has successfully modified Desault's plan by introducing a piece of thick elastic tubing, one end passing into either segment of the bowel, so that by its constant effort to straighten itself the eperon may be pushed backwards. FOREIGN BODIES. 425 restoring the continuity of the gut. To avoid the risk of premature per- foration, Prince suggested the use of a wire loop and pin, by which the sides of the septum could be invaginated, while the necessary pressure was afforded by an elastic cord connecting the pin and loop outside of the body. II Fig. 232.—Dupuytren's enterotome. Fir.. 233.—Enterotome applied. (Erichsen.) Perforation being effected, the little instrument was made to cut its way out through the septum by means of another elastic cord, attached to a miniature "derrick" fixed upon the surface of the abdomen. Other plans are Physick's, which consists in bringing together the sides of the septum with a ligature, and in subsequently dividing the part below; and Schmakhalden's, which consists in transfixing the septum with a ligature, which is then forcibly tied and allowed to cut its way out. Various modifications of Dupuytren's method have been proposed by Liotard, Delpech, Gross, and others. During the application of the enterotome, the patient should be kept fully under the influence of opium. As soon as the continuity of the bowel has been restored, the edges of the external wound may be pared and brought together with the twisted suture, or, as suggested by Duncan, the edges may be split, the mucous surfaces being invaginated and secured with catgut sutures, while the external wound is closed with silver wire; or, if simpler measures fail, an attempt may be made to close the opening by means of a plastic operation. Of 83 cases of Dupuytren's operation collected by Heimann, 50 were completely and 26 partly successful, while only 7 proved fatal. Resection and suture of the affected bowel have, according to Reichel, been performed in 37 cases of this kind, with 21 recoveries, 2 failures, and 14 deaths; a rate of mor- tality which, it will be seen, is much higher than that of Dupuytren's method. Foreign Bodies, such as coins, pins, buttons, or artificial teeth, are not uufrequently swallowed, and may lodge in the stomach or bowels. The domestic treatment of such cases is usually the administration of a purgative—a remedy which is, however, really unsuitable, as the object should rather be to delay peristaltic action, and to allow the foreign body- to become enveloped in a mass of fecal matter, so that it may produce less irritation in its onward passage. Billroth recommends a diet of potatoes for this purpose, and records several cases in which the "potato-cure" has been successfully employed. If the foreign body cannot be extracted through the mouth, as has been successfully done in one instance by L. S Little, and is of such a nature (as a table-knife or fork) that it cannot 426 INJURIES OF THE ABDOMEN AND PELVIS. probably be either dissolved by the gastric and intestinal juices, or natur- ally evacuated, the surgeon will be justified, provided its position can be ascertained by external palpation, in attempting its removal by operation. Gastrotomy appears to have been successful under these circumstances in 42 out of 50 cases in which it has been employed, and, as death would he, sooner or later, almost inevitable without operation, the attempt is at least permissible.1 The incisions, in such a case, should be regulated by the size and shape of the body to be removed, and the after-treatment should be the same as for an incised wound accidentally inflicted. Enterotomi/ might be similarly resorted to, if the foreign body, having reached the bowel, should cause complete intestinal obstruction (see Chap. XLI1I.). A fork was thus successfully removed from the bowel by Rosati, and a spoon by Walker, of Cincinnati. J. C. McKee has recorded a remarkable case in which a piece of wire was accidentally swallowed, and, having made its way into the abdominal parietes, was safely removed by external incision nearly four months afterwards. Stelzner, of Dresden, reports a case in which foreign bodies were several times removed from the stomach and bowels by repeated operations. YV. F. Smartt has successfully extracted a bullet weighiug 80 grains from the right lobe of the iiver. Foreign bodies which had been swallowed, and having ulcerated through the walls of the stomach had lodged in various parts of the abdominal cavity, have been successfully removed by LeDentu, Bardeleben (two cases), Nussbaum (two cases), LeFillier, and Dubois. Injuries of the Pelvic Organs Injuries of the Bladder__The bladder may be ruptured (without external wound) by violence,2 as a kick, applied to the abdomen. This accident is only likely to happen if the organ be distended with urine, as when empty it sinks beneath the pubic arch, and is thus measurably pro- tected from external injury. The rupture usually occurs in the posterior wall of the bladder, involving the peritoneal as well as the other coats of the organ, and allowing urinary extravasation into the peritoneal cavity, an event which, without operation, is almost inevitably fatal, 98 cases col- lected by Bartels having given but 4 recoveries.3 More rarely the rent is confined to the anterior wall of the bladder, urine then escaping into.the pelvic areolar tissue, and inducing a condition which, though very grave, is not so uniformly fatal as that previously referred to, 12 out of 54 such cases collected by Bartels having terminated favorably'. The symptoms, in the former case, consist of intense epigastric pain, collapse, urgent but fruitless efforts to urinate, and in a short time the ordinary signs of perito- nitis; the introduction of the catheter serves to evacuate either none or a very small quantity of bloody urine. If the peritoneum be not involved, the symptoms are less urgent, the patient being, in these cases, gradually worn out by diffuse inflammation and sloughing of the areolar tissue. Weir recommends, as a means of diagnosis, that the bladder should be injected with a weak carbolized solution (1-100); if the organ becomes distended as shown by the increased dulness on percussion, and if the same quantity 1 See, however, this question discussed by Poland (who considers the operation un- necessary), in Guy's Hosp. Reports, 3d s., vol. ix. In the fifth edition of this work I tabulated 42 cases of gastrotomy, and 8 additional cases have since been recorded. 2 Assmuth reports two cases of rupture from muscular action. 3 H. Morris has reported a case in which a patient recovered from rupture of the bladder, and seven years afterwards sustained a second rupture of that organ, the injury upon this occasion proving fatal. INJURIES OF THE BLADDER. 427 of solution that was thrown in flows out again through the catheter, no rupture has occurred. The treatment, in case the rupture involve the peri- toneum, should consist (as suggested many years ago by the elder Gross) in opening the belly in the median line, washing out the extravasated urine with warm boracic solutions or distilled water, and carefully closing the rent in the bladder with the Lembert suture, the external wound being dressed in the ordinary way. Of 33 cases thus treated, as shown by the table on page 422, 13 ended in recovery and 20 in death—a mortality of 60.C> per cent., which compares very favorably with the death-rate of 95.9 per cent, derived from Bartels's figures of cases treated by expectant measures only. After the operation, a long flexible catheter should be in- troduced and secured in place, the urine being allowed to run off con- stantly, bv means of an attached India-rubber tube, into any convenient receptacle. The patient should be got as soon as possible under the influ- ence of opium, and concentrated food or stimulants administered, if indi- cated by his general condition. Diaphoresis should be encouraged by externa] applications, it being an obvious indication to promote the vica- rious action of the skin, and thus diminish the amount of urine secreted. In case the rupture was extra-peritoneal, I would advise, unless the bladder could be kept empty by means of a catheter, an immediate resort to cystotomy, as in the median or lateral operation for stone; a procedure which has been successfully" employed under these circumstances by Walker, Parker, and Mason, and unsuccessfully7 by Harrison, and which would, I think, be preferable to opening the bladder either through the rectum or above the pubis, though the latter procedure also has been employed, un- successfully by Sonnenburg, but successfully by Williams. Free incisions should be made on the first outward manifestation of urinary infiltration having occurred. Weir records a case of extra-peritoneal rupture cured by incision aud drainage both from the perineum and above the pubis. Sonnenburg has resected the bladder for rupture, but the case terminated fatally. A few instances are on record, in which the bladder has been ruptured by the accumulation of its own secretion ; but such an accident is very rare, the urethra usually giving way, in such cases, rather than the bladder. I have, however, seen an extra-peritoneal rupture of the anterior wall of the bladder, caused by the improper use of instruments in a case of retention of urine due to the presence of a tight urethral stricture. Wounds of the Bladder are amongst the most serious complications of fractures of the pelvis. The bladder may also be wounded by gunshot projectiles, by pointed instruments, by the horns of infuriated animals, etc. When the wound is in that part of the organ which is covered with peritoneum, these injuries are usually fatal, unless rescued by laparotomy and vesical suture (cystorraphy), but there are numerous instances of re- covery from wounds of the bladder inflicted in the perineal region. The treatment of these cases is essentially that which has been described in the preceding paragraph ; any foreign body that may have lodged in the bladder should be removed, as its continued presence would produce great irritation, and probably cause the formation of calculus If the wound be through the rectum or vagina, a troublesome fistula may result, requiring, perhaps, the performance of a plastic operation. Foreign Bodies, such as slate-pencils, pins, etc., may be introduced into the bladder through the urethra, through an external wound, or, more rarely (by the process of ulceration), from another viscus—as in remark- able cases recorded by Kingdon and dimming, in which a pin having been swallowed, lodged in the appendix vermiformis, from which it sub- secpiently made its way into the bladder, where it formed the nucleus of a 428 INJURIES OF THE ABDOMEN AND PELVIS. calculus; the ulceration by which this process was attended gave rise to the formation of an intestino-vesical fistula,, through which round worms entered the bladder, and were at different times discharged from the urethra. Foreign bodies may occasionally be spontaneously expelled from the bladder, or may be extracted with urethral forceps (Fig. 234), or a small lithotrite, if the surgeon succeed in catching them in the direction Flu. 2.H.—Luer's forceps for removal of foreign bodies from the bladder. of their long axis. In the male, however, it is usually necessary to resort to lithotrity (if the nature of the body admit of its being crushed), or to lithotomy, the median being in such a case the preferable operation. From the femate bladder, foreign bodies may be conveniently removed, in most cases, by dilating the urethra with two-bladed or three-bladed forceps, or with graduated bougies, until the forefinger can be introduced, when it is very easy with forceps to seize and extract the foreign body, the finger serving to adjust it into a, favorable position for removal. It occasionally happens that, in using the female catheter, the instrument slips from the fingers, and is sucked into the bladder. In the event of such an unfortu- nate occurrence, the surgeon should at once dilate the urethra and remove the foreign body. I have known fatal ulceration to result, under these circumstances, from the delay of only a few davs. Injuries of the Rectum__Wounds of the rectum, provided that thev are uncomplicated, usually heal without much difficulty, as is seen after the operation for fistula, or when the bowel is accidentally wounded in lithotomy. If the lesion involve the bladder or vagina, recto-vesical or recto-vaginal fistula will probably result, and mayT require the performance of a plastic operation. Death may follow perforation of the rectum (from the peritoneum being opened), as has occasionally happened from the in- cautious use of syringes or of rectal bougies. Foreign Bodies are occasionally found in the rectum, and must be re- moved with scoop or forceps, as the ingenuity of the surgeon, and the ex- igencies of each particular case, may suggest. Linear redotomy may be required, as in cases recorded by Raffy and Turgis (see Chap. XLlif ). The removal of masses of impacted feces, of seeds or fruit-stones, etc., may often be accomplished simply by the repeated use of warm enemata. A fish-bone, or similar article, may be caught in one of the pouches of the rectum, and may. by the resulting ulceration, give rise to a fistula in ano. Injuries of the Penis and Male Urethra.— Wound* of the Penis, if limited to the skin, are not attended with any particular risk; they always require the use of sutures, on account of the retractile tendency of the part. In deeper wounds there may be profuse hemorrhage, which may require a ligature, if it proceed from any recognizable artery, but which, if of the nature of general oozing, may be checked by cold and pressure, the latter being best applied by introducing a full-sized catheter, and then compressing the organ upon this with adhesive strips. Contusion, or Partial Rupture, of the corpora cavernosa, is followed by interstitial ex- INJURIES OF THE PENIS AND MALE URETHRA. 429 travasation of blood, attended by marked induration, and sometimes by priapism, which may persist for several days. Such an injury is best treated by the continued application of evaporating lotions. Strangulation of a portion of the penis is sometimes produced in children by tying a string around the part, or, in adults, by the introduction of the organ into a metallic ring, the neck of a bottle, etc. If gangrene has not been in- duced, the symptoms will usually quickly subside upon the removal of the source of constriction. Nelaton, Hey en berg, Molclenhauer, and Roves Bell have reported remarkiible eases of luxation of the penis, the organ being completely separated from its cutaneous covering, and buried in the adjoin- ing tissues. In Ne'laton's case reduction was effected by the use of forceps. The Urethra may be Wounded by cutting instruments, or gunshot pro- jectiles, or may be Lacerated by falls or blows upon the perineum or penis, by injuries received during coitus, or even by violent straining efforts at micturition in cases of stricture. It may also be wounded in rude attempts at catheterization, giving rise to the formation of "false passages." The symptoms of laceration of the urethra are pain, considerable swelling from interstitial bleeding, hemorrhage from the meatus, and inability to urinate. If the patient, by straining, succeed in passing water, Urinary Extrava- sation will usually occur, giving rise to extensive destruction of tissue, and the formation of perineal fistulas. This is less likely to happen in cases of "false passage" than in those of other varieties of urethral laceration, because in the former the direction of the passage is away from the course of the urine. The treatment consists in the immediate introduction of a full-sized catheter (flexible, if possible), which must be retained for several days, until the subsidence of pain and swelling renders it probable that the laceration has healed ; the catheter should not be plugged, lest the accumu- lating urine find its way by the side of the instrument. If it be impossible to introduce a catheter, the surgeon must at once open the urethra in the perineum, when, if the instrument still cannot be passed, a flexible tube may be introduced through the wound into the bladder. This I believe to be safer, in these cases, than puncture through the rectum or prostate, or above the pubis. If extravasation of urine have occurred, free incisions must be made in the perineum, scrotum, and inside of the thighs, or wherever the urine may have reached, to permit the escape of the irritating fluid, and to facilitate the separation of sloughs. Laceration of the urethra, according to its extent, will probably result in an intractable form of stric- ture, or even in complete obliteration of a portion of the tube, with the persistence of an incurable perineal fistula. Guyon advises immediate suture of the ruptured urethra, with or without resection of the lacerated part, according to the severity of the injury. Foreign Bodies in the urethra may be extracted through the meatus, with urethral scoop or forceps (or, in some cases, as suggested by Keyes, Fig. 235.—Urethral scoop of Le Roy d'^tiolles. with a Thompson's stricture expander), or through an incision in the median line. If this incision be in the perineum, the wound may be allowed to heal by granulation, a full-sized catheter, or bougie, being passed every other day ; but if in the penile portion of the urethra, sutures will be required, and in this case a flexible catheter should be retained until union has occurred When the foreign body is long and soft (as a bit of 430 INJURIES OF THE ABDOMEN AND PELVIS. catheter), an ingenious plan of removal, suggested by Van Buren and Keyes, may be adopted; this consists in transfixing the foreign body with a stout needle passed through the floor of the urethra, and pushing back Fig. 236.—Cusco's urethral forceps. the canal as far as possible, like a glove over a finger, then withdrawing the needle and transfixing again, and so gradually coaxing the foreign body forwards until it can be seized at the meatus. Injuries of the Scrotum and Testes—Wounds of the Scrotum require the application of sutures; if the wound be extensive, the testis may be extruded, owing to the great contractility of the dartos muscle. In order to effect relaxation of the part, Birkett advises the use of warm fomentations before the application of stitches, cold lotions being afterwards substituted to produce contraction and prevent bagging. Contusion of these parts is followed by great swelling and eechymosis, and often results in the formation of a hydrocele, or haematocele. Wounds of the Testis usually heal readily, the tunica vaginalis, in such cases, commonly becom- ing obliterated by inflammation. Atrophy of the organ is said to occa- sionally follow these injuries. Injuries of the Prostate —Incised wounds of the prostate heal without trouble, as is seen in cases of lithotomy. The prostate is some- times wounded in rude attempts at catheterization, causing retention of urine and urethral hemorrhage; the treatment consists in introducing a large flexible catheter, or, if this be impossible, in tapping the bladder through the rectum or above the pubis. Injuries of the Spermatic Cord and Vas Deferens__Wounds of the Spermatic Cord require the use of the ligature, or other means of checking hemorrhage, and the divided segments of the cord should be brought together with a stitch, in hope of procuring union. Hilton has met with several cases of Rupture of the Vas Deferens, marked by arterial hem- orrhage from the urethra, with great pain and fever, and followed by atrophy of the corresponding testis. The treatment is that which is appro- priate for ordinary deep-seated inflammation. Injuries of the Uterus—Injuries of the Unimpregnated Uterus are very rare, and could scarcely occur except in combination with other more serious lesions. Injuries of the Pregnant Uterus, besides the risks of hemorrhage and peritonitis, are extremely apt to terminate in abortion. The treatment of such cases must be conducted upon the principles which have been laid down for the management of cases of severe injury to the abdominal viscera in general. If the foetus be partially or completely extruded from the womb, it must be removed per vias naturales, or through the external wound, if there be one, according to the particular circumstances of the case. Rupture of the Womb, occurring during Par- turition, is not a subject properly within the scope of this work. Laceration of the Cervix Uteri is an accident of not unfrequent occurrence during labor, and may require an operation, which consist- INJURIES OF THE PERINEUM. 431 essentially in freshening the edges of the rent with suitably curved scis- sors, and fixing them with metallic sutures, which are allowed to remain for about ten days, or with catgut sutures, which need not be removed. Injuries of the Vulva and Vagina—Contusions and Wounds of these parts are to be treated on the principles which guide the surgeon in the management of similar injuries in other regions of the body. Women are sometimes seriously wounded, while in the act of micturition, by the breaking under them of chamber utensils, and fatal hemorrhage has occa- sionally resulted under these circumstances, from a wound of the internal pudic artery. The treatment would consist in suturing the wound, or in plugging it with lint dipped in a solution of the persulphate or perch'loride of iron, and in the application of a compress and firm bandage. Foreign Bodies occasionally become impacted in the vagina, or may be thrust through its walls into the bladder, rectum, or peritoneal cavity. The treat- ment consists in the removal of the offending substance bv such means as the ingenuity of the surgeon may suggest, and in the subsequent adoption of measures to combat the resulting inflammation. Injuries of any portion of the "genital zone," received during pregnancy, are, as pointed out by Gi.eniot, apt to be followed by abortion Injuries of the Perineum—Wounds of the Male Perineum, not involving the urethra, commonly heal without much difficulty. Lacerations of the Femate Perineum occasionally occur during labor, and, if at all extensive, usually require an operation for their cure. If" the case be seen within twelve hours after the occurrence of the laceration, it will probably be sufficient to approximate the parts with deep and super- fical sutures, maintaining the thighs in apposition until union has occurred, and insuring cleanliness by frequent syringing with a solution of permanga- nate of potassium. At a later period it will be necessary, after emptying the bowel by means of an enema, to draw away the anterior wall of the vagina with a duck-billed speculum and freshen the edges of the opening (making a raw surface at least an inch in depth, and extending the whole length of the fis- sure), then accurately adjusting the parts with the quilled suture, as recommended by Brown, or simply with the inter- rupted suture, as done by Sims, Emmet, and Agnew. In either operation two sets of sutures may be properly em- ployed; a deep set—entering an inch from the cut edge, passing as deep as the denudation extends, and coming out an inch from the cut edge on the oppo- site side—and a superficial set to insure more accurate adjustment of the cutane- ous surfaces. When the sphincter is in- volved, care should be taken in passing the hindmost suture to let the needle enter and come out far back towards the coccyx, so as to insure the close approximation of the separated muscular fibres and thus guard against fecal incontinence. This precaution is par- ticularly insisted upon by Emmet, who finds that its neglect frequently Fig. 237.—Surface denuded in complete perineal rupture, and first two sutures in position. (Thomas.) 432 DISEASES RESULTING FROM INFLAMMATION. allows the persistence of a recto-vaginal fistula. Another and a better plan to secure the same result is to pass two or more sutures through the sphincter from the rectum, knotting them in the bowel; the best material is silkworm-gut. If the whole recto-vaginal septum be torn, it will be necessary' to close this by numerous interrupted sutures passed from the vaginal surface, and in these cases it may be desirable to divide the sphincter ani on either side, as recommended by Horner, Brown, and Koeberle.. If there be great tension upon the deep sutures, a curved incision may be made on either side of the perineum, as recommended by Dieffenbach and T. Smith; Parker employed lateral incisions, through the bottom of which he passed sutures of doubled wire, secured over pieces of catheter. If the quilled suture be employed, either strong whipcord or flexible wire may be used. The best material for the interrupted suture, both superficial and deep, is strong silver wire. The deep sutures are most conveniently introduced by means of a needle fixed iu a handle. In the after-treatment the contents of the bowels should be kept fluid bv laxatives, and the catheter should be used at regular intervals. Sims and Emmet advise the employment of a short rectal tube to allow the escape of flatus. The deep sutures may be removed from the sixth to the eighth day, and the superficial set a few days later. Catgut sutures are recom- mended by Brickell, who further modifies the operation by tying the deep sutures over metallic stays placed between the sides of the wound. Other surgeons employ/ buried sutures of catgut or other animal material to re- store the perineal body, and then stitch the skin and vaginal mucous membrane separately. Ilodgen, instead of merely freshening the edges of the laceration, dissected triangular flaps from both buttocks, and turned them inwards with their cutaneous surfaces toward the vagina, thus in- creasing the size of the raw surfaces to be approximated, and furnishing an apron to prevent the vaginal discharges and urine from irritating the wound. A similar plan is adopted by Parker and Stimson, and is by the latter surgeon attributed to Langenbeck. Collins Warren, instead of cut- ting away the mucous membrane from the freshened surface, leaves it attached at its inferior border, and turns it downwards as an apron to insure closure of the rectal laceration. Lavvson Tait and Duke split the recto-vaginal septum. Modifications of the ordinary operation for rup- tured perineum have also been introduced by Simon and Emmet, the former prolonging the denudation in a triangular form on the posterior wall of the vagina, and the latter aiming to restore the perineal centre rather than the whole perineum, by taking care that the sutures shall bring together the separated ends of muscular fibre. CHAPTER XXI. DISEASES RESULTING FROM INFLAMMATION. Abscess. An abscess is a collection of pus, surrounded by a wall or layer of lymph. Pus existing in a serous cavity (as in empyema), or in a joint, does not strictly constitute an abscess (though often so called), any more than pus widely diffused through the cellular tissue, or covering the granulations of an ulcerated surface. Several varieties of abscess are described by surgical ACUTE OR PHLEGMONOUS ABSCESS. 433 writers, as the acute or phlegmonous; the chronic; the cold, lymphatic, congestive, or scrofulous; the diffused (a contradiction in terms); the emphysematous ; the metastatic or pyaemic ; and the residual. The division which I shall adopt, and which seems to me to be the simplest, is into (1) the acute or phlegmonous abscess, which may be considered the typical form ; (2) the chronic or cold abscess ; and (3) the residual abscess. Dif- fused Suppuration (which, according to the definition above given, does not constitute an abscess) will be described in a separate place, and the so-called Metastatic Abscess in the chapter on Pyaemia. The presence of gas in an abscess (constituting the Emphysematous variety) is a mere coincidence, depending on the locality of the affection, or on the occurrence of putrefaction. Acute or Phlegmonous Abscess.—WThen a part that has been in- flamed becomes more swollen, the dull pain changing to one of a throbbing or pulsatile character, the skin assuming a deeper hue, and presenting a shining and glazed appearance, the surgeon knows that suppuration is Im- pending, and that an abscess will probably be formed. If the seat of pus- formation be deep-seated, the superincumbent tissues become brawny and (edematous, from infiltration of lymph and effusion of serum, and, as the pus gradually approaches the surface (which it has an almost invariable tendency to do), the overlying tissue becomes softened, the thinnest part bulges forwards, the cuticle often desquamates, fluctuation (which was at first obscure) becomes manifest, and pointing of the abscess is said to have occurred. A small circular slough is then formed at the thinnest part, and detached by the outward pressure of the pus, when the abscess discharges its contents, its walls contract by their own elasticity, the cavity is filled by the process of granulation, the remaining superficial ulcer cicatrizes, and the part returns gradually to its normal condition—a scar and loss of substance, however, sometimes persisting for a very long time. The mechanism of pointing has never been explained in a perfectly satisfactory manner. The tissue which intervenes between the abscess and the surface upon which it is to break, is usually said to yield by a combined process of absorption and disintegration ; it seems more probable, however, that under the influence of the inflammatory process rapid cell-proliferation occurs in the abscess wall, with liquefaction of the intercellular substance, thus forming fresh pus-cells, the number of which is probably still further increased by the direct transit of white blood-corpuscles "through the parietes of the capillary vessels. The final step consists, as has been men- tioned, in a small disk of skin becoming deprived of its vitality, and being thrown off as a minute circular slough. Though an abscess usually tends towards the cutaneous surface, it may, under other circumstances, break into a mucous canal, into a joint, or even into one of the large serous cav- ities of the body. A happy provision of nature in the case of abscesses of internaUrgans (as of the liver), pointing externally, is that localized in- flammation and adhesion may open the way for the escape of the pus upon the cutaneous surface, without the intervening serous cavity becoming involved. ' Diagnosis.—The diagnosis of phlegmonous or acute abscess can usually be made without difficulty, by attending to the history of the case, by ob- serving the disposition to point, by noting the presence offluctuation and the other local signs above described, and lastly, if necessary, by using the exploring needle or trocar. Fluctuation, which is the sensation com- municated to the surgeon's hands by a wave of fluid, can best be recog- nized by placing one or two fingers of each hand on the suspected swell- ,ng, and making alternate pressure, first with one hand and then with the 434 DISEASES RESULTING FROM INFLAMMATION. other. The fingers should be placed longitudinally as regards the direc- tion of the muscular fibres of the part, and it must be observed that in anv region in which the muscular and connective tissue is abundant, as in the thigh or nates, or bound down by dense fasciae or ligaments, as in the tem- poral region or the back of the hand, a very slight increase of tension from inflammation or effusion will give a deceptive feeling closely analogous to fluctuation. Again, certain tumors, as the cystic, fatty, glandular, or encephaloid, are often attended with fluctuation, and have been frequently mistaken for abscesses. Finally, a partially consolidated aneurism may give the sensation of deep-seated fluctuation, and thus lead the surgeon into error. Hence, in any case of doubt, more especially if the suspected swelling be in the neighborhood of a large artery or other important part, the surgeon should, by all means, confirm his diagnosis by using the ex- ploring-needle, before making a free incision. A better instrument, in some cases, than the ordinary exploring-needle, is the aspirator, or even the common hypodermic syringe. The temperature of abscess cavities has been particularly investigated by Assaky, who finds that it ranges from 99.5° to 101.3° Fahr., gradually diminishing as the abscess heals. The skin over an acute abscess is from 1° to 4.5C hotter than the corre- sponding part on the other side of the body. This increase of temperature might sometimes prove of diagnostic value, but would not serve to dis- tinguish an abscess from a rapidly growing sarcoma, which affection, as pointed out by Estlander, and, as I have found by personal observation, may cause a very considerable augmentation of local heat. The course of the temperature in an abscess is, according to Assaky, quite independent of that of the body in general. Prognosis.—An acute abscess, unless very large, is usually a compara- tively trivial affection. In certain situations, however, even a small abscess may not only, by pressure on nerves or other important structures, cause great pain and discomfort, but may even seriously endanger life. An abscess of the prostate or perineum may cause retention of urine; one of the fauces or throat, dyspncea and even death ; or one of the parotid or a cervical gland, fatal bleeding from the carotid artery or internal jugular vein. The drain from a very large abscess, or from numerous abscesses, may cause death by exhaustion, with or without the development of hectic fever, or by inducing the peculiar form of visceral disease which has re- ceived the name of amyloid or albuminoid degeneration. Treatment.—This may be divided into the Prophylactic and the Cura- tive treatment. The formation of pus, in acute phlegmonous inflammation, may he prevented; more than this, pus after formation may be absorbed. I have myself seen this in several instances, and a number of cases were collected in the Medical Times and Gazette for 1858, which proved the possibility, at least, of this occurrence. Kor can this be considered at all unreasonable, if we accept the views of Cohnheim and his followers, who maintain the identity of the pus-cell with the white blood-corpuscle, and believe that they have actually seen the latter migrating through the capil- lary walls. Be this as it may, abscesses unquestionably disappear under treatment, though in many cases it is probably the fluid matter only which is absorbed, the solid remaining as a caseous residue, or undergoing creta- ceous degeneration. The old humoralistic doctrine looked upon suppura- tion and abscess as efforts of nature to rid the system of some peccant matter, and hence taught the propriety of promoting and hastening, rather than of endeavoring to prevent suppuration. I suppose, however, that there are few surgeons at the present day who would not consider the prophylactic treatment of abscess at least permissible. The remedies to ACUTE OR PHLEGMONOUS ABSCESS. 435 be employed for this purpose have been already referred to in the chapter on the Treatment of Inflammation : they are such as tend to promote resolu- tion. Sedative and anodyne applications are usually most appropriate- dry cold, or evaporating lotions, are often useful, the former, especially, in cases in which the integrity of a joint is threatened. Warm and emollient fomentations, on the other hand, sometimes answer a better purpose than cold applications; gentle friction with laudanum and olive oil, and the use of cataplasms, will be found most efficient in the prevention of mam- mary abscess. Finally, it is sometimes possible, as it were, to stimulate away an abscess: I have more than once succeeded in dispersing a bubo by the use of a blister, even after pointing had occurred. Curative Treatment.—The length of time during which abortive meas- ures, if not rapidly successful, may be persevered in, should depend a good deal upon the feelings of a patient. If the pain and febrile disturbance which accompany the formation of an abscess be very great, it will usu- ally be wise to desist from such measures, and strive merely to relieve the patient's sufferings. I am not quite sure that we can often materially hasten the pointing of an abscess by treatment, but we can certainly make the patient more comfortable while the pus is approaching the surface, and the best application for this purpose, in the immense majority of cases, is an emollient poultice. Though an abscess will eventually burst of itself, it is usually better to evacuate its contents artificially—this little operation giving great relief to the patient, and rendering the resulting scar less con- spicuous. The time at which an abscess should be opened depends on the circumstances of the case : if the pus be deep-seated and bound down by tense fasciae, the pain being great, an early incision, at the most dependent point, should be practised, and will be found to afford the greatest comfort to the patient; if, on the other hand, the abscess be comparatively super- ficial, and the pain and constitutional disturbance not very intense, it is, I think, better to wait until decided pointing has occurred. The reason for that is that, if the incision be made prematurely in another locality, point- ing and spontaneous opening may still take " place, the surgeon's interference in such a case being afterwards thought by the patient, and not unreasonably, to have been uncalled for. An acute abscess should only be opened by incision^ and this is best accomplished, I think, with a straight, narrow, sharp- pointed bistoury. The surgeon, holding the knife in his right hand as a pen, but almost perpendicularly to the surface, with the edge towards himself, fixes the abscess with the thumb and fingers of the left hand, and rest- ing the ring and the little finger of the right hand upon the skin, quickly plunges the point of the knife into the cavity of the abscess, and rapidly drawing the blade towards himself, enlarges the puncture to the requisite extent as he withdraws the instrument. The depth to which the knife is to penetrate having been mental^ determined beforehand, the in- strument is prevented from going too far by the pressure of the fourth and fifth fingers on the cutaneous surface. The incision should Fig. 238.—Drainage-tube and forked probe. 43t) DISEASES RESULTING FROM INFLAMMATION. be made in a longitudinal direction as regards the part affected. Local anaesthesia by cocaine may be used in these cases ; but freezing the part is in itself not devoid of pain, while it renders the skin much more difficult of penetration. If the abscess were situated veryr deeply, there might be some risk of wounding a large vessel in making the opening as above directed, and in such a case it would be better to adopt Hilton's plan, incis- ing the skin and fascia, and then pushing a grooved director through the overlying muscles into the abscess, the opening being dilated by separating the blades of a pair of forceps introduced along the groove of the instru- ment. A free aperture having been made, the abscess mayr be allowed to evacuate its contents by the elastic contraction of its own walls; the sur- geon may, if necessary, make very gentle pressure with soft sponges on either side of the incision, but all rude handling or squeezing should be strictly avoided. Gosselin advises that after the contents of the abscess have been evacuated, its cavity should be thoroughly washed out with alcohol, and believes that by so doing rapid healing is promoted. Hemor- rhage into the cavity of an opened abscess may occur from a vessel acci- dentally divided, or which subsequently gives way from the relief of pressure upon its walls. The treatment consists in exposure to the air, cold, pressure, or ligation, as in other cases of hemorrhage. After the evacuation of an abscess, poultices may be continued for a few days, until the surrounding inflammation has subsided, when cerate or other simple dressing should be applied to the wound, and the walls of the cavity com- pressed by means of a bandage or adhesive strips. If, from the size or situation of the abscess, or from any other circumstance, there he a ten- dency to bagging of matter, a drainage-tube may be employed, being either simply introduced into the incision by means of a forked probe (Fig. 238), or carried seton-like through the cavity, and brought out by a counter-opening. Instead of the ordinary drainage-tube, a flexible metallic probe may be substituted (the pus escaping by its side), or a coil of wire, as recommended by Ellis, or a self-retaining, India-rubber drainage-anchor, as suggested by Davy. The hygienic and constitutional treatment of abscess, and of suppuration generally, has already been considered in the chapter on the Treatment of Inflammation. Chronic or Cold Abscess—The term chronic abscess is open to objection, as referring etymologically only to time, and being of course merely comparative. A phlegmonous abscess, if deeply seated, may be of slower development than a chronic or cold abscess which is superficial. The term cold abscess is borrowed from the Germans, and is significant, a^ referring to a prominent sym^ton in these cases, viz., the absence, in greater or less degree, of the increased temperature and other common ^sigus of inflammation. These abscesses are chiefly met with in connection with diseases of the bones or joints, or of the lymphatic system. They are not attended with much pain, have little or no disposition to point, and sometimes extend widely beneath the skin, or among the planes of muscu- lar tissue. Their development is sometimes very slow, resembling that of phlegmonous abscesses, only with less local and constitutional disturbance, the investing layer of lymph being occasionally so dense as to obscure fluctuation and give the appearance of a solid tumor; at other times, the patient suddenly discovers in the groin or axilla a large fluctuating swell- ing, no symptom having been previously manifested to call attention to the part. These abscesses may persist, without undergoing* any marked change, for months or even years. The diagnosis must be made with the precautions already pointed out, and often requires the use of the exploring- needle. The pus in these abscesses is usually thin aud ill-formed, contain- RESIDUAL ABSCESS. 437 ing a larger proportion of granules and oil globules, and fewer pus cor- puscles, than ordinary "laudable" pus. The treatment of these cases is somewhat different from that appropriate to those of the phlegmonous variety. If the abscess be quite small, it may be simply opened, healing of the cavity being subsequently promoted by the use of some stimulating application, such as the diluted tincture of iodine. In dealing with a larger abscess, it is better to wait until the skin threatens to give way, unless, from the situation of the abscess, it may be necessary to relieve adjacent organs from pressure. With re<>ard to very large abscesses, particularly those which are connected with disease of the spine or bony pelvis, I am decidedly of opinion that it is better, as a rule, to leave them unopened ; a patient may carry a psoas or iliac abscess for years with comparatively little annoyance* and maintaining very tolerable health, and yet sink in a very short time after such an abscess has been imprudently evacuated. Besides, there is always the hope that complete or partial absorption may occur, when the patient may remain well, if not permanently, at least for a very long period. If it be determined to open a large chronic or cold abscess, this may be done with the aspirator, or, if preferred, by means of a simple incision made with antiseptic precautions. If incision is resorted to, the walls of the abscess should be thoroughly scraped with the curette or Volkmann's sharp spoon (Fig. 239), and through-drainage practised. Willard employs a sharp spoon with a hollow handle, designed to permit antiseptic irrigation during the operation. If an abscess have been freely opened and will not heal^ Fig. 239.—Volkmann's sharp spoon, or curette. stimulating injections of iodine may be tried, or a seton of oakum or tarred rope may be used (as recommeuded by Dr. Sayre, in cases of caries), a method which secures drainage besides stimulating the walls of the sup- purating cavity. Callender advises hyperdistention of the abscess-sac with carbolized water, a plan which I have myself sometimes adopted with advantage, while Webb suggests inflation with carbolized air. Cozin fills the cavity with melted paraffine, and after it has solidified dissects out the whole sac of the abscess. Yerneuil injects an ethereal solution of iodo- form, and Billroth a mixture of iodoform with glycerine ; about a drachm of iodoform is employed, with ten of the menstruum, and the injection is not repeated as long as iodoform continues to be excreted with the urine. Bruns substitutes sterilized olive oil for the glycerine, and reports a large number of cases thus treated, with 80 per cent, of cures. Injections of teuenn, a principle derived from the Teucrium scordium, are commended by Alosetig. In all cases of chronic abscess it is necessary to pay great at- tention to the state of the general health, maintaining the patient's strength by the administration of nutritious food and tonics. Residual Abscess—This term has been introduced by Paget, who proposes to include under it "all abscesses formed in or about the residues of former inflammations." They may occur in the site of previous abscesses which have been partially absorbed, or in the indura- tions and adhesions left by old inflammation which has not reached the suppurative stage. Residual abscesses are chiefly met with in connection with diseases of the spine, of the bones and joints, and of the lymphatic 438 DISEASES RESULTING FROM INFLAMMATION. glands. The prognosis is more favorable than that of ordinary chronic abscess, the healing after evacuation being quicker and attended with hss constitutional disturbance than that of a primary abscess of the same size and in a similar situation. The treatment is that already described as ap- propriate to chronic abscess arising under other circumstances. Sinus and Fistula__These are narrow, and often tortuous, suppurat- ing canals or tubes, left by the incomplete healing of abscesses, or resulting from wounds which have united imperfectly. The term fistula is also applied to an abnormal communication between external and interna] parts (as gastric, aerial, or urethral fistula), or between adjacent mucous canals or cavities (as recto-vesical or vesico-vaginal fistula). When applied to the condition resulting from an abscess or ordinary wound, the term fistula should be reserved for those cases in which there are two openings (as in a fistula in ano), the more general term, sinus, embracing all those tortuous suppurating tracks which have but one orifice. Sinuses may be kept from healing by the presence of a foreign body or a spiculum of bone, by the passage of secretions, as of saliva or urine, or by the action of adjacent muscles. The treatment consists in removing all irritating substances, and in placing the part at rest, by position, bandaging, etc. In a recent case, healing may be promoted by keeping the walls of the sinus in eon- tact by means of compression, while, if the walls of the sinus be callous and indurated, they maybe stimulated to greater activity by means of irritating or caustic injections, the tarred seton, or the galvanic cautery. Finally, it may be necessary to freely lay open the sinus through its entire length, by introducing a grooved director and slitting up the superincum- bent tissues; the sinus may then be dressed as an open ulcer, and made to heal from the bottom. This mode of treatment is especially indicated when healing is prevented by the action of neighboring muscles, as in cases of fistula in ano, or in the troublesome sinuses which are met with in the groin in connection with suppurating buboes. It is often a good plan, after laying open a sinus, to wipe its whole track out with a stick of caustic potassa, thus making a superficial slough, and preventing premature reunion of the cut edges. Winslow Hall has reported a case in which obstinate sinuses were induced to heal by means of sponge-grafting. Diffused Suppuration, though ordinarily occurring in that form of diffuse inflammation of the areolar tissue which is closely analogous to, if not identical with, erysipelas, may, I believe, occur as a sequel of ordinary inflammation in persons in a low state of health, and whose vital powers have been from any circumstance much reduced. It may result from an accidental or other wound, or from the irritation of extravasated urine, but may also occur without any apparent exciting cause. The surface in these cases is but slightly red, the swelling is ill-defined, and rapidly spreads in various directions: there is a feeling of bogginess, rather than of fluctuation, and there is sometimes emphy sematous crepitation, caused by the gases developed by the putrefactive process; the patient does not suffer very great pain, but is in a profoundly typhoid condition. The treatment consists in making numerous punctures, or small or even large incisions (to relieve tension, and to facilitate the exit of pus and sloughs), and in the free administration of stimulants and quinia. Ulcers. The process of ulceration, and the mode in which ulcers heal by granu- lation and cicatrization, have been considered in a previous chapter, and need not be again referred to. Ulcers have been variously classified by systematic writers, either according to the appearance of the ulcer itself, WEAK OR CEDEMATOUS ULCER. 439 or according to the constitutional condition of the patient. Thus we read of healthy, irritable, indolent, weak, inflamed, exuberant, slou"-hino- varicose, and hemorrhagic ulcers; and again, of eczematous, cold, senile] strumous, scorbutic, gouty, syphilitic, lupous, and cancerous ulcers. It is easy to understand that, in a person disposed to eczema, an ulcer may be seriously complicated by an attack of that disease, and that any treatment to be successful, must have regard to the eczematous condition, as well as to the ulcer itself. So in a strumous subject, such remedies as iodine and cod-liver oil may be more important than any local treatment. Scorbutic and gouty ulcers require medicines adapted" to the scorbutic and goutv diatheses; while it is quite idle to attempt to heal the ulcerated surface of a cancer as long as the cancerous mass itself is allowed to remain.1 For practical purposes, the classification usually adopted (which has reference to the appearances of the ulcers themselves, when occurring in persons of ordinarily good health, and not the subjects of any special morbid diathesis) is convenient and sufficiently satisfactory, it being remembered that there is no specific or essential difference between these various forms of ulcer, but that the ulcerative process is identical in nature under all circumstances! Simple or Healthy Ulcer—This may be considered the type of all the other varieties, and that to which they must be brought in order to effect a cure; it is such an ulcer as is seen in a healing burn, or in a super- ficial wound which is closing by the second intention. The natural ten- dency of such an ulcer being towards a cure, the only treatment necessary is to keep the part from being injured. Water-dressing, or a greased rao\ with an elevated position of the part, is all that is usually required ; if the granulations become exuberant, they should be touched with bluestoue or lunar caustic; while if too small and closely set, the resin or carbolic acid cerate may be substituted for the milder applications commonly employed. This variety of ulcer may be met with in any part of the body ; those to be next described are most frequently seen in the leg. Inflamed or Phlegmonous Ulcer—This variety is usually met with in those of full habit, and may arise from accidental irritation of a simple ulcer. One of the worst cases of this kind that I have ever seen, was in a gentleman who, having a slight excoriation of the tibial region! rode for several hours on horseback, with the stirrup-leather constantly rubbing and chafing the injured part; as a consequence, the whole leg was attacked with phlegmonous inflammation, which obliged the patient to stay in the house, with the foot elevated, for a considerable period. The treat- ment of an inflamed ulcer consists in enforcing rest, with elevation of the part; in the use of soothing applications, either cold or warm, as most agreeable to the patient; and in the administration of laxatives, diapho- retics, etc.^as may be indicated by his general condition. Sloughing Ulcer—This may be considered as an aggravated form of the last variety, and is usually met with in cachectic or ill-nourished indi- viduals. The treatment consists in the administration of opium and of concentrated nutriment, with stimulus if required, and in the local appli- cation of iodoform or iodol, with anodyne fomentations, such as diluted audanum. If there be much tendency to spread, the ulcer should be treatedas a case of sloughing phagedena or hospital gangrene. The electric bath" is recommended by Weisflog. Weak or (Edematous Ulcer—In this variety the granulations are dree, pale, flabby, and apparently distended with serum. They are not Ki'owtV'lfv ^T S"g°ested' however, to cover in the ulcerated surface of a malignant an open cancer10 0peratl0n> so as to r«beve tlie patient from the inconveniences of 440 DISEASES RESULTING FROM INFLAMMATION. infrequently detached in large masses by sloughing. This form of ulcer may be induced by long-continued application of poultices or of water- dressing. I have frequently seen it in cases of neglected gunshot wound. The treatment consists in improving the general tone of the patient, and in the local use of stimulating and astringent dressings, such as a solution of sulphate of zinc or of sulphate of copper, zinc cerate, etc , with moderate support by means of a bandage. Roche speaks very highly of applications of the bark of the acacia catechu, so as fairly to tan the ulcer and sur- rounding skin. Neuralgic or Irritable Ulcer.—This variety is characterized by the intense pain and hyperaesthesia which accompany it. It usually occurs about the malleoli, or anterior edge of the tibia, and is most frequent in women past the middle age, and who are in a depressed state of health, though I have seen it in young, and otherwise healthy/, laboring men. The treatment consists in the use of anodyne fomentations, with the occa- sional application of a solution of nitrate of silver (gr. iv.-x. ad fgj ), as recommended by Skey for painful burns. The general health must at the same time be improved by the administration of tonics, especially quinia, nux vomica, etc. If the pain can be traced to any special nerve, this may be resected, as advised by Hilton. Indolent or Callous Ulcer__This is by far the most common form of ulcer; it occurs usually in those of middle life, and is situated in the lower half of the leg, and more often on the fibular than on the tibial sur- face. The floor of the ulcer is somewhat concave, with flattened granula- tions, furnishing a thin and scanty pus. The ulcer is surrounded by an elevated ring of very dense and indurated tissue, which seems to be ;i provision of nature to prevent the spread of the disease, acting, indeed, as a kind of natural splint to keep the ulcerated surface at rest. As long as this hard ring remains, however, healing will not occur, and hence to de- press the edges is the first step in the treatment, of an indolent ulcer. If the patient can remain in bed, with the foot elevated, a poultice may be applied for two or three days, to soften and relax the tissues, pressure being then applied by means of a few adhesive strips, the positions of which are varied at each dressing, while the edges of the ulcer are stimulated with the solid stick of nitrate of silver. A very good plan of hastening the disappearance of the indurated ring is to make across it numerous radiat- ing incisions, extending about a quarter of an inch into sound tissue, a.s recommended b\T Gay. Harbordt and Spaeth split the ulcer longitudinally" through its whole length, and cross this first incision with others made transversely, so as to cut through the base of the ulcer and expose the sub- jacent aponeurosis. Sappey's and Syme's method, which consists in the application of a blister to the whole ulcerated surface and a zone of the surrounding healthy skin, is occasionally very efficient. Finally, the in- durated edges may be trimmed away with the knife, a proceeding which, though apparently heroic, is almost painless, on account of the indolent nature of the sore. As soon as the ulcer has by these means lost its pecu- liar excavated appearance, it may be dressed with resin cerate, or some similar article, cicatrization being assisted by moderate compression with adhesive strips and bandage. The sulphuret of carbon has recently been recommended as a dressing in these cases by Gruillaumet and other French surgeons. Gramshaw applies nitrate of silver in flexible collodion (gr. xv.-f^j.), and then an ointment of prepared chalk and spermaceti ointment (1-7), washing the part frequently with hot water gruel. In case the skin is very irritable, the disease approaching in character to what is called the eczematous ulcer, wet strips of bandage may be advantageously substituted INDOLENT OR CALLOUS ULCER. 441 Fig. 240.—Strapping an ulcer. (Liston. for those of adhesive plaster. It often happens that patients with indolent ulcers find it impossible to lie by, as above recommended, and, under such circumstances, I know of no better mode of treatment than that introduced by Baynton and Critchett, which consists in closely strapping the part, or even the whole limb, with strips of adhesive plaster laid on in an imbri- cated manner, a firm bandage being then applied over all (Fig. 240); or an India-rubber bandage may be used, as advised by H. Martin? The only constitutional treatment usually required in these cases is such as may be indicated by the pa- tient's general condition. Skey recommends the administration of opium, which may be given in doses of one grain, night and morning. In the eczematous cases I have derived advantage from the use of alkaline waters. In some cases an ulcer will heal readily up to a certain point, and there will stop, in spite of the most careful dress- ing—the tension upon the part appearing to be so great that further contraction cannot take place. Under such circum- stances, a longitudinal incision, as advised by Faure, may be made through the healthy skin on each side of the ulcer, the gaping of the incisions permitting the resumption of the healing process ; or circular incisions, surrounding the ulcer, as originally suggested by Dolbeau and since recommended by Nussbaum, may be substituted. Plastic operations have been occasionally practised for the cure of obstinate ulcers of the leg, but, in my experience, have not proved very successful. Berger recom- mends that the flap should be taken from the opposite limb. It has been suggested by Reverdin to treat ulcers by the Transplanta- tion of Cuticle. The operation consists in applying shavings of the epidermis, or of this with a thin layer of the cutis—the latter "plan has been most commonly adopted—to various points of the granulating sur- face, binding these grafts in position by means of adhesive strips. The grafts may at first seem to disappear, but in a few days become converted into isolated cicatrices, from which, as from centres, the healing process rapidlv spreads. It is essential for the success of the experi- ment that the granulations should be in a healthv con- dition, that no fat should be transplanted with the skin, and that the graft should be closely and accurately applied to the granulating surface. Berger advises the preliminary application of a poultice or mustard plaster, so as to increase the vascularity of the skin. 1 his mode of treating ulcers has been extensively employed, chiefly in Fig. 241..—Scissors for skin-grafting. 442 DISEASES RESULTING FROM INFLAMMATION. hospital practice, and occasionally with very favorable results. Thiersch recommends the transplantation of large grafts, four or five inches lon»- and an inch wide. MeBurne\r advises that the skin from which the grafts are to be taken should be stretched as a preliminary measure. Wolfe and Ceci employ single, large grafts, or rather flaps, of sufficient size to cover the surface to which they are adjusted. Leale employs warts instead of ordinary skin. The transplantation of hairs has been suggested as a sub- stitute by Schweninger. Fischer uses large grafts from an amputated limb, in connection with the elastic bandage, while grafts from a dead body have been successfully employed by Girdner and Bartens. Grafts of rabbit-skin have been used with advantage bv F, C. Wilson and Masterman, as have, by the former, grafts from the inner membrane of a hen's egg, which, upon the whole, he prefers to any other material. The gills of a cock have been successfully employed by Altramirano. In some situations, as on the back, between the shoulder-blades, it is very difficult to apply equable pressure by the methods ordinarily employed. Here the application of a zinc plate, or disk of sheet-lead, cut to fit the ulcer, will often be attended with the happiest results—not, I believe, bv the development of any galvanic current, as has been supposed, but simplv by acting as an efficient means of applying mechanical compression. The use of a galvanic current is, however, recommended by Spencer Wells, Golding-Bird, and other writers. The virtues of sheet-lead have been extolled by Van Blaeven, who claims by its use to have effected the restor- ation of parts carried awav by sabre strokes, etc. Hemorrhagic and Varicose Ulcers__Other varieties of ulcer, described by systematic writers, are the hemorrhagic and the varicose. The Hemorrhagic Ulcer is one that bleeds from time to time, occasionally existing in connection with the hemorrhagic diathesis, but more often serving as a channel for vica- rious menstruation. The treatment, in the latter case, consists in endeavoring to re- store the normal flow by means of the reme- dies ordinarily used for amenorrhoea. The Varicose Ulcer is merely an ulcer coexist- ing with varicose veins. It is commonly taught that the varicose disease precedes and causes the ulcer, and obliteration of the veins is accordingly- proposed as the only rational mode of cure. It has been shown, however, I think, byr Gay's researches, that the vari- cose condition is rather a consequence than a cause of the ulceration, and that hence less active measures will commonly suffice. The treatment should vary according to the con- dition of the ulcer, whether inflamed, irrita- ble, or indolent. Borel-Laurez employs a dressing of finely powdered charcoal. Hem- orrhage from the bursting of a vein maybe checked by position and pressure, or may occasionally require obliteration of the vessel, by the method which will be described when we come to speak of varicose veins in general. After the cicatrization of an ulcer is com- pleted, a great deal may be done by care and attention to prevent the scar Fig. 242.—Incurable ulcer with scleroderma, requiring amputation. (from a patient in the University Hospital.) GANGRENE AND GANGRENOUS DISEASES. 443 from again giving way. The part should be kept scrupulously clean, and should be protected as much as possible from external injury. * If the ulcer be situated on the leg, the patient may advantageously wear an elastic bandage or stocking to counteract the tendency to gravitation of blood which necessarily exists in that part. Amputation for Ulcer.—It sometimes happens that an ulcer proves utterly incurable, either from extending completely around the limb, or from deeply involving a subjacent bone or neighboring joint (as in the perforating ulcer which sometimes follows a bunion). In such cases the question of amputation may arise, and the operation under such circum- stances will occasionally be justifiable. It must be remembered, however, that amputation, in the lower extremity, is in itself attended with very great risk to life, and that the disease, in the instances mentioned, is often more a source of discomfort than of danger or even positive suffering. Hence the surgeon should hesitate before proposing an operation which is not imperatively required, and which may be followed by the gravest consequences. When amputation is resorted to. it should be done at such a height as to insure the possibility of forming the flaps from perfectly healthy tissues. Ulcers occurring on Mucous Membranes present the ordinary characters of healthy, weak, or irritable ulcers, as met with in the cuta- neous structures. They usually require the free use of stimulating or caustic applications, the best being, probably, the nitrate of silver, which may be employed either in substance or in solution. Gangrene and Gangrenous Diseases. The nature and treatment of the ordinary forms of gangrene have already been considered in the chapters on Inflammation, on Wounds in General, on Injuries of Bloodvessels, and on Amputation. There remain to be described certain forms of Spontaneous Gangrene, and those affec- tions which are commonly classed together as Gangrenous Diseases. Spontaneous Gangrene may occur at any age, and is due to arrest of the circulation, caused either by disease of the arteries themselves, or by a morbid condition of the circulating fluid. Inflammation of the arte- rial coats may cause gangrene, as may arterial thrombosis without inflam- mation, or embolism from the detachment of fibrinous concretions from the valves of the heart; the latter is, I believe, a more frequent occurrence than is usually supposed. Diabetes and granular degeneration of the kidneys are occasional causes of spontaneous gangrene, and Curtis records a case of moist gangrene of both feet following concussion of the solar plexus from a blow upon the abdomen ; finally, the use of certain articles of food, as of spurred rye, has been followed by spontaneous gangrene. This form of the disease is usually of the dry variety, though moist gan- grene may occur in diabetes, or after embolism, when the main trunks which furnish blood to the part are suddenly occluded—the difference probably depending, as remarked by Coote, upon the rapidity with which the death of the part takes place. Senile Gangrene (which, as ordinarily seen, may be considered the type of the dry variety of the affection, or mummification) is dependent upon calcification of the arterial coats, together with the general loss of tone and enfeebled nutrition which ac- company old age.1 In certain cases, the exciting cause of the disease is Tricomi has found a peculiar bacillus in the blood of patients suffering from senile gangrene. 444 DISEASES RESULTING FROM INFLAMMATION. some slight irritation, such as the chafing of a shoe, and. under such cir- cumstances, the gangrene approaches somewhat to the ordinary inflamma- tory form of mortification. More often the disease begins, without ap- parent cause, as a dark purple or blackish spot, surrounded by a duskv red areola, which spreads with the gangrene and is the seat of intense burning pain, the latter, however, subsiding when the gangrene is com- plete. The seat of the gangrene is commonly the inner side of the foot, and especially of the great toe, though I have seen a precisely similar condition of affairs in the scrotum, in a patient worn out by a low fever; the fact that this form of gangrene occurs, under such circumstances, among comparatively young persons, shows that the term senile gangrene, though significant, is not strictly accurate. Warning is sometimes given of the approach of this form of gangrene by the existence of signs of defective circulation, such as numbness, coldness, tingling, and cramps in the calves of the legs. The course of senile gangrene is usually chronic, lasting sometimes for more than a year, and recovery occasionally follows after the separation of the affected part. Treatment.—This consists in maintaining the general health of the patient by the use of tonics and by the judicious administration of food and stimulants. Among drugs, opium is particularly useful, and may be given in grain doses three or four times in the twenty-four hours. Anti- spasmodics also may be advantageously used in these cases, especially chloroform (internally) and camphor. The local treatment consists chiefly in keeping the part warm by wrapping it in cotton-wadding or wool; if there be much fetor, charcoal poultices may be substituted, or cloths wet with a solution of permanganate of potassium. The question of amputa- tion in senile gangrene has already been referred to. (See pages 105, 106.) Bedsores.—These may occur in anyT case in which a patient is con- fined to bed for a considerable period, simply from the long-continued pressure—just as similar excoriations and sloughs may result from the use of a badly padded splint. The worst forms of bedsore are, however, seen in patients whose general powers of nutrition are impaired by pre- vious illness (as in typhoid fever), or who, from spinal injury, are totally unable to vary their position. In such cases, it is not infrequent for the slough to extend so deeply as to involve the sacrum, or any other bone that is exposed to pressure, or even, in some instances, to lay open the vertebral canal. The pain attending bedsores is usually very great, though, in cases of spinal injury, the patient may be unaware of their existence. The formation of bedsores may commonly be prevented by the use of a water-mattress, or air-mattress, or of soft pillows, the parts being kept scrupulously clean, frequently bathed with stimulating and astringent lotions, and protected by the application of collodion, soap- plaster, or adhesive plaster; Brown-Se".(uard recommends the alternate ap- plication of ice and hot poultices. If a bedsore have actually lormed, the separation of the slough may be hastened by the use of yeast or porter poultices, the ulcer which is left being subsequently dressed antiseptically, or with resin cerate or some similar application ; the part must be entirely freed from pressure, and the patient's general health improved by the ad- ministration of concentrated food, tonics, and stimulants. In obstinate cases, healing may sometimes be promoted by the application of the gal- vanic current, as suggested by Crussel, and recommended by Spencer Wells and Hammond. Bedsores may occasionally prove fatal, "by involv- ing important structures (as the membranes of the spinal cord), by leadin? to hemorrhage, by gradually exhausting the patient, or by the induction of pyaemia. NOMA PUDENDI. 445 Gangrenous Stomatitis, also called Gangraena Oris, Cancrum Oris, and Noma, is an affection of childhood, coming on after various eruptive fevers, especially measles—a somewhat similar affection some- times occurring in adults after typhus. Gangrenous stomatitis has been attributed to the abuse of mercury, and this drug, if improperly exhibited, may of course be one source of depression, in addition to the debilitating effects of illness, deprivation of food, etc. That there is, however, any direct causal connection between the use of mercury and this disease is, I think, at least not proved. Sanson found moving bodies analogous to bac- teria in the blood of a girl who died from noma, and inoculation of the diseased blood in animals produced septicaemia attended with the forma- tion of similar bodies. Special bacilli have also been found in gangrenous stomatitis by Schimmelbusch, Lingard, and Foote. The first symptom of gangrenous stomatitis is usually a dusky red swelling of the cheek, which becomes stiff and shining. Careful examination will now show a sloughing ulcer on the inside of the cheek, extending to the adjacent gum, and discharging fetid, ill-formed pus, which, mingled with saliva, con- stantly dribbles from the mouth. As the disease progresses, a gangren- ous spot appears on the cheek, the whole thickness of the part being finally involved, and perforation of the cheek, with denudation and per- haps necrosis of the alveoli, resulting. The constitutional symptoms are of a typhoid character, coma sometimes supervening before death, which may occur at almost any period of the di?ease. The treatment consists in everting the cheek (the patient being anaesthetized), and thoroughly cauter- izing the whole ulcerated surface w ith strong nitric acid. One thorough cauterization is usually sufficient, though the case must be watched, and a second or third application made if necessary In an aggravated case of noma, occurring in a syphilitic child under my care at the Children's Hospital, cauterization with the acid nitrate of mercury, and the internal administration of iodide of potas- sium, proved very efficient. Yates and Kingsford employ a solution of corrosive sublimate (1-500). The mouth should be frequently syringed with detergent and disinfectant washes, such as a solution of the permanganate or chlorate of potas- sium, or of borax, and the general health sustained by the frequent ad- ministration of concentrated food and stimulus. The application of tincture of iodine is recommended bv Miller, while Popper advises that FlG 243._Uangrene of cneek and necrogis of the SlOUgh Should be scraped away, jaw, following typhoid fever. (From a patient and the parts dressed with creasote. in the children's Hospital.) The deformity hfc after cicatriza- tion may subsequently require a plastic operation for its cure. I have seen, after typhoid fever, a gangrenous condition of the cheek, with ne- crosis of the jaw, closely resembling cancrum oris, but spontaneously limited and attended with less severe constitutional symptoms, which I have attributed to local thrombotic or embolic changes. Such a case is shown in Fig. 243. Noma Pudendi—This grave affection, which seems to be confined to female children, is very analogous to the preceding, and usually attacks 446 DISEASES RESULTING FROM INFLAMMATION. the mucous or submucous tissues of the generative organs, though, accord- ing to Holmes, it sometimes begins in the fold of the groin. The treat- ment consists in early and thorough cauterization, and in the adoption of measures to sustain the patient's strength. Parrot speaks favorably of the local use of iodoform. Death sometimes occurs very suddenly, after the apparent establishment of convalescence. Hospital Gangrene—This affection, which has received a great va- riety of names, such as Sloughing Phagedaena, Pulpy Gangrene, Putrid Degeneration, Traumatic Typhus, Pourriture d'Hopital, etc., is occa- sionally met with as a sporadic disea>e, but has attracted most attention when prevailing epidemically or endemically in hospitals, especially where large numbers of wounded men are crowded together, as in military hos- pitals in the neighborhood of a battlefield. It has been studied by a great many writers, among whom mayr be particularly mentioned Pouteau, La Motte, Ollivier, Delpecb, Legouest, Rollo, Blackadder, Boggie, Hennen, Ballingall, Thomson, Guthrie, and Macleod. It has also been ably inves- tigated by many American surgeons, who had ample opportunities for its study during the late war, and an elaborate monograph on the subject was contributed by Prof. Joseph Jones, of New Orleans, to the Memoirs of the U. S. Sanitary Commission. The characters of hospital gangrene vary in different epidemics. The majority of observers have found the local tn precede the constitutional symptoms, and hence have regarded the disease as a strictly local affection ; while, in other instances, equally careful ob- servers have found constitutional disturbance, headache, furred tongue, etc., to precede the local changes in the wound by an interval of from one to three days Hospital gangrene is undoubtedly contagious? having been developed by indirect inoculation, as well as through the medium of instru- ments and sponges ; the exceptional cases, in which one of two contiguous wounds, in the same patient, suffered from the disease, while the other escaped, merely prove that in those instances the affection was not inocu- lated. While, however, hospital gangrene is usually transmitted by con- tagion, it sometimes seems to originate de novo, as the result of over- crowding, bad ventilation, etc. Two forms of hospital gangrene may be recognized, but the difference ' between them is one of degree rather than of kind. For the development of either, the presence of a wound is probably necessary, though this wound may be of the most trivial character, as the sting of an insect, the prick of a lancet, or even the scratch of a finger-nail. A depressed or depraved state of the system does not appear to be at all essential for the development of the disease, though it may very probably aggravate the 1 Dr. W. Thomson examined microscopically the discharges in several cases of hos- pital gangrene which occurred at Douglas Hospital during the late war, with a view of determining the presence or absence of fungi, which it was supposed might be the source of contagion. " No fungi were found. The discharge consisted of fluid, gran- ular matter, and debris. The connective tissue seemed to have been broken down into unrecognizable granular material. The fibrous tissue was softened and easily teased out, and in the muscular tissue the striated appearance was lost before the fibrous. No evidence of textural growth was found in the discharges, although the 'piled-up' and thickened margins of the ulcers would probably reveal, on examination, a multi- plication of the connective-tissue corpuscles, as reported in a similar group of cases at Annapolis, Md., by Assistant Surgeon Woodward, U. S. A." By microscopic exam- ination, Prof. Joseph Jones discovered numerous animalcules, as well as vegetable organisms, in the gangrenous matter of hospital gangrene, but was unable to estab- lish any relation between the cause of the disease and the nature and character of these organisms, which were absent, in the most extensive gangrene, when excluded from the atmosphere by sound skin. HOSPITAL GANGRENE. 447 intensity of the affection when it occurs.1 The following description, taken from Guthrie, gives a vivid picture of the worst form of hospital gangrene. The wound thus attacked " presents a horrible aspect after the first forty-eight hours. The whole surface has become of a dark-red color, of a ragged appearance, with blood partly coagulated, and apparently half putrid, adhering at every point. The edges are everted, the cuticle sepa- rating from half to three-quarters of an inch around, with a concentric circle of inflammation extending an inch or two beyond it; the limb is usually swollen for some distance, of a shining white color, and not pecu- liarly sensible except in spots, the whole of it being perhaps oedematous or pasty. The pain is burning, and unbearable in the part itself, while the extension of the disease, generally in a circular direction, may be marked from hour to hour ; so that, in from another twenty-four to forty-eight hours, nearly the whole of the calf of the leg, or the muscles of the but- tock, or even of the wall of the abdomen, may disappear, leaving a deep, great hollow, or hiatus, of the most destructive character, exhaling a pecu- liar stench, which can never be mistaken, and spreading with a rapidity quite awful to contemplate. The great nerves and arteries appear to resist its influence longer than the muscular structures, but these at last yield ; the largest nerves are destroyed, and the arteries give way, frequently closing the scene, after repeated hemorrhages, by one which proves the last solace of the unfortunate sufferer.....The extension of this disease is, in the first instance, through the medium of the cellular struc- ture of the body. The skin is undermined and falls in ; or a painful red, and soon black, patch, or spot, is perceived at some distance from the original mischief, preparatory to the whole becoming one mass of putridity, while the sufferings of the patient are extreme." This worst form of hos- pital gangrene is, happily, comparatively rare at the present day. In the milder form, the whole course of the affection is more chronic, causing less destruction of tissue, and accompanied with comparatively little con- stitutional disturbance. The general characters of the wound are the same, especially the circular shape and cup-like excavation or scooped-out appear- ance of the ulcer. There is less eversion and undermining of the skin, less oedema and pain, and the surface of the wound is covered with a pulpy, ash-colored slough, instead of the putrid clots described in Guthrie's vivid account. The constitutional symptoms of hospital gangrene may at first present a somewhat sthenic type, but rapidly change into those of a pro- foundly typhoid and adynamic condition, the patient indeed presenting much the appearance of one suffering from typhus fever. The mortality from hospital gangrene has varied in different epidemics. During the Peninsular campaign, the death-rate, according to Guthrie, was 20 to 40 per cent., the general average being about 1 death in 3 cases attacked. In the Crimean war, the mortality in uncomplicated cases was much less, while in the experience of our own surgeons, during the late war, the number of deaths was comparatively very small. The causes of death, according to Prof. Jones, may be classified as (1) progressive ex- haustion, (2) hemorrhage, (3) entrance of air into veins, (4) opening of large joints, (5) formation of bedsores which subsequently become gan- grenous, (6) diarrhoea, (1) subcutaneous disorganization of tissues around the original wound, (8) mortification of internal organs, (9) direct impli- cation of vital parts, (10) pyaemia, (11) phlebitis, (12) profuse suppura- tion, necrosis, etc. 1 The above-mentioned facts strongly point to the dependence of the disease on the presence of a specific poison, probably a micro-organism. 448 DISEASES RESULTING FROM INFLAMMATION. In the treatment of hospital gangrene, it is very important to secure good ventilation and to enforce the utmost cleanliness. Affected patients should be at once segregated (if possible) from others, and, if it were practicable, it would be better that each person attacked should be placed in a separate apartment or tent. It is, indeed, probable that a certain number of the milder cases would get well under simple hygienic treat- ment, and the risks of exposure are much less than those of overcrowding; as Jungken has somewhat quaintly put it, " It is, after all, better that the patient should shiver a little in a cool but pure air, than that he should die in a warm but poisoned atmosphere.'' As it is certain that the disease may be communicated by means of sponges, etc., the greatest precaution- should be taken in washing and in dressing wounds. The ward carriage (Fig. 10), or some similar contrivance for using a stream of running water, will, in these cases, be found of great service. The adoption of antiseptic methods is important as a prophylactic measure. The Local Treatment of hospital gangrene is now, I believe, almost universally regarded as of the highest importance; many different appli- cations have been employed, varying in severity from the actual cautery dowu to simple syrup, or buttermilk, and each remedy has proved occa- sionally successful. The oil of turpentine is highly recommended by Bartholow, and powdered camphor by Netter and other French writers. Most surgeons are now agreed as to the propriety of thoroughly cauter- izing the entire surface of the wound once, or oftener if necessary; and to insure thorough cauterization, it is necessary first to remove all the adherent sloughs with forceps and scissors, followed byr rough sponging, or scraping with the curette. The varieties of caustic most to be relied upon are, I think, nitric acid, bromine, and a strong solution of permanganate of potassium. The latter article is that which I have myself employed, in the proportion of 3j- to f§j. of water, and I have never, as yet, been disap- pointed in its effect; it is but just, however, to say that I have not had occasion to try it in any cases of the worst form, such as are described by Guthrie. The permanganate has been favorably reported upon by Jackson, Hinkle, Leavitt, and others. Nitric acid seems to be generally preferred by British surgeons, and is recommended by Jones, and by the authors of the '• Manual of Military Surgery, prepared for the Use of the Confederate States Army," while the hot iron seems to be preferred by the French; the latter application would probably be the best in cases attended with hemorrhage. Heiberg, from an extended experience during the Franco- German war, gives a preference to the chloride of zinc. Bromine, the merits of which were first announced, during our war, by Dr. Goldsmith, has been most favorably reported upon by Post, Moses, Thompson, Uerr, and many others, and seems, from the published testimony in its favor, to be, upon the whole, the best caustic which has yet been proposed for these eases. The wound having been previously cleansed, the bromine may be applied undiluted, or in solution with bromide of potassium, by means of a camel's-hair brush, or a sponge or mop, attached to a stick, or by means of a glass pipette or syringe; as the application is very painful, the patient should be first brought under the influence of ether or chloroform. Bro- mine has also been used in the form of vapor (the surface to be acted upon being protected with dry lint, upon which is placed a cloth dipped in pure bromine, and the whole covered with oiled silk), and by means of hypo- dermic injection at the circumference of the sore. The bromine acts by producing an eschar, upon the separation of which the wound will usually be found healthy and disposed to heal. Until the slough separates, the wound may be dressed with dilute liq. sodas chlorinatis, with the perman- FURUNCLE OR BOIL. 449 ganate of potassium (3j--Qj.), or with the ordinary antiseptic dressino-s; the resulting ulcer is, of course, to be treated on general principles. The Constitutional Treatment, if less important than the local, is still not to be neglected. Almost all surgeons, with the exception of Bog«-ie, have agreed in recommending a tonic and stimulant, rather than a deple- tory, course of treatment. The milder cases require scarcely any medica- tion, attention to the state of the secretions being all that is necessary in many instances. When the typhoid condition is more marked, the mineral acids may be used with advantage ; the muriatic acid of the U. S. Phar- macopoeia may be given in five-drop doses, with opium and oil of turpen- tine, every three or four hours, as is done in cases of typhoid and typhus fever. Opium is, of all single remedies, the most useful in this affection ; it may be given quite freely, and a case is reported by Pick, in which gradually increasing quantities of laudanum were administered for fifteen days, the patient taking at the last nearly half an ounce in the twenty-four hours. Quinia and iron (especially in the form of the muriated tincture) are particularly valuable in the later, though they may be required in the earlier, stages of the disease. The diet should consist of nutritious but easily digestible articles of food, such as milk and beef-essence, and on the first manifestation of adynamic symptoms alcoholic stimulants should be freely administered. Amputation may be occasionally rendered necessary by the occurrence of uncontrollable hemorrhage from a wound which has been attacked by hospital gangrene, or the same measure may be required at a later period, on account of the extensive destruction of tissue, involving, perhaps, bones and joints, as well as the more superficial structures of the part. It is said that hospital gangrene may occur as an idiopathic affection, upon an unbroken surface, the disease then beginning as a vesicle sur- rounded by a dusky areola, the vesicle ultimately breaking, and leaving a slough, upon the separation of which the characteristic appearances of the affection are manifested ; these idiopathic cases are, however, at least, extremely rare, and in those which have been reported it maybe fairly doubted whether some excoriation may not in fact have existed^ though so slight as to have escaped observation. Furuncle or Boil—This very common affection consists of a localized inflammation of the skin and subcutaneous areolar tissue, almost invariably running on to suppuration, and attended by the formation of a small cen- tral slough, which is popularly called the core. Boils may occur at any age, and in any part of the body; they are, however, most common in youth, and are generally seen on the nucha, back, or gluteal region. They are often multiple, frequently come out in successive crops, and occasion- idly occur epidemically—those who are affected being usually in a de- pressed state of health. The affection, though very painful and annoying, is not commonly attended with danger. The treat'ment consists in improv- ing the general health by attention to the state of the secretions, and bv the administration of tonics, especially quinia, if the patient be debilitated. least is a favorite domestic remedy. Arsenic is sometimes of benefit, given in small doses, and continued for a considerable period. The liq. potassse has been similarly used with advantage, and the celebrated John Hunter, who suffered much from boils, declared that he had cured himself bv taking the carbonate of sodium. The local treatment should vary with he circumstances of the case. If the boil be not very painful, it should be leit to open of itself, being poulticed, or simply protected by means of the ceratuni saponis, spread upon a piece of soft buckskin or wash-leather. mere is some reason to believe that boils are less apt to recur if left to — J 450 DISEASES RESULTING FROM INFLAMMATION. themselves than if too actively7 treated. If, however the patient be in great pain, with much constitutional disturbance, the surgeon should not hesitate to make a free single or crucial incision, the case being afterwards treated as one of abscess. It may be sometimes possible to abort a boil bv purging, and by the application of tincture of iodine, spirit of camphor (Simon), or mercurial ointment (Roth), or by touching the vesicle which usually marks the point of central slough with lunar caustic, a solution of corrosive sublimate, or the strong aqua ammonia?. Planat recommends the use of arnica, both as an internal remedy and locally, mixed with honev. Heitzmann speaks favorably of a five-per-cent. or ten-per-cent. ointment or plaster of salicylic acid. Anthrax1 or Carbuncle.—A carbuncle may be regarded as an ag- gravated form of boil. It usually begins as a vesicle, surrounded bv an indurated, dusky areola. The subcutaneous tissue sloughs at an earlv period, giving the part a peculiar, boggy feel, before the skin itself give's way.2 The skin may slough merely beneath the central vesicle, but if the carbuncle be large, numerous apertures will be formed, arranged in a cribriform manner. The carbuncle continues to spread, reaching its height in from three to eight days, and accompanied, while it is extending, with great pain and constitutional disturbance. The average diameter of car- buncles is two or three inches, though in some instances they attain a very- much larger size. Paget mentions a case in a man aged eighty, in wrhich the carbuncle measured fourteen by nine inches. Carbuncles are usually met with on the back of the neck, or between the shoulders, but may occur in any portion of the body. They are most frequent in the male sex, and in persons in advanced life. The causes of carbuncle are obscure. The affection is usually met with in those who are enfeebled by age, or worn down by overwork or privation, and is sometimes associated with visceral disease, particularly affections of the kidneys, or diabetes The prognosis should always be guarded: though the large majority of patients recover, the disease is always serious. Death may occur from the extension of in- flammation to an important organ, as the brain or peritoneum, from visceral complications, from simple exhaustion, or from the development of erysip- elas or pyaemia. Treatment.—If the surgeon be called at an early stage, it may be possi- ble to abort the disease, by opening the central vesicle and applying some caustic agent, such as the nitrate of silver, the Vienna paste, or a strong solution of the permanganate of potassium ; or the plan proposed by Physick might be resorted to, and a blister applied over the whole inflamed surface. Whitehead injects the base of the carbuncle with a concentrated ethereal solution of iodoform. It usually happens, however, that the cast' is first seen when the bogginess and cribriform ulceration show that sloughing of the areolar tissue has already occurred. Under these circum- stances, it is commonly advised to make crucial or radiating incisions, deep and free, so as to include the healthy tissue beyond the utmost limits of the disease. Other surgeons make subcutaneous incisions; while others again rely upon the use of caustics, applying these either to the surface to the incision wounds (when these are made), or around the circumference of the carbuncle, in the form of caustic arrows (cauterisation en fieches). 1 By French and German writers the term anthrax is applied to malignant pustule. 2 Much light has been thrown upon the pathology of carbuncle by Dr. J. Collins Warren, who describes it as a rapidly spreading, phlegmonous inflammation, or pur- ulent infiltration, of the subcutaneous areolar tissue, its characteristic appearance depending on the anatomical peculiarities of the part affected, (t'olumnce Adipose, tt<:. p. 25. Cambridge, 1881.) MALIGNANT PUSTULE. 451 It is not proved, however, that any of these methods are effective, either in limiting the extent of the carbuncle, or in shortening its duration. It is possible that incision may, in the early stage of the disease, give relief from pain, but it does so at the cost of considerable loss of blood; while the healing of the incision wounds themselves imposes an additional tax upon the already overweighted powers of the patient. In most cases it will be found sufficient to cover the carbuncle with a piece of leather or thick kid, spread with lead plaster or soap cerate, a central aperture being left for the escape of the slough. Another plan which I have found very useful, is to apply pressure, as suggested by O'Ferral, by means of strips of adhesive plaster, beginning at the circumference and laid on concentric- ally until all except the central portion is covered. A poultice may be applied over all if there be much pain, or the ulcerated centre of the car- buncle may be simply dressed with wet lint. The extrusion of the slough is much assisted by the concentric pressure (which is not at all painful), and may be further aided by the use of forceps and scissors. Teale, Page, Parker, and Weir recommend that it should be freely removed bv scraping. Le;tner accomplishes the same purpose by the application of a cupping- glass. When the slough has come away, the resulting ulcer should be treated upon general principles. The constitutional treatment is equally simple. In the milder cases a little opium may be required as an anodyne, and, if there be constipation, the bowels should be relieved by a mild laxative. Should the tongue be dry and covered with a brownish fur, muriatic acid, in combination with laudanum and oil of turpentine, may be usefully administered. At a later period, quinia and the tinct. ferri chloridi will come into play, while at any stage, if there be delirium or other nervous complication," camphor and ammonia may be given with advantage. The diet should, as a rule, be mild but nutritious, consisting of such articles as milk, beef-essence, soft- boiled eggs, etc. Alcoholic stimulus, though not necessary in every case, will usually prove a serviceable adjunct to treatment, and is often impera- tively demanded, especially in the later stages of the affection. Facial Carbuncle.—Under this name is described, by British sur- geons, a malignant carbunculous affection, which attacks chiefly the lips, and which presents some analogous features to the disease known in France and in this country as malignant pustule.1 The affection is a very painful one, and frequently proves fatal, through the development of pvaemia. Of 45 cases collected by Lidell, only five terminated in recovery. "The treat- men^ consists in the administration of stimulants and of large doses of quinia. Local measures are of minor importance, but an incision may be required to relieve tension and allow the exit of sloughs. Malignant Pustule (Pustule Maligne, Charbon)__This affec- tion is usually communicated by inoculation, from direct contact with the blood or other fluids derived from diseased animals, as from horned cattle affected with the murrain, or from septic material conveyed by flies, and is said to have occasionally resulted from eating the flesh'of such animals, or even to have been transmitted through the medium of the atmosphere. It is constantly associated with the presence of a peculiar micro-organism, the bacillus anthracis. The affection begins a day or two after inoculation, Reverdin maintains that the gravity of carbuncles of the face, and particularly oi the lips is solely due to the frequent occurrence of phlebitis, which may cause aeatn by the inflammation spreading to the sinuses of the dura mater, or by the de- velopment of pyamiia. He regards the affection as totally distinct from malignant I wi n ai , recomme"rts early and free incisions. A similar view was held by Dr. Mttell, and has been acceded to by Sir James Paget. 462 DISEASES RESULTING FROM INFLAMMATION. as an itching red spot followed by a vesicle, which bursting leaves a dry brown eschar. A fresh crop of vesicles next appears around the slough, and the subcutaneous tissue becomes involved, forming a hard swelling to which the French give the name of Ronton or Tumeur Charbonneuse. The neighboring lymphatic glands often become secondarily inflamed. There is a good deal of fever and of constitutional disturbance, the patient, in un- favorable cases, rapidly sinking into a typhoid state, and dying with the ordinary signs of blood-poisoning.1 The affection is said by (iross and other American writers to be intensely painful, but Bourgeois speaks of the absence of pain as a prominent characteristic. The disease may be distinguished from carbuncle by the fact of its beginning in the skin and only involving the subcutaneous tissues at a later period, and by the almost complete absence of suppuration. The treatment consists in thor- ough cauterization with caustic potassa, either with or without previous scarification, according to the progress which the disease has made when first seen ; Gross and Popper recommend total excision. The constitu- tional treatment consists in the administration of concentrated food and stimulus, with tonics, especially quinia, and the mineral acids. Muskett and Davies Colley advise the use of ipecacuanha, both internally and locally. Ce^zard recommends the use, both internally and externally, of iodine held in solution by means of iodide of potassium, looking upon this drug as a positive antidote to the poison of the disease, while Estradere speaks very favorably of the use of carbolic acid both internally and as a local application. Hypodermic injections of iodine are employed by Chipault, Richet, and Rollin, and those of carbolic acid by Trelat. Romei advises the external use of corrosive sublimate, and the same remedy has been successfully employed hypodermically by Casson. A crucial incision followed by the application of liq. ammonite to the cut surfaces, with the internal use of acetate of ammonium, is recommended bv A veudaao, while Rivas employs a paste of quinia and oil of turpentine. Other Gangrenous Affections.—Various forms of gangrene are occasionally met with, which cannot be referred to any of the diseases above described. Under the name of White Gangrene of the Skin, is de- scribed by Quesnay, Brodie, and others, a form of dry gangrene, in which successive patches in various parts of the body, especially the neck, arms, and back, undergo mortification, preserving at first their white color, but becoming subsequently horny and straw-colored, and showing, in the form of red streaks, the capillaries filled with coagulated blood. After the sepa- ration of the sloughs, the ulcers heal without difficulty. Quesnay state.- that this form of gangrene is due either to arterial obstruction, or to com- pression or paralysis of the nerves of the part. The treatment, according to Brodie, is rather unsatisfactory. In one case, in which the disease was associated with irregular menstruation, the sulphate ot copper was given with advantage. Tonics would seem to be usually indicated, and when, as in one of Brodie's cases, and in one quoted by Quesnay from De La Peyronie, the disease succeeds an affection of the skin, arsenic might prob- ably be advantageously employed. Cases of symmetrical gangrene are reported by Raynaud, Southey, Dayman, Mills, Moore, Finlayson, Fox, Myers, Affleck, Beader, Warren, and other surgeons, and are believed by the last-named writer to be due to some irritation of the vaso-motor nerves, causing permanent spasm of the vessels of the affected part, and therefore 1 Dr. Gerald Yeo and some others believe that the disease is identical with tliat known to European writers as Mycosis Intestinalis, and that the development of au ex- ternal pustule is not an invariable occurrence. CAUSES OF ERYSIPELAS. 453 anaogousto the cases of "local asphyxia" described by Raynaud and known under the name of " Raynaud's disease." Wigglesworth, however in one case, found well-marked changes in the peripheral nerves, consisting in overgrowth of the fibrous elements, with atrophy and degeneration of the nervous elements. The change was most advanced in the distal ends of the nerves, and appeared to be the result of primary degenerative atrophy followed by fibrous hyperplasia, rather than of chronic interstitial inflam- mation. Similar changes, but less well marked, have been observed by Pitres, Mounstein, and Bowlby. Affleck has also noted degenerative changes in the nerves of the affected part, but believes them to be°secondary to a peripheral neuritis. In Myers's case the affection was associated with paroxysmal hemoglobinuria, and in a case recorded by Raw, with the same affection, following acute mania. A curious case came under my observation at Cuyler Hospital, in which a soldier, noticing a painful pimple or pustule on "the back of his hand applied to the " medical officer of the day," who ordered a flaxseed poul- tice; the next day the man came to me in great alarm, with a black dry slough upon his hand exactly the size and the shape of the cataplasm ; the eschar, which was quite deep, separated in a few days, and the remain- ing ulcer healed rapidly under the use of the permanganate solution. CHAPTER XXIT. ERYSIPELAS. Erysipelas1 is an acute febrile disease, attended by a peculiar form of inflammation, which affects the skin, areolar tissue, and mucous or serous membranes. It occurs as an idiopathic affection, or as a complication of a wound, being called in the latter case traumatic erysipelas. External erysipelas, or that which affects the skin and connective tissue, is much more common than the internal variety, or that which attacks the mucous and serous membranes. External erysipelas may be divided into the sim- ple, or cutaneous, the phlegmonous or cellulo-cutaneous, and the cellular or areolar, often spoken of as diffuse, inflammation of the areolar tissue. Causes of Erysipelas—These may be divided into the predisposing and the exciting. Of the Predisposing Causes, some relate to the patient's oivn condition, and others to the circumstances by which, he may be sur- rounded. Among the former may be enumerated a depressed or debili- tated state of the system, resulting from any source, such as chronic visce- ral disease, especially of the kidneys or liver, diabetes, chronic diarrhoea or dysentery, deprivation of food, neglect of hygienic rules, intemperate habits, overwork, etc. Any sudden source of depression may act as a predisposing cause of erysipelas; thus, in military hospitals, the disease is often seen to follow in the wake of secondary hemorrhage. Among the surrounding circumstances which predispose to erysipelas may be men- tioned overcrowding, bad ventilation and sewerage, and the season of the (n*H\ U!!! de,nvatl0n g'ven f- to derive it from lfu0p,f (red) and mxk (livid). (See, edit 1-SU Jon4 a "°te t0 Mr- D«Morgan's article in Holmes's S9st. of Surgery, 2d vol 1 IB A and Dr' Still^'s article i« the International Encyclopaedia of'Suryery, 4o4 ERYSIPELAS. year and the state of the atmosphere ; it is notorious that erysipelas is most apt to occur during the cold, damp weather which often prevails about and after the vernal and autumnal equinoxes. The principal Ex- citing Causes of erysipelas are epidemic influence, contagion, and the pres- ence of a wound. Fehleisen believes the essential cause of erysipelas to be the presence of a special microbe, the streptococcus erysipelatosus. Symptoms of Erysipelas. 1. Simple or Cutaneous Erysipelas— Constitutional disturbance, consisting of rigors, headache, nausea, and fever, may precede the local manifestations for one or two days, though in many instances the patient is not conscious of any marked indisposition, until the appearance of the rash or cutaneous inflammation. In traumatic erysipelas the locality of the rash will be determined by the position of the wound; in the idiopathic variety, though the disease may appear on any part of the body, it is most frequently seen upon the face (especially about the nose, ears, and eyelids), next upon the legs, and more rarely upon the trunk. Its development is often preceded by pain and swelling of the neighboring lymphatic glands. The eruption appears as a red spot, rapidly spreading into a large patch, with pretty well-defined margins; somewhat elevated; of a bright rosy hue, disappearing under pressure; with a smooth, glazed, shining surface, and attended with a tingling and burning sensation. Except in the mildest cases, vesicles appear on the affected part, containing serum, which at first is clear but soon becomes turbid, these vesicles eventually drying into browrnish scabs. The erup- tion of simple erysipelas lasts (as a rule) but four days in the same part; it may, however, spread to adjacent parts, or may break out in an entirely different region of the body, the affection in these cases constituting re- spectively the erysipelas ambulans and the erysipelas erraticum of the older writers. As the eruption fades, the swelling subsides, the margins lose their definition, and the skin assumes a dry and somewhat wrinkled ap- pearance. The constitutional symptoms are rather aggravated than di- minished by the appearance of the eruption, the period of defervescence usually coinciding with that of the decline of the local phenomena. 2. Phlegmonous, or Cellulo-cutaneous Erysipelas.—In this form of the affection both the local and general symptoms are more marked. The in- flammation involves the subcutaneous connective tissue as well as the skin, the swelling being greater, the color darker, the vesications larger, and the pain more intense than in the simple variety. These signs continue gradu- ally increasing up to the sixth or eighth day, when resolution may com- mence, or, as is very apt to happen, suppuration and extensive sloughing of the areolar tissue take place; the part, from being hard and tense, now becomes soft and boggy ; the skin, at first deeply congested, becomes pale in spots, and then black, and quickly falls into a state of moist gangrene. The constitutional symptoms, which may appear in the beginning to be of a somewhat sthenic character, rapidly degenerate into those of a typhoid type, and death mav occur from exhaustion, hectic, diarrhoea, or pyaemia. This form of erysipelas is that which most often occurs in connection with wounds, simply because in such cases the deeper planes of fascia are usually opened, and thus exposed to the influence of the disease. Under the name of cedematous erysipelas is described a modification of the phlegmonous form of the disease, which is chiefly met with in the legs, and about the genital organs of old or feeble persons. Both the local and general symptoms are less marked than in ordinary phlegmonous erysip- elas, but there is a considerable effusion of lymph and serum, solid (edema sometimes persisting, and giving the part the appearance of Scleroderma or Elephantiasis of the Arabs. DIAGNOSIS OF ERYSIPELAS. 455 3. Cellular Erysipelas (Diffuse Inflammation of the Areolar Tissue) —The former name is preferable, as there may be a diffuse inflammation of the connective tissue unconnected with the erysipelatous influence (see page 438). In this variety of the affection there are great swelling tension and pain, but comparatively little redness. The disease extends rapidly and widely, sometimes from a wound, but at other times beginning at a distance from the point of injury. Suppuration, sometimes attended"with emphysematous crackling, occurs about the fourth day, or even earlier and the skin quickly falls into a state of gangrene, this affection may also attack the deep planes of connective tissue, as in the pelvis or anterior mediastinum. The constitutional symptoms are of a profoundly typhoid type, death sometimes occurring on the second or third day of the disease 4. Traumatic Erysipelas is attended with changes in the condition of the wound itself. The edges become flabby, and the neighboring tissues (Edematous. A thin sanious fluid replaces" the ordinary healthy °pus the granulations become pale and shining, and the healing process is arrested- recent adhesions may even be broken down and absorbed. A sensation of weight and heat, with great pain, may precede by several hours the de- velopment of the characteristic eruption." 5. Erysipelas of Mucous Membranes.—The parts most usually affected are the fauces, pharynx, and larynx. Beginning in the fauces, which are swollen and deeply red, the uvula being markedly (Edematous, the disease may spread to the larynx, giving rise to a croupy cough, dyspnoea, aphonia and sometimes death from cedema of the glottis. At a later period fatal consequences may result from extension of the disease to the bronchi or lungs, from sloughing of the part, or from the development of pVienna. This variety of erysipelas is considered peculiarly contagious. Goodhart believes certain cases of the affection known as " Surgical Kidney" to be really examples of erysipelas affecting the kidney and urinary tract 6. Erysipelas of Serous Membranes.—T\\\s is chiefly met with in the arachnoid and peritoneum, the former being secondarily affected in cases of erysipelas of the scalp, or of injuries in the cranial region, and the latter m cases of injury of the abdomen or pelvis, or after various operations such as herniotomy, ovariotomy, etc. The symptoms are those of inflam- mation of the affected parts, with the general evidence of a profoundly typhoid condition J Diagnosis of Erysipelas.—Simple erysipelas may be distinguished from erythema, by the fact that the latter occurs in patches of various size, which have no particular tendency to spread, are not elevated and are unaccompanied by the formation of vesicles. The marked constitu- tional disturbance also is absent in erythema. From scarlet fever the diagnosis may be made by observing the circumscribed character of the erysipelatous eruption, its well-defined margin, the tenseness and "dazed appearance of the surface, and the presence of vesicles. There is a peculiar intiammation of the skin which results from contact with the poison sumach Utnus radicans, Rhus toxicodendron), which is almost identical in appear- ance w^h erysipelas: the diagnosis can only be made by the history, and oy the invariably mild course of the former affection, which, moreover, is frnm a-' c.onfltaolous- Phlegmonous erysipelas mav be distinguished nom ordinary inflammation by its defined margin, by the presence of tMcies, by the greater extent of surface involved, by the absence of any ^naency to point, by the rapidity of its course, and by the asthenic type bv th c°nstl.tutl0nal symptoms. From phlebitis, it may be distinguished y me pard, cord-like condition of the vein, and the absence of general tuness in that affection ; and from angeioleucitis, by the fact that in that 456 ERYSIPELAS. disease the redness and pain are confined to the course of the lymphatics and their neighboring glands. Cellular erysipelas may be distinguished from common diffuse inflammation of the connective tissue, by the even greater rapidity of the course of the former disease, and by the more asthenic type of its general symptoms. Erysipelas of the fauces or larynx may be distinguished from ordinary inflammation of those parts, bv the dusky redness exhibited in the former affection, and by the generally typhoid condition of the patient. Moreover, the manifestation of erysipelas on the cutaneous surface will usually throw light upon the diagnosis. From dijditheria, erysipelas of the throat may be distinguished by the greater degree of constitutional disturbance, and by the absence of exuda- tion. Erysipelas of the arachnoid or peritoneum, can only be distinguished from common arachnitis or peritonitis, by the primarily typhoid character of the constitutional symptoms in the former affections. The presence of delirium is a very frequent accompaniment of erysipelas of any form which affects the scalp, and must not be considered as in itself any evidence of meningeal complication. Prognosis.—The prognosis, in any case of erysipelas, depends chiefly upon the form which the disease assumes, the locality of the part attacked, and the constitutional condition of the patient. Simple erysipelas is usually a mild affection, and, in the large majority of instances, terminates in recovery ; if, however, it involve the scalp, or the abdominal wall, there will be a risk of transference to the arachnoid or peritoneum ; if the face be affected, it may spread to the fauces or larynx ; while, if there be serious visceral disease, especially of the kidney, the slightest attack of erysipelas will be likely to prove fatal. Parinaud has collected eight cases, including two observed by himself, in which facial erysipelas has been followed by atrophy of the optic nerve. Phlegmonous and cellular erysipelas are always very serious affections. In the head, abdomen, and lower extremi- ties. theyr are particularly apt to prove fatal, extensive sloughing in the latter situation sometimes laying bare the bones and opening the articula- tions. Faucial and laryngeal erysipelas sometimes prevail in an epidemic form, and have occasionally, under the name of " black tongue,'' produced frightful ravages in certain regions of our country. Finally, erysipelas in any form is a serious disease in new-born children, in very old persons. and in women in the puerperal state. Treatment.—A great deal may be done to prevent the development and spread of erysipelas. For this purpose, hospital wards, or the apart- ments occupied by sick or wounded persons, should be well ventilated and scrupulously clean. All excreta and soiled clothing should be promptly removed, and particular attention should be given to the sewerage; the presence of a foul drain has not seldom proved the starting-point of a local epidemic of erysipelas. Some years ago erysipelas prevailed in my ward- in the University Hospital, and was finally accounted for by discovering that a cellar had been neglected, and contained great deal of rubbish that should have been removed. As soon as the cellar was cleaned, the ery- sipelas disappeared. As the disease can be unquestionably propagated In- direct inoculation, precautions should be taken against the transference of morbid material from one patient to another. The washing of wound- should, if possible, be effected with a stream of running water; if this be impracticable, each patient should, at least, be provided with his own basin and sponge; the dressings should be of such a nature that they can be frequently renewed, and they should, therefore, be as simple and as inex- pensive as possible. Disinfectants, such as the chlorine preparations, the permanganate of potassium, carbolic acid, or bromine, may be placed in TREATMENT OF ERYSIPELAS. 457 various portions of the room, or may be employed in the dressings. Per- sonal cleanliness on the part of nurses and dressers should be rigidly enforced, and the latter should not be allowed to come directly from the post-mortem or dissecting-rooms to engage in their ward duties The surgeon himself should exercise similar precautions, and, as there is an undoubted connection between erysipelas and certain forms of puerperal fever, should, while attending cases of the former affection, if possible, temporarily decline engaging in obstetric practice. On the first appearance of a case of erysipelas in a surgical ward, the affected patient should be isolated, and disinfectant measures resorted to, in order to prevent the further spread of the disease. The Curative Treatment of erysipelas may be divided into the constitu- tional and the local treatment. 1. Constitutional Treatment—In simple or cutaneous erysipelas, very little medication is, as a rule, required If the patient, as'is usually the case, be constipated, with a furred tongue, a mercurial purge mav be ad- ministered. Emetics are often recommended, but unless it be known that the stomach contains some irritating material, they are, I believe, as un- necessary as they are disagreeable; their reputation is probably derived from their known efficiency in those cases of erythema which result directly from the use of certain articles of food. As a cathartic, two or three grains of blue mass may be given, to be followed, in the course of twenty-four hours, by a dose of castor oil or a Seidlitz powder. If there be much heat of skin, neutral mixture may be given, combined with camphor-water if the nervous symptoms are at all prominent. Anorexia will usually indi- cate the propriety of abandoning solid food, for which milk with lime- water, and beef-essence, may be substituted, in small quantities and at frequent intervals. In most cases, at least as met with in hospitals, a small quantity of alcoholic stimulus may be serviceable directed, but there is seldom occasion to give large quantities, four or five fluid-ounces of wine, or two or three of brandy, in the course of the day, being usually quite sufficient. Most cases of cutaneous erysipelas will run a satisfactory course under the above simple mode of treatment. If, however, the "surgeon wishes to do more, there can be no objection to giving the muriated tinc- ture of iron, which is a remedy of undoubted value in the phlegmonous form of the disease, and which may be conveniently combined with the solution of acetate of ammonium. The sulphites and hyposulphites have been rather extensively used in erysipelas, and have, with some surgeons, acquired a reputation which is, I believe, due more to the natural ten- dency of this form of the disease to spontaneous recovery, than to any curative virtue of the remedies themselves. The benzoate of sodium in large doses (5v. daily) is highly commended by Haberkorn. In phleg- monous and in cellular erysipelas the patient may be put at once, after attention to the state of his bowels, upon the use of the muriated tincture of iron, which must be believed, from published experience, to exercise a controlling influence over the course of the disease. This remedy, which was first brought prominently to the notice of the profession in 1851, by Br. G. Hamilton Bell, may be given in large doses—as much as twenty or thirty minims—every three or four hours, or even every hour if the urgency of the case require it. Quinia is another drug which may be use- fully employed, particularly in the later stages of the disease. Free stimu- lation may be employed in these cases from the very outset, and as the symptoms assume more and more a typhoid aspect, carbonate of ammo- nium and oil of turpentine may be properly added to the remedies previ- ously employed. A complication which demands special attention is the 458 ERYSIPELAS. supervention of arachnitis, of peritonitis, or of erysipelatous laryngitis. In the case of arachnitis, benefit may be expected from free purgation and the use of turpentine enemata. If coma occur under these circumstances, Copland recommends a full dose of calomel and camphor, followed bv an electuary of castor oil and oil of turpentine, placed upon the back of the tongue, and repeated from time to time until purging is begun. Enemata may then be used as adjuvants, and blisters may be applied to the nucha and thighs, as derivatives. In erysipelatous peritonitis, opium is the remedy most to be relied upon. If the disease attack the aii'-passages, the greatest risk is from oedema of the glottis; here (beside the local mea- sures which will be presently alluded to) a cautious trial may be given to antimony in combination with opium, the latter remedy serving to coun- teract the spasmodic tendency which almost always exists in laryngeal affections. If the dyspnoea, however, should increase, no time should be lost in resorting to laryngotomy ; the cedema does not extend below the vocal cords in these cases, and hence this operation is preferable to that of opening the trachea. 2. Local Treatment.—The local treatment of erysipelas is almost as important as the constitutional. Very various applications have been used in these cases, and each, at least in simple erysipelas, often with apparent success. It must not be forgotten, however, that, as pointed out by Vel- peau, the duration of the eruption in one spot is limited to four days, and that in many instances no other part may become affected In this, as in many other diseases, a knowledge of the natural history of the affection may tend to shake our faith in the curative power of the remedies em- ployed. With regard to local applications in erysipelas, a good general rule is given by Reynolds, viz., to avoid anything which shall expose the skin to variations of temperature, or which shall interrupt its natural function. Hence cold applications and oily or unctuous substances should not be employed. In simple or cutaneous erysipelas, if the affected patch be small, it may be sufficient to keep it well dusted with rice flour, toilet powder, oxide of zinc, or even common wheat flour. If the patch be large, particularly if a limb be the part affected, and generally in hospital practice, it will be better to cover the whole seat of eruption with carded cotton, loosely applied ; the cotton excludes the atmosphere and keeps the part in a kind of continuous vapor bath. In cases in which the tension of the part is very great, and which approach, in character, to the phlegmo- nous form of the disease, warm fomentations, such as chamomile or hop poultices, may be substituted for the simpler applications. Various other articles are recommended by surgical writers, particularly collodion, sul- phate of iron, tincture of iodine, nitrate of sil ver, nitrate of lead, creolin, and ichthyol. Bromine in the form of vapor, applied as described in speaking of hospital gangrene, was somewhat extensively used during our late war, and with alleged advantage. The nitrate of silver, which was first recom- mended in this affection by Higginbottom, is used in the form of a very strong solution (one part to three), and is applied, after thoroughly cleans- ing the part, "two or three times on the inflamed surface and beyond it, on the healthy skin, to the extent of two or three inches." Another plan, if an extremity is affected, is to apply the caustic in a broad band, entirely around the limb, a few inches above the seat of inflammation. The spread of the eruption certainly seems, in some cases, to be arrested by the caus- tic application thus made, but perhaps not oftener than it would have been spontaneously arrested at the same point had the treatment not been employed. Scarification in the form of a double ziz-zag line, at or just beyond the margin of the erysipelatous patch, and followed by the appH- TREATMENT OF ERYSIPELAS. 459 cation of a 1-1000 solution of corrosive sublimate, is recommended by Kraske, Iliedel, Lauerstein, Mcintosh, and W. Meyer. Compression of the limb by adhesive plaster or by a tight band is suggested by Woelfler and by C. W. Allen, as a means of limiting the affection by arresting the "onward march of the micro-organisms." The contractile power of col- lodion is employed for the same purpose by Niehans and Schneider. In phlegmonous erysipelas more active measures are required. In the early stages benefit may be derived from making numerous punc- tures with the point of a sharp lancet, as advised by Dobson ; these may be frequently repeated, and act by relieving tension and promoting resolution. Kraske supplements the punctures by applying a 1-20 solu- tion of carbolic acid, and dressing the part with a" weaker solution of the same. If punctures fail, or if the case be first seen at a later stage, when the brawny feel of the surface indicates impending suppuration of the subcutaneous areolar tissue, incisions from one to two inches long, and two or three inches apart, should be made over the inflamed surface in the general direction of the subjacent muscular fibres. These incisions, which should extend through the superficial fascia, were first popularized by Cop- land Hutchison. They gape pretty widely, owing to the great distention and swelling of the part, their edges presenting a gelatinous appearance from the infiltration of serum and lymph, and soon breaking down into pus mingled with shreds of disintegrated tissue. If the hemorrhage from these incisions be troublesome, they should be stuffed with scraped lint until the bleeding has ceased. South advises that the incisions should be arranged in the form of a lozenge, thus | |, the greatest relief from tension being thus obtained with the least destruction of tissue. At a still later stage when brawniness has given place to bogginess, showing that sloughing of the subcutaneous tissues has already occurred, free and deep incisions, three and four inches long, may be required, in order to prevent gangrene of the skin, and to afford an exit for sloughs, the separation of which may be hastened by means of forceps and scissors. Warm fomen- tations should be constantly applied, and antiseptics may be freely used, not only in the dressings, but injected among the tissues by syringing. When the suppuration is very profuse, the fomentation may be'omitted, the part being simply covered with lint and charpie, tow, oakum, or carded cotton, the now relaxed tissues being supported by the gentle pressure of a bandage. The abscesses, sinuses, and ulcers which are left after phlegmo- nous erysipelas, are to be treated on the principles laid down in the last chapter. Cellular erysipelas requires the same local treatment as the phlegmonous form of the disease ; the incisions should be made even ear- lier and more freely than in that variety, on account of the greater rapidity with which sloughing of the connective tissues occurs under these circum- stances. In certain localities, as in the orbit, the scalp, and the scrotum, early incisions are particularly imperative. In the orbit, the incisions are to be made by everting the lids, and pushing the blade of a lance, or bis- toury held flatwise, through the conjunctiva, between the eyeball and orbital walls : in the scalp, crucial incisions are the most effective; while in the scrotum, a single.free incision on either side of the raphe will usu- ally be all that is necessary. Erysipelatous arachnitis may be met by the application of cold to the scalp—the only form of erysipelas. I believe, in which the use of cold is admissible. In erysipelatous peritonitis the whole abdomen should be covered with a warm hop poultice. If erysipelas attack the fauces, a 460 PYEMIA. strong solution of nitrate of silver, or the muriated tincture of iron, mav be freelv applied with a sponge or camel's-hair brush; while in erysipela- tous laryngitis, before resorting to laryngotomy, a trial should be given to free scarification of the glottis and of as much of the larynx as can be reached, followed by the inhalation of steam and the free application of a solution of nitrate of silver (5j--fo.i)- The scarification may be effected with a probe-pointed curved bistoury, wrapped with adhesive plaster, or, more conveniently, with an ordinary hernia-knife. Should the patient survive the first risks of the disease, the inevitable sloughing will require the use of detergent gargles (especially such as contain chlorine or bro- mine), to obviate the fetor and diminish the risk of secondary blood- poisoning. In a case of traumatic erysipelas, if the disease appear to originate directly from the wound, it will be proper to apply to the latter some disinfectant, such as a solution of bromine with bromide of potassium, in hope that the disease may thereby be, if not arrested, at least favorably modified in its course. Hirschberg recommends in these cases hypodermic injections of a two-per-cent. solution of carbolic acid. CHAPTER XXIII. PYEMIA. Pyemia (in the sense in which the term is used in this work) is a pecu- liar morbid condition resulting from the absorption of septic material, and usually accompanied by the formation of puriform collections in various tissues and organs of the body. Virchow, to whose labors we are greatly indebted for our knowledge of the pathology of this disease, distinguishes several forms of blood-poi- soning, which are usually classed together as pyaemia, and proposes the names Ichorrhaemia, Septhaemia, and Septicaemia, for that variety which results from the absorption of putrid material from wounds, and is not accompanied by the development of those puriform collections which the older surgeons called "metastatic abscesses," and the formation of which he believes to be invariably due to plugging of the capillary vessels by fragments of disintegrated venous coagula. A similar distinction is made by many French surgeons, who differentiate between what thev call puru- lent and putrid infection, and the late Dr. Lidell was disposed to limit the term Pyaemia to those cases which are connected with pre-existing suppu- ration, and to apply the term Septhaemia to the forms of blood-poisoning which occur in connection with traumatic and hospital gangrene, dissection wounds, etc. Van Buren, too. taught that septhaemia was a distinct and well-defined malady, due to the absorption of a definite and peculiar poison, and Senn declares that pyaemia " is not a disease per se, but that its occur- rence depends upon an extension of a suppurative process from the primary seat of infection, and suppuration in distant organs by the transportation of emboli infected with pus microbes through the systemic circulation.'' The term sapreemia is used for the form of septic poisoning caused by the presence of ptomaines exclusively, and in which few if any microbes enter the blood. While it is quite possible that further experience and more accurate investigation may, at some future time, enable us to separate and NOMENCLATURE AND PATHOLOGY. 461 classify different varieties of septic poisoning, to recognize their several sources, and to distinguish the courses which they severally pursue, I can- not but think, with Verneuil, that in the present'state of science it is more practically useful, as it is certainly more convenient, not to aim at these theoretical refinements, but to use the word pyemia (as has been done in the definition given above) as a generic term, embracing one or more morbid systemic conditions, and to study such condition or conditions as parts of one disease, considering successively its pathological, clinical, and therapeutical relations, with the light afforded by observation and experience. Nomenclature.—The fact has long been known that patients who have received injuries (especially of the head or of the long bones), or who have undergone operations, may die from inflammation or suppuration in widely different parts of the body ; and various names have been suggested by surgeons, expressive of the theories adopted to account for these phe- nomena. Pyaemia or Pyohemia (meaning literally purulent blood) was the name proposed by Piorry, in the early part of this century, and has been used by the large majority of surgical writers; though a misnomer, as far as any pathological significance is concerned, it is perhaps no more objectionable than any other term, and is adopted in this work simply from motives of convenience. Among the other names that have been employed may be specially mentioned Phlebitis, Purulent Infection, Purulent Ab- sorption, Purulent or Pyogenic Diathesis, Multiple or Metastatic Abscess, Thrombosis, Surgical Fever, Pyogenic Fever, Suppurative Fever, and Surgical Typhus. These are all more or less objectionable, either as im- plying an untenable theory, or as referring to some mere incident of the disease. Surgical Fever (the name used by Simpson) is perhaps the least objectionable name—even less so than Pyaemia—but is not adopted here because it is usually recognized as a synonym for Inflammatory Fever, which' is quite a different condition. Pathology—Various pathological theories have been advanced upon the subject of pyaemia, which, though affording an interesting field for study, cannot be entered into within the limits of this work. I shall merely refer very briefly to the views which have most advocates at the present day, and which are—1. The theory which makes pyaemia dependent upon the existence of pus in the blood ; 2. That which makes it dependent upon thrombosis (the formation of venous clots or thrombi), and subse- quent embolism,1 or plugging of the capillary vessels with fragments broken off from these clots and called embola; and 3 That which makes it dependent on the introduction of a septic material into the blood, and which looks upon the processes of thrombosis and embolism as subsidiary and not absolutely necessary. This seems to me in the present state of our knowledge to be the nio'st plausible theory, and it is that which is here adopted. The theory which accounts for the phenomena of pyaemia by iissuming the existence of a morbid diathesis, merely puts the difficulty one step further back ; it is as hard to account for the" diathesis as for the disease which it is supposed to produce. The theory which looks upon the symptoms of pyaemia as reflex phenomena brought about through the agency of the nervous system, is somewhat plausible, but must be rejected as ignoring the facts which have been obtained by clinical observation and dissection, as well as by experiments upon the lower animals. Ogston believes, with Kocher, that simple acute inflammation, pyaemia, and septicaemia are identical, and differ only in intensity ; he considers 1 From two Greek words, Iv (in) and SiXKu (I throw or cast). 462 PYEMIA. them all examples of micrococcus poisoning, affecting the tissues primarily and the blood only secondarily, either by means of soluble ptomaines (septicaemia), or by accumulation and arrest of micrococci in the capillary networks, causing the so-called metastatic deposits (pyaemia). Experi- ments on the lower animals, however, by Jeannel and Laulanie*, F. A. Packard and Shober, and others, lead them to believe that both forms of disease are due to the effect of microbes rather than of ptomaines. Kingzett, on the other hand, maintains that micro-organisms only produce their effects secondarily by inducing chemical changes, and Blum berg declares that the blood of animals destroyed by "putrid intoxication" contains no bacteria, and that the poison therefore must be a chemical one. Cheyne believes that the microbes of septicaemia act by producing poisonous pto- maines, and themselves only grow locally, or, if they enter the blood, do not form embola. According to Jiirgensen, streptococci enter the circula- tion, while staphylococci cause the topical changes. 1. Pus in the Blood.—The existence of pus in the blood of pyaemic patients has been affirmed by a very large number of observers, but strenu- ously denied by Virchow and others, who declare the supposed pus-cells to be merely the white corpuscles of the blood in increased numbers, and the condition of the blood in these cases to be one of leucocytosis, as in the disease called by Virchow, Leukaemia, and by Bennett, Leucocythemia. SeMillot indeed pointed out certain diagnostic marks as to size, color, etc., by which he believed that the pus-cell could be distinguished from the white blood-corpuscle, but it is now generally conceded that they are un- distinguishable. It may be added that, if Cohnheim's observations are correct—if the white corpuscles and pus-cells are really identical, and capa- ble, by means of their amoebaform movements, of wandering through the unbroken capillary walls—the whole question of pus in the blood will have lost much of its significance. The entrance of pus into the blood has been accounted for in two ways, viz., by the previous existence of suppurative phlebitis, and by the occurrence of direct absorption.1 Phlebitis was supposed to be the cause of pyaemia by Hunter, Abernethy, Guthrie, Arnott, Cruveilhier, and Liston, and this view has been and perhaps still is adopted by the majority of practical surgeons. The pus is supposed to be formed from the lining membrane of the vein, and thus to enter the circulation, either directly, or by the breaking down of the lim- iting clot. The objection to this view is that in many cases of pyaemia the veins are not inflamed at all, and that when inflammation does exist, it is secondary and does not involve the lining membrane of the vessel, being what is called by Virchow a meso-phlebitis or peri-phlebitis. Even when the inner coat is involved in phlebitis, the entrance of inflammatory products into the general circulation is prevented by the coagulum which in these cases fills the vein. The theory of absorption of pus has received support from the well- attested fact that pyaemia is particularly apt to occur after injuries or oper- ations in parts in which open veins are, from mechanical causes, unable to collapse when cut, or to contract at a subsequent period, as veins ordi- narily do, upon the shrinking of their contained clots. On the other hand, it has been repeatedly shown by experiment that (1) the effect of applying 1 Piorry's idea that the blood itself could become the seat of inn"animation and sup- puration, may, in the present state of science, be looked upon as purely chimerical; while the theory which supposes pus to enter the circulation by absorption through the lymphatic system, must be rejected on anatomical grounds, the lymphatic glands acting as filters to prevent the passage of solid particles much smaller than the pus- corpuscles. (See Virchmc's Cellular Patholoyy (Chance's edit.), pp. 184-1*5.) PATHOLOGY. 463 healthy pus to blood is simply to induce coagulation ; (2) that injection of pus into the blood of healthy animals is not usually followed by fatal results, though repeated injections may produce death ; (3) that the injection of {he fluid part of pus is of itself followed by no evil result; (4) that injec- tions of small quantities of pus act just as injections of various other sub- stances, such as mercury, oil, powdered oxide of zinc, etc., by producino- local obstructions (infarctus) in the first set of capillaries; and that (5) these obstructions may, in healthy animals, spontaneously disappear, the subjects of the experiments eventually recovering. Hence'it is shown'that if pus be absorbed into the blood, its action can be only mechanical, and it is very reasonably argued that the pus-corpuscle, being at least no' laroer than the white corpuscle of the blood, is no more likely to produce the obstruction which results in the formation of the " pyaemic patch" or " metastatic abscess," than the white corpuscle itself.1 Finally, as already remarked, if Cohnheim's views be correct, this -whole question will have lost much of its importance. 2. Thrombosis or Embolism—Thrombosis, or the coagulation of blood in the vessels during life, may depend upon a variety of causes as (1) quiescence or simple retardation of the circulation, (2) the contact of a rough surface, and (3) an alteration of the blood itself, consisting prob- ably in an increase in the proportion of fibrin.2 Thrombi form in the veins in almost every case of injury, or of inflamma- tion of the surrounding tissues, as well as in cases of phlebitis. These venous thrombi or clots increase by aggregation^ until they reach the points at which the veins in which they are seated anastomose with their parent trunk; if the force of the circulation in this be sufficiently strong, it may prevent the further increase of the thrombi, but if not, these will continue to en- large till they project into the main trunk, as shown in the annexed diagram taken from Callender (Fig. 244). A fragment of the projecting part of a throm- bus may be broken off and swept into the circulation, passing through the heart and plugging an artery', producing embolism, and, if the vessel be of sufficient size, perhaps leading to gangrene; just as we have seen in a previous chapter that gangrene mav be in- duced by embolism, from the breaking up of a clot formed in the heart. Under certain circumstances, probably owing to an unhealthy condition of the fibrin, a ve- nous coagulum or thrombus softens and undergoes genera] disintegration; a large number of small frag- ITSare hbivs crried i,nto the ci-uiati-> «»<*. past z r::r;:z7£Z ng through the heart, plug the first set of capillaries gregation; b, clot un- (which, if the seat of thrombosis be in the systemic dergoing disintegra- circulation, will of course be the pulmonary) causing tion and allowing fras- thus capillary embolism. A few embola may slip m™t.s t0fT, *h°„cir- tbrough the first, to plug other sets of capillaries, o? ™T J\\ UJS' ho*eve5' Possible, as remarked by Bristowe, that aggregated masses of pus- embolism F circulation as Pellets or flakes, and prove a mechanical source of but fCcor<*,n£ ,t0 Schmidt, fibrin (as such) does not exist in the circulating blood, vlaJl pnTced hy the union of two substances, which he calls fibrinogen and fibrino- tint, nf fi coaSulat,on is d"e to the action of a ferment produced by'the disintegra- "on ot the white corpuscles. Fig. 244. — Diagram illustrating processes of thrombosis and em- bolism ; a, clot project- ing into venous trunk 464 PYEMIA. each point of obstruction may cause fresh thrombosis, and a repetition of the whole process. In the same way capillary embolism may be due to disintegration of cardiac coagula, and to cases of this kind Wilks has applied the name " Arterial pyaemia " The secondary effects of capillary embolism consist essentially in the development of congestion and in flam*. mation in the part deprived of its vascular supply, which often, though not always, goes on to the occurrence of suppuration and gangrene—the embola themselves, in the latter case, breaking down and mingling their debris with the products resulting from the disintegration of surrounding tissue. It is probably to this process of thrombosis and capillary embo- lism that is due the formation of the large majority of secondary deposits, or " mestastatic absee>>es," in cases of pyaemia ; but that this process is not necessarily present in every case, is shown by the facts that(l) precisely the same set of changes may result from capillary stagnation, produced by the introduction into the circulation of putrid fluids, (2) that the secondary deposits are sometimes absent from the lungs, though present in other viscera (which would be unaccountable on the supposi- tion that they were clue solely to mechanical obstruction by solid particles, as in that case these particles, or embola, would necessarily block the first set of capillaries),1 and (3) that in cases of capillary embolism from car- diac disease (arterial pyaemia) the eouive of the affection is very much less acute than is seen in the immense majority of cases of ordinary venous pyTaunia, as met with in surgical practice, showing that in the latter there must be something more than the simple processes of throm- bosis and embolism. Indeed, Virchow and his followers acknowledge that certain of the phenomena of pyaemia (as ordinarily seen) are not ac- counted for by these processes, and declare, therefore, that in many ca>e.- there is in addition a state of ichorrhaemia, due to the absorption of septic material. 3. Absorption of Septic Material.—We are thus brought to the conclu- sion that the only theory which is capable of accounting for all the phe- nomena of pyaemia is that which supposes the pyaemic condition to be induced by the absorption of septic material (liquid or gaseous, containing ptomaines, micro-organisms, or both), which unfits the blood for the pro- cesses of healthy nutrition, induces capillary stagnation and its conse- quences, low forms of inflammation, or serous and synovial effusions, and may, and probably does, in most cases, cause venous thrombosis, giving rise to the occurrence of loose and ill-formed coagula, which, rapidly under- going disintegration, cause capillary embolism, and thus produce the second- ary deposits, or metastatic abscesses, which are so common in this affection. Morbid Anatomy—-Under this head I shall describe very briefly the chief post-mortem appearances observed in fatal cases of pyaemia. In cases which prove very rapidly fatal (the septieemie foudroyante of Ver- neuil and his followers), time is not afforded for these changes, and, under such circumstances, the post-mortem appearances are almost negative. The characteristic lesions of this affection consist in local congestion, ex- travasation and inflammation, with gangrene, and occasionally true sup- puration. Small fibrinous plugs (embola) can sometimes be detected in the smaller vessels leading to the afi'ected part, but more often the micro- scope reveals only a mass of granular matter, lymph and blood cells, fibrils, 1 According to 0. Weber, however, as quoted by Billroth, certain forms of embola, especially flocculi of pus, may pass the pulmonary capillaries and enter the systemic circulation. Busch explains the occurrence of hepatic embola by the occurrence of retrograde movements of the blood in the vena cava. MORBID ANATOMY. 465 oil globules, and dibris of tissue. If there is true pus, it is the result of suppuration occurring secondarily around, not in, the pyaemic patch. Lungs.—Pyaemic patches, or, as they were formerly called, metastatic abscesses, are most often seen in the lungs, and (according to Callender) in the left more frequently than in the right. They vary in size from that of a small pea to an inch or more in diameter. " They may occupy ap- portion of the lung, but are most frequent at the posterior part, and are usually present in considerable numbers. They are hard and resisting to the touch, and when cut open present varying appearances, according to the stage which has been reached, their color being reddish-black, brown, pale buff, or yellowish-gray. They are always surrounded by a well- marked vascular zone. When near the pleural surface, they often cause pleurisy, marked by the formation of lymph, in patches, and by the effusion of turbid serum. Beside presenting these pyaemic patches, the lungs are often diffusely congested, or even inflamed. Liver.—The liver is most often affected next to the lungs. The prog- ress of pyaemic patches in this organ seems to be more rapid than in the pulmonary tissues, so that the puriform appearance is very quickly de- veloped ; a circumstance which accounts for the fact that " metastatic ab- scesses" are often observed in the liver, when the morbid changes in the lungs have escaped attention. Other Viscera—The Kidney, Spleen, Heart, Brain, Bowels, Testes, Prostate, Eye, etc., may all be similarly affected, and probably in the order named, as regards frequency. Bristowe, indeed, considers that the kidnevs are more often affected in pyaemia than the liver. The spleen may be much enlarged, even when not the seat of the characteristic pyaemic patches. The Peritoneum is not unfrequently locally inflamed, as the result of pyaemic deposits in the various abdominal viscera. Joints.—The articulations are often swollen and inflamed, containing a turbid, puriform fluid (sometimes, probably, true pus), the synovial struc- ture being deeply congested, and the cartilages eroded. Bones.—The bones are probably occasionally, but very rarely, the seat of secondary pyaemic changes. On the other hand, pyaemia very often originates in inflammatory affections of bone, especially (as we shall see hereafter) in osteo-myelitis. Muscles and Areolar Tissue.—Pyaemic deposits are not unfrequently met with among the muscular layers of the thoracic or abdominal walls, or in the neighborhood of joints, and, according to Bristowe, occasionally in the tongue. True suppuration may occur under these circumstances, re- sulting in the rapid formation of abscesses of large size. External Surface.—The skin presents a yellowish appearance, and is sometimes absolutely jaundiced. Open wounds are found dry, the granu- lations having often completely disappeared, and the surface being pale and glazed, or occasionally covered with a grayish slough. Lymphatics.—The lymphatics in the neighborhood of a wound are often inflamed, and abscesses form in the adjoining lymphatic glands. It is doubtless to the irritation of the lymphatic system that is due the increased number of white corpuscles sometimes observed in the blood in pyaemic cases. It was this phenomenon (which Virchow calls leucocytosis) which nrst suggested to Piorry the name of Pyaemia. Bloodvessels.—Phlebitis is a very frequent accompaniment of pyaemia. ine veins are thickened and somewhat contracted, containing clots, which are usually firm and adherent above, but softened below, and disintegrated into a puriform fluid, which was formerly supposed to be actually pus. ine arteries are, I believe, not affected in cases of ordinary pyaemia, except 466 PYAEMIA. that the smallest branches may be sometimes the seat of embolism. Wilks believes that in some cases of what he calls arterial pyaemia, the pathological condition is one of arterial thrombosis in situ, rather than of embolism from softening cardiac clots. The capillaries in various parts of the body are occasionally seen to be plugged by embola ; but, as already indicated, this condition is, in most instances, inferred, rather than demon- strated. Blood.—The blood often presents no abnormal appearances, though in other cases it contains an unusually large proportion of white blood-cor- puscles (leucocytosis). Its coagulability is usually- diminished, and it is commonly found fluid or imperfectly clotted. This want of coagulability is one cause of the liability to capillary oozing or parenchymatous hemor- rhage, which is often observed in cases of pyaemia, a tendency which is probably assisted, as pointed out by Stromeyer, by the venous obstruction due to thrombosis, and which is still further aided by the complication of leucocytosis, when present—capillary bleeding being, as is well known, a frequent occurrence in cases of leukaemia or leucocythemia. Small organ- isms (bacteria) are commonly found in the blood of pyaemic patients, but, as already mentioned, it has not been positively determined whether they exert a direct causal influence in producing the disease, or whether they act by inducing secondary chemical changes. Causes of Pyaemia__As Predisposing Causes of pyaemia may be mentioned previous illness, visceral disease (especially of the kidneys or liver), exhaustion, loss of blood, prolonged shock, over-crowding (especially of suppurating cases), a scorbutic condition, the puerperal state, certain diseases—such as erysipelas, hospital gangrene, carbuncle, osteo-myelitis etc.—and, finally, the presence of an open wound. The Exciting Cause, according to the pathological view adopted in this chapter, is the absorp- tion of a septic material, usually in the form of a liquid, with or without micro-organisms, from a wound or ulcer, but, in some cases, from the ali- mentary or other mucous membrane, or, possibly, in the form of a gas, by the medium of the lungs. It is asserted by many writers that pyaemia never occurs except in connection with the existence of an open wound. There are, however, cases on record in which pyaemic symptoms have not appeared until after the cicatrization of a wound, and Savory declares that pyaemia not only occurs without the previous existence of any wound, " but sometimes, so far as most careful and complete examination can show, without any previous suppuration or any other local mischief whatever." Savreux-Lachappelle has collected a number of cases of so-called idiopathic or essential pyaemia, and has shown that in most of these instances expos- ure to cold has been the apparent cause of the affection. There is. more- over, reason to believe that, in some cases, the pyaemic poison is generated in the secretion which lubricates mucous membranes. Hence, while in the immense majority of cases we may safely assume that the materies morbi of pyaemia is developed in the fluids of" a wound or ulcer, we are forced to believe it possible that the septic material which gives rise to the disease may originate de novo in the system, as the result of extraneous influences. With regard to the question of the contagiousness of pyaemia, we must speak with a certain degree of hesitation ; in the ordinary -ense of the term it is certainly not contagious—not in the same sense, that is. as typhus fever and measles. Pyaemia may, undoubtedly, be inoculated by careless use of sponges, etc., or may possibly be tran.-mitted by prox- imity alone ; but in either case the septic material must be generated in the fluids of the wound or ulcer of the person about to be affected, before infection can take place. Even in the rare cases in which the peculiar septic SYMPTOMS AND DIAGNOSIS. 467 matter of pyaemia is supposed to have been absorbed in a gaseous form through the lungs, it is possible that the sole office of the morbid substance derived from without has been to produce a change in the fluids of the part, the true pyaemic poison being there developed, and causing infection as a secondary consequence; just as in other instances it is probable that the pyaemic poison is generated in the secretions of the alimentary or gen- ito-urinary mucous membranes. Symptoms of Pyaemia—The first symptom of pyaemia, at least in surgical cases, is almost always a sensation of cold, with usually a de- cided rigor or chill. These chills are subsequently repeated, at irregular intervals, and are commonly followed by profuse a*nd exhausting diapho- resis, the hot stage which is usually observed after malarial chillsbeing, in cases of pyaemia, absent, or but slightly marked. The greatest elevation of temperature coincides with the period of rigor, the thermometer not often going above 104°, though occasionally, if the chill be very severe, reaching 106° or 107°, or, according to Billroth, even 108° Fahr. The irregular variations of temperature, which range over 10° or 11° Fahr. are considered by Wagstaff'e of diagnostic value. During the sweating stage, the temperature rapidly falls. According to Ringer and Le Gros Clark, the elevation of temperature begins before the development of the chill, and the former author believes that the occurrence of the rigor may be predicted by thermometrical observation. The pulse-rate is rarefy below HO, usually ranging from 100 to 130, and (according to Bristowe) occa- sionally reaching 200. The respiration is usually hurried and anxious, ranging from 40 to 50 in the minute, and sometimes even more. The breath is said to have a hay-like odor, though I cannot say that I have myself observed this symptom. There is commonly cough, with expecto- ration of viscid or of blood-stained sputa, and physical examination reveals the signs of pulmonary congestion, with pneumonia (lobular or lobar) and pleurisy. Pericarditis may be present, but its signs are often masked by the respiratory sounds. The countenance is flushed, the skin presents a dusky, sallow, somewhat jaundiced hue, and is often marked with suda- mina, which, being surrounded by a zone of congestion, have been mis- taken for the spots of typhus, or of typhoid fever. At a later stage, a pus- tular eruption resembling that of smallpox has been observed. Pe'techiae, ecchymoses, and localized gangrene, occur in some cases. The tongue is usually furred ; there is commonly complete anorexia: often nausea and vomiting; and usually diarrhoea" The urine is frequently albuminous. The patient is often delirious, particularly at night, or may be profoundly soporose, though rousing up and answering intelligently when addressed. Intense pain often accompanies the formation of the secondary deposits or inflammations, particularly when these are superficial, as in connection with the joints. If there be an open wound, it will probably become dry and glazed, all reparative action ceasing; occasionally, however, healthy granulations continue to be formed almost to the end of the case, or, on the other hand, absolute sloughing may occur. Profuse capillary hemor- rhage may tend still further to weaken the patient. Before death the symptoms assume a profoundly typhoid character : sordes accumulate upon the lips and gums; the tongue becomes dry and brown, and sometimes cracked and bleeding; subsultus tendinum and carphologia, with low, mut- tering delirium, mark the profound implication of the nervous system, and tnepatient may die comatose, or apparently from pure exhaustion. .Diagnosis—The diagnosis of pyaemia can usually be made by care- tully observing the history and the symptoms of the case. From Inflam- matory Fever, from Hectic, and from Typhoid Fever, pyaemia can usually 468 PYEMIA. be distinguished by its greater fluctuations of temperature and higher thermometrical range, and by its repeated rigors, occurring at irregular intervals. From inflammatory fever it further differs, in that the former affection commonly yields on the occurrence of suppuration. The irregu- larity of the chills, together with the absence, or at least the wanfof prominence, of the hot stage, will prove of diagnostic value as regards Intermittent and Remittent Fevers. From Rheumatism,1 and especially from what is called Rheumatoid Arthritis, the diagnosis is often extremely difficult, particularly if the pyaemia assume a chronic form. Under such circumstances, the surgeon must rely chiefly upon the history of the case the condition of the wound (if there be one), the degree of prostration, and the tendency to suppuration—which occurs as a rule in pyaemic joint- affections, and only exceptionally in those of a rheumatic character. The secondary local manifestations of pyaemia may be readily confounded with other diseases. Thus an idiopathic pneumonia, occurring after an ampu- tation, might be mistaken for the lung complication of pyaemia, and a similar error might be made in regard to other organs. I was once asked to see a patient in whom marked brain symptoms, with general febrile dis- turbance, had followed traumatic erysipelas supervening upon an excision of the elbow. The case had been supposed to be one of pyaemia, but I diagnosticated tuberculous meningitis, chiefly from observing the intense headache, with screaming, the absence of prostration, and the existence of the tache cerebrate, or red mark produced by lightly drawing the finger- nail over the surface of the chest or abdomen. The correctness of this opinion was subsequently demonstrated by an autopsy. Prognosis—The prognosis of pyaemia is always unfavorable, and in an acute form the disease is almost invariably fatal. The subacute and chronic varieties, however, are less hopeless, and, in any case, the longer the patient can be kept alive, the better is the prospect of ultimate re- covery. I have myself seen at least five cases of pyaemia terminate favor- ably—three after partial excision of the radius or"ulna, one after partial amputation of the hand, and one after amputation at the knee—but in none of the five did the affection assume a very acute form. The duration of the disease varies greatly in different cases. Occasionally, in what the French call the foudroyante form of pyaemia, death may occur within a day or two of the first rigor. From four or five days to a week is the usual duration of acute cases, though life may be prolonged for ten days, a fortnight, or even longer. In cases which recover, the patient usually goes through a long illness, and may be left permanently crippled by sec- ondary implication of the articulations. The occurrence of abscesses in superficial parts, where they can be evacuated, is looked upon as rather a favorable omen; and I have sometimes thought that the diarrhoea, in these cases, appeared to act as a derivative in relieving the internal viscera. Treatment—As Prophylactic Measures, all those precautions should be adopted which were discussed in speaking of operations in general, and of erysipelas, hospital gangrene, etc., diseases which are often followed by pyaemia. As every patient with a suppurating wound is liable to this affection, the surgeon should use every effort to obtain primary union, or at least cicatrization, without any unnecessary delay; at the same time he must take care to secure free drainage from the wound, lest, in his zeal for early healing, he cause purulent and other fluids to be pent up and con- 1 There is reason to believe that the affections known as Gonorrheal Rheumatism, Urethral Rheumatism, Urethral or Genital Fever, etc., are actually mild forms of pyaemia, resulting from the development of septic material in the secretion of the genito- urinary mucous membrane. TREATMENT. 469 fined, thus defeating the very object which he is seeking to promote. Bv the judicious use of drainage-tubes, perfect cleanliness, carefully applied antiseptic dressings, and rest, the risk of the occurrence of pyaemia will be reduced to a minimum. The various predisposing causes of pyaemia should, as far as possible, be obviated, for we know of no way by which the development of the poison can be certainly prevented, nor by which it can be hindered from produc- ing its deleterious effects. The administration of various drugs has been proposed with the idea that they would exercise a prophylactic influence; the permanganate of potassium, and more particularly the sulphites and hyposulphites (the latter agents on the recommendation of Polli), have been somewhat extensively employed, but have not, I believe, fulfilled the expectations of those who have used them, and the same may be said of carbolic acid and the carbolates. Labat has advised the internal exhibition of ergotine, which he believes acts by increasing the plasticity of the blood; the evidence adduced in its favor is, however, but negative, as is that in favor of the tincture of aconite, recommended as a prophylactic in these cases by Chassaignac. Curative Treatment.—The treatment of this disease must be conducted on those principles which guide the surgeon in the management of other affections of a typhoid character : there is no specific for pyaemia. If the patient be at first constipated, with a deeply furred tongue, it may be proper to give a small dose of blue mass, followed by magnesia or other mild cathartic. Under such treatment the tongue will often clean off, to become, however, again furred in a short time, a.s the case progresses. Quinia is, I believe, more valuable than any other single drug, in the treat- ment of pyaemia: it may be given in doses of four or five grains, every three or four hours. Guerin, who had great confidence in this medicine, used very large doses—giving as much as a drachm in twenty-four hours. Socin used still larger quantities—90 to 105 grains in the" twenty-four hours—with success during the late Franco-Prussian war. Legouest and Bouillaud think the cinchona bark itself a preferable agent to quinia. Iron may be combined with the quinia in the form of the muriated tincture, or, which Braidwood prefers, the citrate of iron and quinia may be sub- stituted. The oil of turpentine is, I think, a useful stimulant in these cases; it may be given with muriatic acid, in an emulsion, a few drops of laudanum being added to each dose, if there be a tendency to undue purg- ing. As diarrhaea, however, appears in some cases to be a means adopted by nature to eliminate the poison, it should not be hastily checked, unless so profuse as to be in itself a cause of exhaustion. Opium may be required to relieve pain or restlessness, and in such cases may be given in any form that convenience may indicate. Carbonate of ammonium may often be employed with advantage, not only as a cardiac stimulant, but, if the pul- monary complications be prominent, as an expectorant. Transfusion of blood is recommended by Marcacci. In all cases the patient should be supplied with abundance of light but nutritious food, given in small quan- tities and at short intervals, and alcohol, in the form of wTine or spirit, must be likewise administered very freely; Socin, in connection with the huge doses of quinia above referred to, gave his patients three bottles of wine per diem. In the worst case of pyaemia in which I have ever known recovery to follow, the patient got*every hour, day and night, a tablespoonful of whiskey, with six of milk and four of lime-water, for more than a week; his anorexia was complete, with constant nausea, and retching at the very idea of food, and it was only by his taking this com- bination regularly, as medicine, that life was sustained. 470 DIATHETIC DISEASES. With regard to Local Measures, beyond care as to the cleanliness of wounds, and the use of disinfectants, I do not know of any plan worthy of much confidence. The application of the actual cautery in the course of the superficial veins (if these be inflamed), or to the wound itself, has been highly recommended by several writers. Legouest advises that the wound should be washed with the perchloride of iron. Nitric acid and various other caustic agents have been likewise employed, but the evidence is not very satisfactory as to any benefit derived from their use. Ligation of the principal vein of the limb has been employed with alleged benefit in cases recorded by Kraussold and others. Probably the most rational plan is to be satisfied with keeping the wound clean and lightly dressed; and diluted alcohol, or weak solutions of the permanganate of potassium, car- bolic acid, or corrosive sublimate, are probably better applications, in these cases, than poultices or other more cumbrous forms of dressing. Free drainage from the wound should be secured by position or otherwise, and if abscesses form in accessible situations, they should be opened at an early period, and their cavities afterwards frequently washed out with disinfect- ant fluids. Under the course of treatment above described, a certain number of the milder cases of pyaemia may be conducted to a favorable termination, and, occasionally, a patient more severely attacked, may be snatched as it were from the very jaws of death ; but there is reason to fear that the large ma- jority of pyaemic cases will prove fatal in spite of all our care and attention, and that this frightful affection, happily much rarer at the present day than it was twenty-five or thirty years ago, will, when it does occur, still continue to deserve the name which has been not inaptly bestowed upon it, of the "Bane of Operative Surgery." CHAPTER XXIV. DIATHETIC DISEASES. Struma (including Tubercle and Scrofula) ; Rickets. Beside the affections to the consideration of which this chapter is de- voted, there are two diseases which have claims to be regarded as of a diathetic or constitutional nature, viz., Cancer and Hereditary Syphilis. The former will be described when we come to speak of malignant tumors, and the latter under the head of Venereal Diseases. Struma. The terms Struma, Scrofula, and Tubercle have been very variously applied by pathologists. Some look upon them as identical, while others use struma as a general term embracing both the others; some subdivide scrofula into two varieties, the sanguine and phlegmatic, and ignore the independent nature of tubercle, while others recognize the two forms of scrofula, and consider tubercle as a distinct affection ; some, again, recog- nize but one form of scrofula (the phlegmatic), and apply the term tubercle to the sanguine variety, while still others are disposed to doubt the exist- ence of any form of scrofula, apart from a syphilitic taint. It will thus be TUBERCLE OR TUBERCULOSIS. 471 seen that the use of these words is necessarily attended with a good deal of confusion, and it would be well if we could dispense with them all, and adopt others which might be universally adopted as having a definite signification. Under the general term of struma, surgeons (whatever be their theoretical views) practically recognize, as justly remarked by Holmes, three classes of cases, viz.: (1) those in which there is evidence of the existence of tubercle, (2) those in which there is no tubercle, but in which the ordinary processes of inflammation, etc., present modifications which can only be accounted for on the supposition of the antecedent existence of some morbid condition or diathesis; and (3) cases which present, in reality, nothing more than the constitutional effects of long-continued local disease. Under the latter head come certain cases of chronic bone and joint disease, which are commonly though incorrectly called strumous. Rejecting then entirely the third class, we have the cases in which tubercle exists, and which may be pro- perly called tuberculous, and those in which there is evidently a morbid diathesis (not tuberculous), to which we may conveniently, if not very scientifically, applv the term scrofulous. Tubercle or Tuberculosis.—I shall not enter into any discussion as to the nature and origin of tubercle, a question which belongs more properly to the domain of general pathology than to that of practical sur- gery, further than to say that it is now generally conceded that all tuber- culous affections are caused by the presence of a peculiar form of bacillus, first described by Koch, wrho believes that tuberculous infection usually occurs by inhalation of dry and scattered phthisical sputum, though the tubercle bacilli may also gain entrance through abrasions or cutaneous eruptions, then being carried to the nearest lymphatic glands, where they develop foci of the disease. The occurrence of localized tubercle in internal organs, or in bones or joints, is therefore regarded by Koch as a secondary condition. It is usually said that tubercle occurs under two forms, the gray or miliary tubercle and the yellow tubercle. The latter is probably in many instances not tubercle at all, but the result of caseous or cheesy degeneration (tyrosis) of pus, cancerous deposits, or other pathological formations; in other cases, however, the yellow is the result of caseous degeneration of the miliary tubercle. Gray or miliary tubercles occur as small, granular masses, about the size of millet-seeds, rather hard, semi-translucent, and presenting a glis- tening, cartilaginous appearance. Under the miscroscope, these masses show a homogeneous or slighty fibrous stroma, containing cells with one or more nuclei, free nuclei, granules, etc. In the so-called yellow tubercle, which usually occurs in larger masses, the cells have a withered appear- ance, and the granular matter is in larger proportion, and mixed with oil- globules. The following scale of the frequency of tubercle, in various textures and organs, is taken from Rokitansky: lungs, intestinal canal, lymphatic glands (particularly the abdominal and bronchial), larynx, serous mem- branes (especially the peritoneum and pleura), pia mater, brain, spleen, kidneys, liver, bones and periosteum, uterus and tubes, testicles with pros- tate and seminal vesicles, spinal cord, and striated muscles. The favorite primary seats of tubercle, after the lungs and lymphatic glands, are the urinary and sexual organs, and the bones. Tubercles are only met with in vascular parts (hence not in cartilage), and are often deposited in the external coats (adventitia) of the smaller vessels, a circumstance which may account for their frequent appearance in the choroid coat of the eye, 472 DIATHETIC DISEASES. where they have been recognized during life by means of the ophthalmo. scope. Tubercle may become indurated and calcified (obsolete), but usually tends to softening, disintegration, and liquefaction ; the fact of its absorp. tion is not established, though its possibility is admitted by both Roki- tansky and Virchow. The causes, symptoms, course, and general treatment of tuberculosis are described in every work on the Practice of Medicine, and need not, there- fore, be referred to here; it may be stated, however, that there are strong grounds for believing that, among the sources of depression which act as predisposing causes of the development of tubercle, long-continued suppu- ration* is one which must not be ignored. Hence an additional reason, in the treatment of surgical cases, for paying attention to the constitutional condition of the patient, and for preventing, if possible, deterioration of the general health. With regard to the question of operative interference in tuberculous cases, no general rule can be given. The prognosis of an am- putation or excision for tuberculous disease is undoubtedly less favorable than that of a similar operation for scrofulous or simple chronic inflamma- tion. If there be evidence of tuberculosis of internal organs, any operation should as a rule be avoided ; the only exceptions are—(1) when it appears that the visceral disease is caused by the external affection, and when, therefore, there would be reason to hope that by removing the latter the progress of the former might be checked; and (2) when the patient's suf- fering from the external disease is so great that the operation is called for simply for the relief of pain. The local use of iodoform is of special value in all cases of surgical tuberculosis, and may, according to Schiiller, be properly combined with the internal administration of guaiacol. Kidd reports a cure of tuberculous ulceration by the application of lactic acid. Scrofula or Scrofulosis, as the term is here used, denotes a consti- tutional condition or diathesis, which imparts a peculiar character to the processes of inflammation and ulceration, and which is particularly marked by a tendency to cheesy degeneration in the lymphatic glands and to alow form of inflammation of the bones and joints. Many writers speak of a scrofulous temperament, and describe certain peculiarities of feature and complexion, as characteristic of the scrofulous diathesis. Erichsen describes two forms, the fair and the dark, and subdi- vides each of these into two varieties, the fine and the coarse: Jenner, on the other hand, regards the fine varieties (which constitute what is usually called the sanguine temperament) as belonging to the tuberculous diathesis, and limits the term scrofulous to the temperament commonly recognized as the phlegmatic. Although, however, there are doubtless many cases of tuberculosis met with among persons of a sanguine temperament, with delicate features, clear complexions, and highly developed nervous system?, there are, perhaps, almost as many among those whose temperament would be unhesitatingly pronounced phlegmatic; so that, as Holmes justly re- marks, the exceptions to the rule are almost as numerous as its exemplifi- cations. It is, indeed, questionable whether there be any temperament that can be positively declared to predispose to either scrofula or tubercle, or, on the other hand, any temperament in which either or both of these diseases piny not under favoring circumstances be developed. The scrofulous diathesis may be inherited, or may be acquired by sub- jection to various sources of depression ; such as bad or insufficient food, intemperance, bad ventilation, exposure, mental anxiety, etc. Even when 1 Rurdon Sanderson looks upon tuberculous deposits as closely analogous to the "metastatic abscesses" of pyaemia. scrofula or scrofulosis. 473 not manifesting itself in the form of any particular malady, it is usually character- ized by weakness and irritability of the di- gestive system, by a feeble circulation, and by a state of general anaemia. Manifestations of Scrofula.—The mani- festations of scrofula which chiefly come under the notice of the surgeon are scro- fulous inflammation and ulceration, affect- ing the skin and mucous membranes, scro- fulous disease of the bones and joints, and cheesy degeneration of the lymphatic glands. 1. Skin.—Various cutaneous eruptions have been considered as scrofulous, but upon somewhat questionable grounds; there can be no doubt, however, that cuta- fig. 245.—Scrofulous ulcer of leg. neous ulcers are modified in their appear- (Erichsen.) ance and course by the scrofulous diathesis, the tissues around the ulcers in these cases being greatly thickened and infiltrated with serum, the granulations large and feeble, and the cicatrices, when formed, thin, weak, and liable to reulcerate (Fig. 245). 2. Mucous Membranes.—The mucous membranes, under the influence of the scrofulous diathesis, become thickened and irritable. The secretions may be thin and acrid, or sometimes mixed with pus. In the eyes there may be granular conjunctivitis, with perhaps haziness or ulceration of the cornea, and in the Schneiderian membrane, hypertrophy, giving rise to obstructed breathing and snuffling ; the antrum may swell, discharging purulent mucus into the nostrils; the tonsils are not unfrequently enlarged, and the voice rendered huskyT by relaxation or thickening of the laryngeal mucous membrane ; diarrhoea is frequent, and cystitis, urethritis, and leu- corrhoea may each in turn be due to the scrofulous diathesis. 3. Bones and Joints.—The scrofulous diathesis seems to render the bones and joints peculiarly disposed to unhealthy and destructive forms of inflammation. Thus an accident, which occurring to a healthy person would be quite trivial, may in one of a scrofulous diathesis be productive of the most serious consequences. I have known a fall on the ice, which would ordinarily have caused a mere bruise, to give rise, in a scrofulous child, to acute osteo-myelitis of the humerus, with pyarthrosis of both elbow and shoulder, amputation at the scapulo-humeral articulation being eventually required. Under the influence of scrofulosis, inflammation of hone is apt to assume the form of caries, or of caries with limited necrosis (canes necrotica), while in the joints are found the various affections popularly called "white swellings," gelatiniform degeneration of the syn- ovial membranes, ulceration of cartilages, etc. 4. Lymphatic Glands.—Perhaps the most unequivocal manifestation of scrofula is the tendency which it induces to cheesy degeneration (tyrosis) of the lymphatic glands. Indeed, Waldenburg defines scrofula as " a con- stitutional anomaly in which the lymphatic glands have an abnormal ten- dency to disease, and possess a local disposition to undergo cheesy degen- eration." Glandular enlargement, particularly in the cervical and sub- maxilliary regions, is very frequently observed in cases of scrofulosis; and, under very slight irritation, suppuration is apt to occur in the neighboring areolar tissue, the glands themselves breaking down, and mingling the caseous products of their degeneration with the surrounding pus. The abscesses thus formed are extremely indolent, not healing permanently 474 DIATHETIC DISEASES. until all the affected glandular structure has been removed, and cicatrizin" finally with depressed and disfiguring scars. 5. Other Organs are occasionally though less frequently affected by- scrofula. Among those which are most important, from a surgical point of view, may be enumerated the mammary gland and the testis. Treatment of Scrofula.—The treatment of scrofulosis should consist more in attention to hygienic rules than in the use of medicines. Good air, good food, habitual cleanliness, sufficiently warm clothing, and protec- tion from exposure or other sources of depression, are of the highest im- portance. Special attention should be given to the digestive functions, and either constipation or diarrhoea should be obviated, rather, however, by regulating the diet than by the use of drugs. Among medicines, cer- tain tonics are particularly serviceable. Cod-liver oil probably deserves the first place, the most useful articles after it being iron, quinia, and the preparations of iodine. The syrup of the iodide of iron is a very good combination, particularly for administration to children. These tonics should not, however, be given indiscriminately, and, as a rule, not while there is evidence of marked intestinal derangement. Alcoholic stimulants must be used with great moderation, and the lighter wines, or malt liquors, such as lager beer, are commonly preferable to the stronger forms of stimulus. Byr local treatment, it is doubtful whether much can be accomplished. A most important rule, and one which should constantly be borne in mind, is to take care lest by our treatment we convert this, which is essentially a chronic affection, into one which is acute. Hence in many instances the best thing for the surgeon to do is to let the part alone, merely protecting it from external injury. In other cases more active measures may be employed, though always with care and watchfulness. Scrofulous ulcers may be dressed with iodoform or iodol, and the livid, unhealthy-looking edges of the sore may be touched with the actual cautery, or even removed with the sharp spoon or knife. Lymphatic enlargements should be pro- tected by means of soap-plasters, or, if very indolent, may be submitted to gentle frictions, with moderate pressure, and the use of mildly discutient lotions. Even if abscesses form, it is better, I think, to delay opening them, as long as there is the slightest chance of absorption and spontaneous disappearance. If an opening be inevitable, it is probablyr better made with the knife than left to nature, as the resulting scar will be less disfig- uring. Any sinuses that are left may be encouraged to heal by stimu- lating injections, or by means of a seton. Repeated tappings with the hypodermic syringe, or exploring needle, are recommended by Lawson Tait and Crocq in the treatment of suppurating glands in the neck. In- jections of a ten-per-cent. solution of chloride of zinc are advised by Lanne- longue, and those of teucrin, a derivative of the Teucum scordium, by Mosetig. With regard to operations in scrofulous cases no rule of universal appli- cation can be laid down. I am decidedly of the opinion that, in the ma- jority of instances, enlarged cervical glands should not be interfered with; apart from the fact that the disease in such a case commonly extends much deeper than it appears to, these operations almost always come into the category of operations of expediency, and, as such, are only exceptionally justifiable. If an operation be decided upon, Lesser's plan of scooping out the affected glands with a sharp spoon, through a small opening, may sometimes be preferable to excision. With regard to operation for scrofu- lous bone and joint disease, the question is more doubtful. As a rule, it may be said that no operation should be performed while a rcasonahle RICKETS. 475 hope remains that a cure can be effected by expectant treatment: if, how- ever, the powers of nature should be manifestly incompetent for the' task or if (as is often the case among patients of the poorer classes) the time which would probably be required for a natural cure be an important consideration, operative measures may be properly resorted to, and will often be followed by the most gratifying results. Excision is'of course preferable to amputation, when the circumstances of the case permit a choice. Rickets. Rickets or Rachitis is a constitutional disease, occurring almost exclusively in childhood, and characterized by a peculiar lesion of the osseous system, and by a tendency to the so-called amyloid or albuminoid degeneration of certain viscera, especially the spleen and liver. Causes.—Rickets may possibly in some cases be inherited, but is, at least, much more frequently acquired, and usually results from malnutri- tion, or from other sources of constitutional depression to which children may be exposed. According to Heitzmann, rickets can be artificially pro- duced by the continued administration of lactic acid. Morbid Anatomy—The most characteristic manifestation of rickets is seen in the skeleton, and affects the long bones as well as those of the head, chest, and pelvis. The bone-changes consist essentially in increased cell-growth, with deficiency of earthy matter. The epiphyseal cartilages (cartilages of conjunction) become enlarged, giving what is often called the " double-jointed" appearance observed in these cases. The periosteum is also greatly thickened, while the osseous shaft itself undergoes softening, its lacunas being much enlarged, and filled with red, pulpy granulations! Under the influence of muscular action, or other mechanical causes, the bones undergo modifications of shape, giving rise some- times to great deformity ; if the child has begun to walk before the development of rickets, these changes will probably be most marked in the lower extremities. The cra- nial bones are often much thickened, giving a massive appearance to the head ; in other cases they are abnormally thin, or even per- forated (craniotabes), the pericranium and dura mater seeming to be in contact; the anterior fontanelle remains open longer than in health. Circumscribed swellings may occur in the frontal and parietal bones, as pointed out by Taylor, and may be mistaken for syphilitic nodes. These swellings may subsequently undergo resolution, or may remain as permanent deformities. Sub- periosteal hemorrhages in the femur and tibia have been observed by Page. The ribs bend at their junction with the costal cartilages, allowing the sternum to project, and causing the so-called " pigeon-breasted" deformity. In some cases the enlargement of the sternal extremities of the ribs gives the appearance of a deep gutter on either side of the breast-bone, the beaded enlargements of the ribs themselves receiving the name of the " rachitic Fig. 246.—Rickets in child, showing rachitic rosary. (From a patient in the Children's Hospital.) 476 DIATHETIC DISEASES. rosary" (Fig. 246). The spine is occasionally' the seat of lateral, but more often of antero-posterior curvature, the backward curve being in the dorsal, and the forward in the cervical and lumbar regions. The pelvis often becomes very oblique, in consequence of the deformity of the lower extremities, and of the " lordosis" or anterior curvature of the lumbar spine ; and serious complications may thus arise in after-life, in the process of parturition, or in operations on the pelvic organs. Symptoms and Course.—In the earlier stages of rickets, there are disorder of the digestive system and other evidences of malnutrition, but nothing that can be considered distinctive. Teething is delayed, and often accomplished with difficulty. The child sleeps badly, and is restless; sweats profusely about the head, and constantly' kicks off the bed-clothes. The muscular system is weak, and the patient, if he has already begun to walk, soon loses both the power and the disposition to do so. The urine is abundant, and usually loaded with phosphates. As the disease ad- vances, a curious state of muscular hyperaesthesia is often observed, either voluntary motion or the touch of another being attended with acute pain, and the child, as a consequence, maintaining an almost fixed position, and appearing listless and indisposed to even the slightest exertion. There is a tendency to bronchial and pulmonary inflammation, laryngismus stridulus, and cerebral irritation with convulsions. Fever is often, but by no means always, present; the appetite is capricious or wanting, and the fecal evacuations (whether there be or be not diarrhoea) are ill-formed and offensive. The liver and spleen are often enlarged, and sometimes albumin- ous or amyloid in the later stages of the affection, while the bony de- formities, which have been described, frequently persist even after the entire restoration of the general health and strength. Intelligence is diminished during the existence of the disease, but the mental powers are usually completely restored with bodily convalescence. Diagnosis and Prognosis__There are no symptoms by which, in its earliest stage, rickets can be distinguished from the other diathetic dis- eases which we have considered. In any case in which dentition is much delayed, or in which difficulty in walking is observed, the surgeon may suspect rachitis, and, by careful attention to the symptoms above described, will usually be able to recognize it if present. When the characteristic osseous changes have begun, the nature of the affection can scarcely he mistaken. The prognosis of rickets, if the disease be not too far advanced, is usually favorable ; as justly observed by Hiller, however, mortuary records recognize the secondary affections which complicate rickets, while the primary condition which renders those complications fatal is itself ignored. As a rule, it may be said that the earlier the disease appears, the less is the chance of recovery, while even in the most favorable cases the affection may last for several years. Treatment.—The hygienic management of rickets is of the greatest importance; if the disease occur during the first six or eight months of life, and the mother's milk be found either scanty or of bad quality, a healthy wet-nurse should be procured, or the natural food supplemented or replaced by fresh cow's milk, diluted with lime-water (1 part to 4); dog's milk is preferred by Bernard. After a time beef-tea may be made to alternate with the milk, and wine or brandy may be given in quantities adapted to the patient's age. The child should be warmly clothed, and kept as much as possible in the open air, and at night in a well-ventilated apartment. Warm or cold sponging, or sea-bathing, will often prove of great service. If the digestive system be much disordered, a few doses of mercury with chalk, or some similar combination, may be given, but the gonorrhoea. 477 remedies of greatest importance are tonics, especially cod-liver oil, iron, quinia, and nux-vomica. The cod-liver oil is probably the most valuable, and may be given in gradually increasing doses as the child is able to as- similate it. Withers recommends the sulpho-carbolate of lime, and Kas- sovvitz advises phosphorus. Some difference of opinion exists as to whether mechanical appliances should be used to obviate deformity in these cases. In the most acute form of rachitis, when, in the vivid language of Sir William Jenner, the child "is indeed fighting the battle of life, . . . striv- ing with all the energy it has to keep in constant action every one of its muscles of inspiration," the use of splints and bandages would be doubt- less an unnecessary annoyance; again, after the stage of bony consolida- tion has come on, splints can be of no use, and would do harm by impeding the natural motions; but, while the bones are yet soft and yielding, a great deal may often be accomplished by the use of light apparatus, to prevent if not to remedy deformity. For the lower extremities, simple wooden splints may be used, and may be made to project below the feet, so as to prevent the child from standing or walking ; while for the spine, various forms of apparatus, such as will be described in speaking of spinal curvature, may be employed. When excessive deformity of the long bones persists after consolidation has occurred, it will usually be proper to remedy it by cutting through the bone with saw or chisel (osteotomy), or by removing a wedge-shaped portion. The operations required for this purpose will be more particularly referred to in the chapter on Orthopaedic Surgery. CHAPTER XXV. VENEREAL DISEASES. Gonorrhoea and Chancroid. The term Venereal Disease is applied to certain affections which are usually acquired in sexual intercourse. There are three separate diseases which are properly described as venereal, which until within a compara- tively recent period were all confused together, and the distinction between two of which is even at the present time not recognized by a large number of surgeons. These diseases are Gonorrhoea, Chancroid, and Syphilis. The first two are strictly local, while the latter is a constitutional affection. The non-identity of gonorrhoea with the other venereal diseases, though pointed out by Balfour, B. Bell, Hernandez, and others, was not clearly established until the publication of Ricord's treatise in 1838, while the diversity of chancroid and syphilis—first clearly shown by Bassereau, in 1852—is even now denied by a few surgeons, and is practically ignored by a larger number. Gonorrhoea. Gonorrhoea, Blennorrhagia, or, as it is vulgarly called, Clap, is a virulent, contagious, muco-purulent inflammation, affecting the mucous membranes. It is chiefly seen in the generative organs, being usually met with in the male urethra and in the vulvo-vaginal canal—the glans penis and lining membrane of the prepuce, the uterus, and the female urethra being less often involved. It also occurs in the conjunctiva, and is said to nave been seen in the rectum, nose, mouth, and umbilicus. 478 VENEREAL DISEASES. Causes.—The most frequent cause of gonorrhoea is unquestionablv direct contact with the muco-pus derived from a person similarly affected, though a muco-purulent discharge, indistinguishable from gonorrhoea, may arise from contact with the vaginal secretions in cases of leucorrhoea, from contact with the menstrual fluid, or even, possibly, from intercourse be- tween healthy persons, if coitus be violent, prolonged, or attended with unusual excitement. In the immense majority of instances gonorrhoea is acquired in sexual congress, and hence is observed in the mucous mem- branes of the urino-genitary apparatus. Ophthalmic gonorrhoea, or, as it is usually called, gonorrhoeal conjunctivitis—is caused by transference of the contagious secretion from the private parts to the eye, by the patient's hand, or possibly by means of dirty towels, etc., while the rarer forms of rectal, nasal, umbilical, and buccal gonorrhoea may be similarly produced, or may be due to practices the nature of which it is not necessarv to specify. Neisser, Cheyne, Bumm, and others, believe that gonorrhoea is caused by the presence of a special microbe, the " gonococcus." This is denied, however, by DeAmicis and other careful observers, and, though probable, certainly has not been proved beyond question ; and since micro-organisms, not distinguishable from gonococci, have been found in pus which was known not to be gonorrhoeal, the conclusion of Yibertand Bordas appears to be justified, that the diagnosis of this affection by bac- teriological study cannot as \ret be made absolutely^. Gonorrhoea of Male Urethra.—I shall first describe, under this heading, the course, symptoms, and appropriate treatment of an ordinary gonorrhoeal attack, considering subsequently the various complications which may arise, and the modifications of treatment required by each. The first symptoms are usually manifested from one to five days after ex- posure to contagion, though the disease is occasionally not observed until a week, or even a fortnight, after the infecting coitus. The patient first notices an uncomfortable stinging or tickling sensation (which the French call picotement) at the urinary meatus, and, on examining the part, ob- serves the lips of the urethra slightly swollen and reddened, and moistened with a small quantity of viscid secretion. This fluid gradually increases in amount, and from being, as at first, colorless, soon becomes milkv or yel- lowish-white in appearance, and under the microscope is found to consi>t of mucus mingled with pus. In this, which is called the first or incubative stage, the inflammation is confined to the anterior portion of the urethra, and especially the part known as the fossa navicularis, but in the course of two or three days spreads backwards, and becomes much more intense. The discharge is now quite profuse, of a greenish-yellow color, somewhat thicker than at first, and occasionally streaked with blood; the urethra is tense and painful, and the whole penis—but particularly the glans—red and turgid. Urination is frequent, and attended with a good deal of irritation, or scalding (chaude-pisse), and the stream is lessened in size, on account of the swelling of the mucous membrane. If the bulbous portion of the urethra be affected, the perineum is tense and painful; while, if the prostatic portion be involved, the anus feels hot, and as if stuffed with a foreign body. If the inflammation run very high, there may be a good deal of general febrile disturbance. This, the second or acute stage of gonor- rhoea, lasts from one to three weeks, and then gradually subsides into the third or chronic stage, which, when long persistent, receives the name of Gleet or Blennorrhcea. In the third stage, the discharge diminishes m quantity and gradually loses its purulent character, while the intensity of all the symptoms, and especially of the scalding in urination, becomes markedly lessened. The inflammation lasts longest in the posterior por- GONORRHOEA OF MALE URETHRA. 479 tion of the urethra, and matter can be sometimes made to flow by pressure from behind forwards applied to the perineum, when the anterior portion of the canal has apparently quite resumed its normal condition. Gonor- rhoea, in most cases, tends to a spontaneous cure, lasting on an average from six to twelve weeks; but occasionally an intractable gleet may per- sist for many months, or even years. Under the name of Dry Clap have been described cases of gonorrhoea, in which it is said that all the symptoms were well marked, with the single exception that at no time was there any discharge. I am disposed to think, with Bumstead, that in these cases closer observation, with perhaps ex- amination of the urine, would have shown that some muco-pus was actually present. I do not believe that gonorrhoea can exist without dis- charge, though it is very possible that the amount of discharge may some- times be so slight as readily to escape detection. Diagnosis.—I do not believe that it is possible to distinguish, with ab- solute certainty, gonorrhoea caused by impure coitus from other forms of muco-purulent urethritis. It is usually said that the diagnosis can be made by observing the greater virulence of the blennorrhagic affection, and un- questionably, ordinary inflammation of the urethra rarely attains the intensity which is common in cases of gonorrhoea. Very intense muco- purulent urethritis may, however, be caused by the contact of the acrid vaginal secretions in cases of leucorrhoea, or by the contact of the men- strual fluid ; and it is believed by many authorities, that genuine gonor- rhoea is thus not unfrequently produced. 'Whether this be admitted or not; whether, that is, we believe in the existence of any special gonorrhoeal virus, microbic or otherwise, or consider, as has been done in the preceding pages, that gonorrhoea is merely a peculiarly virulent form of ordinary in- flammation, we must grant that it is often quite impossible to fix upon the exact source of the disease, in any particular instance ; and hence the prac- tical inference, that the surgeon should, in cases the history of which is not clear, exercise great caution in expressing an opinion, of the correctness of which he cannot be absolutely sure, and which may not only cause great unhappiness, but may perhaps involve some innocent person in un- merited disgrace and blame. Fortunately the question is one of theoreti- cal rather than of practical interest, for the treatment of muco-purulent urethritis is the same, no matter whence its origin. In its chronic stage, the diagnosis of gonorrhoea presents still greater difficulty, for a thin' gleety, urethral discharge may come from various sources of irritation__ being indeed a not unfrequent attendant upon the gouty, strumous, and scorbutic diatheses, or a mere secondary affection resulting from diseases of neighboring parts, such as the rectum or prostate gland. The form of urethral discharge which, as will be seen hereafter, is a manifestation of secondary syphilis, can usually be recognized by its gravish-white color, and by the absence of inflammatory symptoms. Prognosis—Though in the large majority of instances gonorrhoea proves a perfectly tractable affection, and passes off without any disagree- able consequences, cases are occasionally met with in which a troublesome gleet proves utterly rebellious to treatment, remaining as the starting-point tor an acute attack of the disease, which may be provoked by any sexual excess, indulgence in intoxicating beverages, or even imprudence of diet; in other cases gonorrhoeal inflammation gives rise to organic stricture of kidn"16 °F maj °aUSe serious and even fatal disease of the bladder and inTrerfm!nt—The treatment of gonorrhoea is principally of a local charac- ter, if the patient be seen in the first stage, before the"inflammation has 480 VENEREAL DISEASES. reached its point of greatest intensity, what is called the abortive treatment may be properly employed. The plan which I am in the habit of following is to direct urethral injections of a solution of nitrate of silver (gr. ^-fjj).1 Of this preparation from two to four fluidrachms should be carefully injected into the urethra, three, four, or five times a day, the patient taking the precaution to wash out his urethra by urination ten or fifteen minutes before each injection. The injections are best made with a small hard- rubber syringe, which is in every way preferable to the common glass syringe usually sold for the purpose. In using the syringe, the patient should gently introduce its beak as far as it will go into the urethra, the lips of which are then closely pressed against the instrument with the thumb and fingers of the left hand, while the piston is slowly driven down by the forefinger of the right hand, which holds the syringe. By this method the escape of fluid is prevented, and the whole amount is introduced into the canal; there is no risk of the injection entering the bladder, and even should it do so, no harm would result, for it would be instantly de- composed by the salts of the urine. Two syringefuls may be used on each occasion of injection, as the effect of the first is always to some extent neutralized by the mucus which lines the urethra. The first effect of these injections is apparently to aggravate the disease, the discharge becoming purulent and profuse ; in the course of a day or two, however, it again becomes thin and watery, and perhaps streaked with blood, while the con- comitant symptoms lessen in intensity ; the injections may now be used less frequently, or altogether discontinued, and very7 often no further treat- ment will be required. If, however, the discharge do not cease in a few days, mildly astringent injections may be used to complete the cure. No constitutional treatment is required during this stage, except a saline ca- thartic if there be constipation. The patient should be kept as quiet as possible, and upon rather low diet. The recumbent position should be maintained (confinement to bed is desirable, but often impracticable), and all sources of excitement, particularly of the sexual organs, carefully avoided. Some surgeons use, in this stage, very strong injections of nitrate of silver (gr. x to xx-fjj), and a very rapid cure may thus occasionally be obtained. The treatment should in such a case be conducted by the sur- geon himself, one injection being all that is usually employed. The plan which I have recommended is, I think, safer, and equally satisfactory. Hutchinson recommends as abortive treatment injection of a solution of chloride of zinc (gr. ij-foj), in conjunction with the internal use of oil of sandalwood, and of sulphate of magnesium and bromide of postassium, taken at bedtime. Von Wedekind reports several successes by the injec- tion of undiluted peroxide of hydrogen. In the second or acute stage of gonorrhoea, the precautions already re- ferred to, as to rest and quiet, are of the highest importance. After the bowels have been freely moved, the patient should be put at once upon the use of alkaline and diluent diuretics—the following combination being per- haps as suitable as any other : R. Sodii bicarbonat. 3j; Spt. aeth. nitr. fjss; Infus. lini comp. Oj. M. A wineglassful of the mixture, which is not dis- agreeable to the taste, may be taken every two or three hours—the whole pint being consumed during the day. The glans penis and prepuce should be gently freed from the discbarge as often as it accumulates, and much comfort may be derived from the local application of water as hot as can be borne. Injections are not usually available during the first twenty-four 1 Neisser declares that the remedies which most effectually destroy the gonococci, while not aggravating the existing inflammation, are nitrate of silver (gr. { or ^-f3J)i ichthyol (gr. v-f^j), and corrosive sublimate (gr. ^ or ^V"f3J)' GONORRHOEA OF MALE URETHRA. 481 hours of the acute stage, but if the meatus be not so much inflamed as to render the use of the syringe painful, anodynes1 may be thus employed with advantage—or even simple demulcents, such as thin starch—or local sedatives, such as the subnitrate of bismuth. Kiichenmeister and Jullien employ diluted lime-water. As soon as the first intensity of this stage has passed by, injections become again the most important remedies, the best articles being probably the sulphate or acetate of zinc, the acetate of lead, and, as the disease becomes chronic, the sulphate of copper, or tannic acid. The following formulas will usually be found satisfactory : R. Zinci sulphat., Plumbi acetat., aa9ij; Morphia? sulphat. gr. j-ij; Aquas fgviij M.—R. Cupri sulphat. gr. xij; Vin. opii t3j; Aquae rosae f|vj. M.—R. Ac. tannici 5j; Glycerinae fJj; Aqua? fjv. M. It is advised by Stern that urethral injections should be made with lanolin and oil of almonds instead of water. Se"e, speaks very favorably7 of injections of silicate of sodium (gr. v to xv-f'3j); while Boyland recommends salicylic acid (gr. v-fgj); Radha Nauth Roy, the sulphate of quinia (gr ij-f|j); Mannino and Rebatel, a decoction of lemons, or a solution of citric acid (gr. iij-f^j); Reverdin, one of permanganate of potassium, and Jullien, solutions of corrosive sublimate (gr. jo-f'Ij), salicylate of mercury (gr. H3J)> resorcin (gr. x-lgj), creoline (gr. v-fgj), or pyridine (gr. iss-i'3j). Eldridge advises the local use of ergotin, and Vaughan that of dermatol, while Jadassohn commends the employment of ichthyol. The application of dry powders of boric acid, bismuth, calomel, etc., is recom- mended by Pixley, Zeisler, and other surgeons. Cotes and Slater advise the application of nitrate of silver (gr. x-f^j) through the tube of an endoscope. During this stage the patient should keep the testes constantly supported with a well-fitting suspensory bandage, a precaution which seems to lessen the risk of the inflammation spreading to the epididymis. During the third stage, injections should be continued, and advantage may be sometimes derived from the use of deep injections, applied through a double catheter, or simply by using a syringe with a long nozzle. Special forms of apparatus for this purpose have been devised by various surgeons, among others.by Reliquet, Morgan, Dick, Durham, Windsor, Bumstead, Bigelow, and Hewson. Harrison advises irrigation or douch- ing of the urethra with a solution of sulpho-carbolateof zinc. H. H. Cur- tis employs, in all stages of the disease, irrigations or retrojections with large quantities of hot water. In some cases, a slight discharge will per- sist long after the subsidence of all inflammatory symptoms; for these chronic gleets, a very strong solution of tannin (3j-f3j) will sometimes be found useful; it may be used as an injection, or the preparation described in the U. S. Dispensatory as the glycerite of tannic acid may be applied on a sponge through the tube of an endoscope. This instrument, which will be again referred to, is occasionally useful in obstinate cases of gleet, by enabling the surgeon to ascertain the exact point to which local medica- tion should be applied. It will usually be found that the continuance of the discharge is due to persistence of inflammation in some of the mucous crypts or follicles which line the urethra, or to the existence of a slight stricture; in the latter case, the occasional passage of a full-sized bougie will be found of service, and this may be smeared, as suggested by Unna and Fleiner with an ointment of nitrate of silver in cocoa-butter, gr. v-xx to 3j ; J. W. Williams has devised an "irrigating sound" by which dilatation and local medication may be simultaneously effected. 1 The following formula is given by Bumstead : R. Extract, opii 9J ; Glycerinae r3J; Aquae fgiij. M. 482 VENEREAL DISEASES. During the later stages of gonorrhoea, the general condition of the patient often requires the use of tonics, with good food, and possibly malt liquors, or other forms of alcoholic stimulus. The plan of treatment sketched in the preceding pages is that which seems to me best adapted to ordinary cases of urethral gonorrhoea, and I have seldom found it necessary to resort to any other. Many surgeons place great reliance upon the internal administration of certain stimulating diuretics, especially copaiba and cubebs, which they employ to the partial or complete exclusion of the various injections which have been described. These remedies are, however, both inconvenient and disagreeable, and I believe in the large majority of cases quite unnecessary7, though they may occasionally7 prove useful in the chronic stage of the affection. They may be administered separately or together, and may be combined with alkalies, and given either in pill or as an emulsion, or with salol in gelatine capsules. The oil of sandalwood may be administered in the same way, as may methyl-blue, a remedy recommended by Adler and Einhorn. On account of the disagreeable taste and nauseating quality of copaiba, when swal- lowed, it has been proposed to use it by enema, or as an injection for the urethra. I have employed the latter plan, but without benefit, and indeed it appears that the effect of the drug can only be obtained by allowing it to pass through the kidney, and thus medicate the urine. Other modes of treatment have been used, and may occasionally be tried with advantage ; such are the application of blisters to the thigh, or even to the penis itself, painting the latter with tincture of iodine, the use of medicated bougies,1 galvanism, etc. Complications of Gonorrhoea.—The complications of gonorrhoea which require special notice are chordee, inflammatory bubo, strangury, retention of urine, hemorrhage from the urethra, perineal abscess, and epididymitis. 1. Chordee consists of a painful erection, in which the inflamed state of the urethra prevents the spongy portion from becoming elongated to the same extent as the cavernous portions of the penis. Hence the organ often presents a twisted appearance, and laceration of the lining membrane of the urethra, or of its submucous tissue, may take place, giving rise to hemorrhage, or laying the foundation for the development of stricture. The treatment consists in the use of camphor and opium by the mouth, or as a suppository, in the application of an ice-bag to the perineum, in in- unction of that part with belladonna ointment, or, as suggested by Otis, in the application of dry cold to the penis by Petitgand's method of " mediate irrigation" (p. 56). Inhalations of amyl nitrite have afforded relief in some cases. 2. Bubo.—The inguinal lymphatic glands occasionally become inflamed in cases of gonorrhoea, constituting the sympathetic or inflammatory bubo. The treatment consists in endeavoring to promote resolution by the appli- cation of blisters, or of the tincture of iodine around but not over the gland ; if suppuration occur, the pus should be evacuated through a small incision made in the direction of the long axis of the body, and the after- treatment should be conducted as in a case of ordinary abscess. 3. Strangury and Vesical Irritation may arise from inflammation of the prostate, of the seminal vesicles, or of the neck of the bladder; or, at a late stage, apparently from an atonic state of the part; the treatment consists in the use of warm fomentations and hip-baths, with anodynes, 1 Bongies, or urethral suppositories, containing iodoform and the oil of eucalyptus, are recommended by Cheyne. COMPLICATIONS OF GONORRHOEA. 483 such as Dover's powder, or the tincture of hyoscyamus. The introduction of lumps of ice into the rectum is highly commended by Horand. When of the atonic form, advantage may be derived from the use of the mineral tonics. 4. Retention of Urine, if dependent upon spasm or inflammatory swell- ing, should be treated by the use of the warm bath, with full doses of opium, and perhaps leeches to the perineum, catheterization being avoided if possible. If an instrument be required, a large flexible catheter should be used without the stylet. If the retention arise from prostatic or perineal abscess, or from stricture, other measures may be required, which will be described in the proper place. 5. Urethral Hemorrhage may occur in the form of capillary oozing, or may result from rupture or laceration of large vessels, as a consequence of chordee, or of attempts at catheterization. The treatment consists in the local use of cold, or in pressure, applied by introducing a full-sized catheter and strapping the penis to the instrument. 6. Perineal Abscess may occur as a complication of gonorrhoea, and be- side causing great suffering, may give rise to retention of urine; the treat- ment consists in the use of poultices or warm fomentations, with an earlv incision in the median line, so as to prevent, if possible, the abscess from opening into the urethra—an occurrence which would almost certainly be followed by the formation of a perineal fistula. An early incision is also required in the rare case of an Urethral Abscess appear- ing in front of the scrotum. 1. Epididymitis, Hernia Humoralis, or Swelled Testicle, is one of the most important complications of gonorrhoea, rarely occurring before the third, and usually as late as the sixth week of the disease. From the fact that it commonly appears as the discharge from the urethra is diminishing, it was formerly consid- ered a sympathetic or metastatic affec- tion ; but it is now pretty well established that it is merely the result of the exten- sion of inflammation from the prostatic portion of the urethra, through the ejacu- latory ducts and vas deferens, to the epididymis, and more rarely to the tes- tis itself. The left side is more often affected than the right, probablv because, as usually hanging lower in the scrotum, the left testicle is natu- rally less well supported by that structure; both testes are occasionally involved, rarely at the same time, but more often in succession or alter- nately. The symptoms are those of acute inflammation in any tense struc- ture, great pain and tenderness, especially over the region of the globus minor and marked swelling, which is, however, chiefly due to effusion into the tunica vaginalis (acute hydrocele). The diagnosis from orchitis, or innammation of the testis proper, can only be made by noting the mstory of the case, and by observing the localization of the svmptoms to inei region of the epididymis. Epididymitis affecting an undescended testicle, or one retained in the inguinal canal, may be mistaken for inflam- mation of a lymphatic gland, or for strangulated hernia; but the true "aiure of the case, under such circumstances, will be at once suspected, if, Fig. 247 -Gonorrhoeal epididymitis. (Liston.) 484 VENEREAL DISEASES. on examining the scrotum, the testis be found absent from its place. The prognosis of swelled testicle is always favorable, but the globus minor may become permanently7 obliterated by the inflammation, and, if this should occur on both sides, the patient would, of course, be rendered impotent. The treatment which I have for many years employed for this affection, when seen in the acute stage, is that which was suggested by Petit, and recommended by Vidal (de Cassis), and which has been since revived by H. Smith. It consists in making a puncture or limited incision into the inflamed organ at its most tender part, with a sharp and narrow straight bistoury ; a few drops of blood follow the withdrawal of the knife, and the pain is almost instantaneously relieved, the tenderness quite or almost disappearing within twenty-four or forty-eight hours. The patient is con- fined to bed for a few days with the scrotum supported on a pillow, and covered with a cloth dipped in cold water, or in lead-water and laudanum. The use of urethral injections should be temporarily discontinued, and may be resumed, if necessary, when the acute symptoms have subsided. Iodine ointment, or some similar sorbefacient, may be used to remove the induration of the globus minor, which often remains after all tenderness has disappeared. This mode of treatment has proved in my hands per- fectly satisfactory, the patient being at once relieved, and resolution following without any unfavorable occurrence. Several cases have, how- ever, been recorded by Demarquay and Salleron, in which hernia and complete extrusion of the seminiferous tubules followed the incision, the patient being thus effectually castrated on the affected side; the incision is said, in Salleron's case, not to have exceeded one centimetre in length— about four-tenths of an inch. On the other hand may be placed the re- markable success obtained by Vidal and Smith, the former surgeon having punctured four hundred testes, without one bad result, while the latter de- clares that the method has served him well in five hundred cases. To guard against the accident which occurred to Demarquay and Salleron, it would be prudent, however, to limit the incision to one not exceeding a quarter of an inch in length. This little operation appears to act by re- lieving the tension due to the want of expansibility of the tunica albuginea; it is therapeutically analogous to the incisions practised in cases of paro- nychia, and, in the words of Mr. Hutchinson, "appears to relieve pain much with the same certainty that iridectomy does in acute glaucoma." Other modes of treatment have been recommended for epididymitis, among which may be mentioned Velpeau's plan of making numerou.- punctures of the tunica vaginalis with the point of a lancet; Fricke's method of strapping the testicle with adhesive plaster (very painful during the acute stage);' the application of ice, as advised by Borgioni, of iodoform ointment, as practised by Alvares, or of subnitrate of bismuth in the form of a paste, as recommended by Comingor; Langlebert's method of sur- rounding the scrotum with wadding and India-rubber cloth, and applying a suspensory bandage; and the plan recommended by Rouse, who relies chiefly upon the administration of opium, in doses of a grain, night and morning. The plan formerly advised in most text-books, and still favored by many surgeons, consists essentially in local bleeding and the free use of tartar emetic and calomel—in the adoption, in fact, of a decidedly "anti- phlogistic" course of treatment. Among the rarer complications of gonorrhoea must be mentioned perito- 1 Hawes and T. R. Chambers have devised ingenious means of applying elastic pressure by India-rubber bags, which are inflated after adjustment. GONORRHOEA OF THE FEMALE GENITAL ORGANS. 485 nitis and subperitoneal abscess, due, according to Faucon, to irritation transmitted from the vas deferens, seminal vesicles, prostate, bladder ureters, or kidneys. Spermato-cystitis, or inflammation of the seminal vesicles, is said by F. B. Robinson to be a frequent sequel of gonorrhoea. Balano-posthitis, or External Gonorrhoea, is the name given to inflammation of the prepuce and glans penis. When confined to the latter, it is called balanitis, and when limited to the former, posthitis. This affection is usually due to exposure in coitus, but may result from the irritation caused by the accumulation of smegma, in cases of phimosis, or in persons who neglect ablution. It is chiefly seen in those whose prepuce is elongated, and may be very generally prevented by the practice of circumcision, the covering of the glans losing the character of mucous membrane after this operation, and becoming assimilated to skin. The symptoms are those of ordinary muco-purulent inflammation, and the affection is often accompanied with a temporary phimosis. The treatment consists in the application to the inflamed surfaces of the solid stick of nitrate of silver, or in packing the preputial fold with lint dipped in a solution of the same salt Qj-f 3j), the whole penis being then surrounded with an evaporating lotion. If phimosis exist, it may be necessary to relieve this by an operation which will be described in another portion of the volume. An erosive circinate form of balanitis is described bv Berdal and Bataille as due to the presence of a microbe. The disease is contagious, and is best treated by the application of silver nitrate, carbolic acid, or corrosive sublimate. Gonorrhoea of the Female Generative Organs is usually lim- ited to the vulvo-vaginal canal, though the urethra is occasionally affected, as are likewise the lining membranes of the uterus and Fallopian tubes'. The ovaries may be secondarily inflamed (furnishing a pathological analogy to the swelled testicle of the male), or peritonitis may ensue from the escape of gonorrhoeal matter into the cavity of the abdomen. The symp- toms are those of acute inflammation, attended with profuse muco-purulent discharge. The diagnosis from leucorrhoea and from ordinary vulvovagi- nitis, is often difficult, and occasionally impossible. Leucorrhoea usually proceeds chiefly from the womb, while gonorrhoea affects principally the exterior parts, but these positions may be occasionally reversed. Muco- purulent vulvo-vaginitis may, as is well known, result from various causes independently of contagion, such as exposure to cold and moisture, the presence of ascarides, external violence, masturbation, or immoderate coitus. Hence, the surgeon should be very cautious in pronouncing an opinion as to the nature of a suspicious discharge in a woman, andpar- ticularly in a female child, as vaginal discharges in children are not unfre- quently made the ground of criminal accusations against totally innocent persons. Even the implication of the urethra is not positive, though it is certainly prima-facie, evidence of the inflammation being the result of impure contact. The treatment of gonorrhoea, in the female, should, during the acute stage, be limited to the use of laxatives and diaphoretics, with warm hip- baths and emollient fomentations to the external parts. In the subacute stage, astringent injections (especially of alum or sulphate of zinc) may be used, the patient applying them herself by means of a self-injecting enema apparatus (in quantities of not less than a pint), or the surgeon making the application through a speculum. In either case the patient should be recumbent, with the hips somewhat elevated. After the use of an injection, it is well to keep the inflamed surfaces apart by introducing a strip of lint, or a small tampon, dipped in the astringent solution. Another 486 VENEREAL DISEASES. plan, proposed by Simpson, is to introduce medicated pessaries, or vaginal suppositories. Vaginal poultices are employed by Fournier. When the urethra is affected, injections mav, if thought proper, be employed as in the male, or copaiba and cubebs may be administered internally. The in- flammation may persist in the vulvo-vaginal ducts and Cowper's glands long after apparent recovery. Bubo rarely follows gonorrhoea in the female, but, when met with, should be treated as in the male. Ophthalmic Gonorrhoea, or, as it is usually called, Gonorrhoeal Ophthalmia or Conjunctivitis, is produced by direct inoculation of the palpebral or conjunctival mucous membrane with gonorrhoeal matter, and must not be confounded with a form of ophthalmia principally affecting the sclerotic, which is dependent upon what will be presently described as gonorrhoeal rheumatism. Ophthalmic gonorrhoea usually affects but one eye, more frequently the right, and runs a very rapid course, ending, if not checked, in destruction of the organ. It is more frequent in men than in women, and is believed by some writers to accompany only cases of urethral gonorrhoea. The symjytoms are first manifested in from six to eighteen hours after inocula- tion. The discharge, at first thin, soon becomes thick, purulent, and pro- fuse. The conjunctiva is the seat of great chemosis, rising above and partially overlapping the cornea, while the eyelids swell and often com- pletely close the eye. The cornea soon becomes hazy, ulceration occurs (usually near the margin), perforation follows, with perhaps prolapse of the iris and consequent staphyloma, or the whole cornea may slough, in which case the eye is of course irretrievably lost. The treatment must be both constitutional and local: the practice of depletion which was formerly common in these cases, is now generally abandoned, it being recognized that the disease is invariably one of depres- sion. The bowels having been relieved by a laxative, the patient should be at once put upon the use of quinia, with or without the mineral acids, and should take concentrated food in the form of beef-essence, with alco- holic stimulus, if required. The local treatment is of the highest impor- tance. The sound eye should be protected by the application of a compress of charpie, held in place by a disk of adhesive plaster covered with collo- dion, or by the use of an ingenious bandage devised by Buller, which con- sists of a square piece of Mackintosh fitted with a watch-glass, and fastened by adhesive plaster, great care being taken that the discharge does not obtain entrance beneath the shield. If there be much chemosis, radiating incisions through the swollen conjunctiva may be practised, as recommended by Tyrrell, and in the earliest stages, before the use of caustics is permissible, iced compresses dipped in an aseptic solution, or Leiter's tubes (page 56), should be applied to the swollen lids, while the conjunctival cul-de-sac should be frequently cleansed with a saturated solution of boracic acid, or a solu- tion of bichloride of mercury (1-8000). When the secretion becomes thick and purulent, and the conjunctiva assumes a velvety aspect, a strong solu- tion of nitrate of silver (gr. xv or xx-f^j) should be freely painted with a camel's-hair brush over the inflamed surfaces, and allowed to remain a few seconds until the part is whitened, when the surplus should be washed off with a gentle stream of tepid or cool water, or neutralized with a solution of common salt. This application may be repeated once or twice a day, according to the severity of the case. The accumulating discbarge must be very frequently washed away, preferably with the boric or corrosive sublimate lotion, though many surgeons have employed with satisfaction solutions of sulphate or chloride of zinc, alum, carbolic acid, or cyanide of mercury (1-1500), aqua chlorinata, the trichloride of iodine, or copious GONORRHOEA AFFECTING THE NOSE, ETC. 487 irrigations of permanganate of potassium, applied with a syringe, or with an irrigation apparatus, a good form of which has been described by Mr. Edgar Browne and Mr. Collins. The lids should be anointed with pure vaseline and the drug freely applied to the conjunctival cul-de-sac after each cleansing. Free and, if necessary, repeated division of the external canthus, so as to relieve the eye from pressure, is recommended by Van Buren and Keyes, while Critchett went further, and in a bad case divided the upper lid as far as the margin of the eyebrow, separating the flaps thus made, and keeping them apart wMth sutures attached to the brow during the whole course of treatment, the lid being subsequently restored bv a plastic operation. If ulceration of the cornea occur, instillations of atropia should be resorted to, so as to prevent, if possible, prolapse of the iris. Under similar circumstances some surgeons prefer the use of eserine ; if perforation has actually occurred, and prolapse of the iris has taken place, the alternate use of eserine or pilocarpine, and atropia, may effect reduc- tion, but the ordinary operations for recent hernia of the iris are not per- missible at this stage. Cold applications may be employed throughout the duration of the disease, if agreeable to the patient, although hot com- presses often answer a useful purpose, especially if the vitality of the cornea be threatened by the pressure of the surrounding exudations. Opium may be given in full doses to relieve pain. Figs. 248 and 249.—Ophthalmic gonorrhoea. (Daleymple.) As the severity of the inflammation subsides, the application of the strong solution of nitrate of silver may be stopped, the use of the milder remedies being continued until convalescence is established. Agranular condition of the lids is sometimes left, requiring the occasional application of the sulphate of copper in substance. Counter-irritation, by blisters or tincture of iodine, applied in the form of a horseshoe to the brow and temple, has been highly recommended in cases of ophthalmic gonorrhoea by Furneaux Jordan. In the earlier stages of the affection, the application of a few leeches to the temple will often afford relief. Gonorrhoea affecting the Nose, Mouth, Rectum, or Umbili- cus, presents no features of special interest; in each locality it requires �0936057 488 VENEREAL DISEASES. the use of emollient applications during the acute stage, and of stimulating astringents at a later period. Rosinsky has observed a number of cases of buccal gonorrhoea in new-born infants, infected by the maternal passages during parturition. Rectal gonorrhoea may prove an occasional cause of organic stricture of that portion of the alimentary canal. Gonorrhoeal Rheumatism is a sequence of gonorrhoea which is almost exclusively confined to the male sex, and which, in the rare instances in which it is seen in women, seems to be dependent upon implication of the urethra in the gonorrhoeal affection, never occurring, according to Cul- lerier, in cases of simple vaginal gonorrhoea. It is, in fact, a variety of urethral fever, and is probably due to the absorption of septic material generated in the muco-purulent secretion of urethritis, being thus (as has already been remarked) a mild form of pyaemia. It has been objected, by some, to this explanation, that, if pyaemic, the disease should arise equally from vaginal as from urethral gonorrhoea, and it has been maintained that its invariable urethral origin indicates a peculiar sympathetic connection between the urinary canal and the articulations, and that the affection must therefore be considered metastatic. Other writers have regarded the connection as accidental, and have taught that a rheumatic diathesis is a necessary antecedent; while others, again, have looked upon the rheumatic manifestations as indicating the essential identity of gonorrhoea and syph- ilis. It is well established, however, that, in very many cases, no antece- dent rheumatic diathesis can be traced; while, apart from the total want of resemblance between this affection and constitutional syphilis, and the fact that the latter does, and that this does not, arise from vaginal infec- tion, the absolute diversity of the disease has been so clearly established by the unerring test of inoculation, as to render the suggestion of their identity scarcely worthy of consideration. The notion of metastasis is dis- proved by the fact that the urethral discharge does not usually disappear, but is rather increased, upon the development of the rheumatic symptoms, while the anatomical differences in the structure of the urethral and vaginal mucous and submucous tissues are quite sufficient to account for the oc- currence of septic absorption from one and not from the other. Gonorrhoeal rheumatism affects principally the joints (particularly the knee and ankle), the synovial bursas, the muscles and tendons, and the sclerotic coat of the eye, from which, however, it may extend to the con- junctiva, or to the iris and cornea. The articular symptoms resemble those of rheumatoid arthritis, rather than those of acute rheumatism, the disease not tending to attack many joints in succession, and being very rarely accompanied with cardiac complications, though blennorrhagic en- docarditis is described by Lacassagne, De"suos, Marty, Baudin, Railton, Derignac and Moussons, and Cianciosi. The joints are painful and swol- len, and occasionally reddened; the inflammation rarely ends in suppura- tion, but not unfrequently in false anchylosis. The muscular affection is principally manifested in the fleshy parts of the thigh and arm, and in the soles of the feet. Gonorrhoeal Rheumatic Ophthalmia is attended with pain, dimness of vision, photophobia, and lachrymation ; if the conjunctiva be much involved, there may be a muco-purulent discharge, but there is not much chemosis, and the cornea very rarely ulcerates. Various authors have looked upon this as a definite form of conjunctivitis, accompanying gonorrhoea and depending upon an exacerbation of the rheumatic diathesis produced by the primary disease. Gonorrhoeal Iritis may result in adhe- sion to the capsule of the lens, and permanent impairment of vision. It is a rare form of the disease, and does not actually accompany the attack of gonorrhoea, but follows a rheumatic arthritis, usually of the knee. Peri- CHANCROID. 489 carditis and Endocarditis are occasional complications of gonorrhoeal rheumatism, and sometimes follow gonorrhoea without the occurrence of other rheumatic symptoms. According to Marty, the aortic are more often •affected than the mitral valves. Sde has met with two cases of gonor- rhoeal pleurisy. The treatment of the articular affection is best conducted by the use of repeated blisters and by the internal administration of anodynes, with or without quinia, according to the constitutional condition of the patient; in the later stages, compression by means of adhesive strips may be em- ployed with advantage. If suppuration be imminent, the intra-articular fluid may be withdrawn by means of a capillary trocar and aspirator, as advised by Laboulhene. The iodide of potassium is particularly adapted to those cases in which the muscular and fibrous structures are affected, and may be given in large doses. The same remedy may be employed in the ophthalmic variety of the disease and may be supplemented by the oil of turpentine, in drachm doses, if the iris be involved ; in the latter case in- stillations of atropia should also be practised, while astringent collyria may be required ifthere be much conjunctivitis. Counter-irritation, by blisters or iodine, may be applied to the temples, if thought necessary, or a more permanent effect may be produced, as suggested by Thomson, by applying the mouth of a bottle containing a small quantity of bromine—a brief con- tact with the vapor of this powerful agent sufficing to produce an eschar which will continue for several weeks. Chancroid. The Chancroid, or Simple Venereal Ulcer (often called Soft, or Non-infecting Chancre), is a strictly local infection, resulting from contact with the secretion from a similar sore in the same or another per- son.1 It is usually acquired in impure coitus, but may be mediately trans- mitted by means of towels, etc. Surgeons, or accoucheurs, are occasionally infected in the discharge of their professional duties, particularly if they happen to have abrasions on the fingers at the moment of exposure. Fin- ger, Ducrey, Unna, and Krefting believe that they have isolated a special bacillus, which they consider to be the cause of chancroid. Locality—Any part of the body may be the seat of chancroid, though the most usual position is, of course, the generative organs—in the male about the preputial fold, corona glandis, fradnum, and urinary meatus, and, in the female, about the nymphae, or os uteri. It was formerly supposed that the cephalic region was insusceptible to this affection, but it is now known that the chancroid can readily be artificially inoculated upon the face, and at least seven cases (Puche, Profeta, Diday, Labarthe, R. W. Taylor, Venot—two cases) are on record, in which a cephalic chancroid resulted from the ordinary mode of contagion. Course—The chancroid has no period of incubation, the varying inter- vals between exposure and the appearance of the sore depending upon whether the contagious matter is deposited upon an abraded, a delicate and soft, or a thick and callous surface. When artificially inoculated, the first symptoms appear within a few hours, the inoculated point becoming ele- 1 Kaposi, Bumstead, R. W. Taylor, and some other writers have taught that chan- croid results from the inoculation of pus from any source, as from acne, the pus- tules of scabies, etc. This view has always seemed to me to lack confirmation, and is certainly contrary to anything that I have observed in my own practice. It will, ot course, be effectually disproved if the discovery of the chancroid bacillus shall be confirmed. 490 VENEREAL DISEASES. vated and surrounded with a red areola, in the course of the second or third day". The papule thus formed in another day becomes a vesicle, and sub- sequently a pustule, which either bursts, exposing the chancroidal ulcer or dries into a scab beneath which the ulceration progresses. If the chan- croidal matter be deposited in an abrasion, the ulcerative stage may beg-in at once. The fully formed chancroid is thus usually developed from four to six days after exposure,1 and appears as a round ulcer, from a line to half an inch in diameter, unadherent to the subjacent tissues, with sharp. cutedge*, as if punched out of the skin, covered with an adherent gray slough, furnishing pus which is auto-inoculable,2 and at first surrounded with a reddish areola. It is commonly multiple, eighty per cent, of affected persons having, according to Fournier's observations, from two to six sores each. The chancroid may present, at its base, a slight degree of hardness, which is the result of inflammatory action, but which must not be mistaken for the induration commonly observed in the true chancre, or initial lesion of syphilis. According to Balzer, microscopic examination always shows the presence of elastic fibres in chancroids, mingled with pus corpuscles and epithelial cells. Bubo.—The chancroid is not unfrequently followed by swelling of the inguinal glands, or bubo, which may come on at an early period, but from the risk of which the patient is never free as long as the chancroidal ulceration continues: Puche met with it three years after infection.8 The bubo which follows chancroid may be of the simple inflammatory variety, such as is seen in cases of gonorrhoea, or after injury ; or may be the result of direct absorption of chancroidal pus, in which case it receives the name of virulent or chanc?-oidal bubo. The chancroidal bubo is usually mono- lateral, and commonly on the same side as the sore from which it origi- nates, though it is occasionally seen on the opposite side, as the result of the interlacement of the lymphatics on the dorsum of the penis. It affects only the superficial glands, and only one at a time; hence, it is said to be monoganglionic. The chancroidal bubo invariably tends to suppuration, the resulting ulcer being precisely analogous to the original chancroid, and furnishing a contagious and auto-inoculable pus. Sometimes suppuration occurs first in the areolar tissue around the affected lymphatic gland, when the abscess will not assume the chancroidal character until disintegration of the gland itself has begun. The chancroid and chancroidal bubo have little or no tendency to a spontaneous cure. While one ulcer is healing, others may be produced by auto-inoculation, and fresh glands involved by absorption, the disease, perhaps, begun thus prolonged until the patient is carried off by some intercurrent affection, or dies utterly worn out by sup- puration and long-continued suffering. Complications.—A chancroid may be complicated by the existence of warts or vegetations (which are by no means necessarily of a venereal origin); by inflammation of the penis and prepuce, which may lead to phimosis or paraphimosis, or to gangrene of the prepuce; by the coexist- ence of gonorrhoea or of syphilis; and by phagedaenic or serpiginous ulceration. Phagedaenic Ulceration is a very serious complication, and is apparently 1 F. N. Otis, however, records a case in which the chancroid did not appear until the tenth, and was not fully formed until the thirteenth day. 2 That is, which can, by inoculation, produce in the same person a sore of the same nature as that from which it was derived. 8 According to Horteloup, chancroidal pus may be absorbed and remain latent in a lymphatic gland for many months, finally causing a true chancroidal bubo long after the original chancroid has been completely healed. TREATMENT OF CHANCROID. 491 due more to the constitutional condition of the patient than to any pecu- liar virulence of the source of contagion ; it is, in other words, not a distinct variety of chancroid, but a complication which may affect any simple venereal sore. Its occurrence is sometimes traceable to distinct sources of depression, such as intemperate habits, the previous existence of syphilis, or the abuse of mercury. The phagedaenic chancroid is attended with wide and deep erosion of tissue, a considerable portion of the head of the penis being occasionally eaten away in the course of a few hours, and the disease sometimes not being arrested until almost the whole organ has perished. The ulcer is usually covered with a yellowish-gray, pultaceous slough, the appearance of which is compared by Barton to that of melted tallow, though the slough may in other cases be blackened by exposure. Phage- denic ulceration may attack a chancroidal bubo, and death may result under such circumstances either from exhaustion or from hemorrhage__byT the giving way of the femoral artery—as happened in a case recorded by Sir A. Cooper. Serpiginous Chancroid.—The serpiginous or creeping chancroid differs from the preceding, chiefly in pursuing an extremely chronic course. This complication, which is fortunately rare, is exceedingly intractable, occa- sionally persisting for many years. It usually occurs in the groin, attack- ing, perhaps, an open chancroidal bubo, and slowly creeps onwards, eroding the adjoining skin at one part, while a thin blue or violet cicatrix forms at the opposite side of the ulcer It is chiefly seen in persons whose consti- tutions have been undermined by long-continued want and neglect. Diagnosis.—From herpetic or aphthous eruptions on the prepuce or glans penis, and from excoriations from mechanical causes, the chancroid may be ordinarily distinguished by the fact that the former make their appearance almost immediately after the suspicious connection, while the latter is not usually fully developed before the fourth day. In some in- stances, however, the diagnosis is extremely difficult, though it may be determined by observing the further progress of the affection, or by inocu- lation, which, in the case of herpes, etc., will give a purely negative result. If the chancroid be situated within the urethra, it may simulate gonorrhoea ; if within the cervix uteri, leucorrhoea; and if on the glans, and compli- cated with phimosis, balanitis Here, again, to ascertain the nature of the affection, it may sometimes be necessary to resort to inoculation, which proceeding, if the affection be chancroidal, will result in the formation of a chancroid, but in the case of gonorrhoea, etc., will result merely negatively. The diagnosis from chancre, or the initial lesion of syphilis/will be con- sidered when we come to speak of that affection. All of these diseases may exist together, and it thus sometimes happens that the same woman may infect three persons differently, according to their several susceptibilities, giving to one gonorrhoea, to another chancroid, and to a third syphilis. Prognosis—The prognosis of a case of uncomplicated chancroid, if this be properly treated, is always favorable; the phagedaenic chancroid is a more serious affection, frequently entailing considerable loss of substance, though rarely endangering life, unless neglected ; the serpiginous chancroid is the most intractable form of the affection, and the surgeon should be very guarded in his prognosis of a case of this kind, as, though not in itself attended by any particular risk to life, it often persists for years, in spite ot the most judicious treatment. Treatment—I shall first describe the treatment of the ordinary chan- croid, or simple venereal ulcer, indicating subsequently the modifications required by the various complications of the disease. In the first place, it is to be observed that, as the chancroid is a strictly local affection, it re- 492 VENEREAL DISEASES. quires, in itself, merely topical treatment. If any constitutional remedies are to be employed in a case of chancroid, they are only such as are indi- cated by the patient's general condition, without regard to the particular disease with which he is affected. The first object to be accomplished, as soon as the surgeon has made up his mind that he has to deal with a chancroid, is to apply some agent which will entirely destroy the whole surface of the ulcer, thus removing at once the tendency of the disease to spread, and converting the sore into a healthy granulating surface.1 To do this, various forms of caustic may be employed, the best, in my judg- ment, being the strong nitric acid. The surface of the sore having been carefully dried with lint, the acid is applied on the end of a piece of soft wood, well rounded and smoothed (this is better than a camel's-bair brush), in such a way as to reach every portion of the ulcer. Every cranny and crack should be penetrated, as any portion of the chancroidal surface which escapes will inoculate the whole ulcer. After the acid has remained a few moments, it mav be washed off with a stream of cool water. The effect of the application is to convert the whole surface into a slough, upon the detachment of wThich a healthy ulcer is left, which rapidly fills up and be- comes cicatrized, the pus, however, retaining its contagious character until the ulcer is almost, if not until it is quite, healed. If there be a number of chancroids, or if the surface to be cauterized be very extensive, it may be necessary to resort to anaesthesia before applying the acid, or, as has been recently suggested, a preliminary application of carbolic acid may he made, so as to utilize the local anaesthetic power of this agent One ap- plication of nitric acid, if thorough, is sufficient; but it occasionally happens that, in spite of the surgeon's care, some portion of the ulcer escapes, when the cauterization must be subsequently repeated once or oftener. After the cauterization, water-dressing or lime-water may be applied until after the separation of the sloughs, when the remaining ulcer should be treated upon general principles. Black wash (calomel 3j, lime-water Oj) answers a very good purpose as a stimulating astringent, but has no specific virtue. A solution of salicylic acid is recommended by Boyland and Autier. Iodo- form, in powder, in the form of ointment (gr. xv to xxx-^j), or in solution with glycerin and alcohol (iodoform 9'iss, glycerin f 3 vj, alcohol f 3ij), is an excellent application, which has been particularly recommended by Izard and by Damon. The solution may be employed as long as there is profuse suppuration, wrhile the powder and ointment are particularly useful in a later stage of the affection. Resorcin, applied as a powder or in a watery solution (1-4), has been successfully employed by Leblond and Fissiaux, and has the advantage over iodoform of not possessing its penetrating odor. Iodol and europhen may also be used as substitutes for iodoform, the latter, besides being unobjectionable as regards odor, being so light that its " covering power" is very great. Chancroid in the Female should be treated in the same way, the acid being carefully applied in these cases through a suitable speculum; black- wash may be used as an after-dressing, or the aromilic wine2 which is a more elegant though somewhat expensive preparation. If the chancroid be seated in the male urethra, at such a point that it cannot be seen by separating the lips of the meatus, it may be touched through the tube of 1 The fact that mild chancroids may sometimes heal under iodoform dressings, with- out the use of caustics, does not invalidate the truth of the doctrine that thorough cauterizatioa is the safest remedy. 1 The following formula is taken from Bumstead : Claret wine, Compound spirit of lavender, of each f^v ; Tinctureof opium fgss ; Water f Jiijss ; Tannin 3J-3J- Mix" To be diluted if necessary. TREATMENT OF CHANCROID. 493 an endoscope with a strong solution of nitrate of silver (3ss-fjj) • the use of nitric acid in this situation is undesirable, on account of the risk of a stricture following its caustic action. Chancroids on surfaces which are ordinarily in contact, as the glans and lining membrane of the prepuce, or the inner surfaces of the nympbae, should after cauterization be kept apart by the interposition of a fold of lint, dipped in black-wash or other astringent lotion. Treatment of Bubo.—In the treatment of a bubo occurring after a chan- croid, as it is impossible in the first instance to determine whether it be really a chancroidal, or merely an inflammatory, bubo, an effort should be made to promote resolution by the use of blisters, iodine, or iodoform, which may be conveniently applied in the form of an ointment (gr. xxx-^j).'1 If, however, suppuration have evidently occurred, and particularly if the integument be thin and discolored, it is better to make a free opening (by an incision in the direction of the long axis of the patient's body), so as to evacuate the contents of the abscess, and the ulcer which remains, if it assume the chancroidal character, must then be treated as the original sore. Some surgeons prefer to open a chancroidal bubo with caustic potassa, but I do not see that this agent is in any way preferable to the knife, while it is certainly more painful. It sometimes happens that, when the pus is evacuated from a chancroidal bubo, an enlarged lymphatic gland is found, more or less dissected from the surrounding tissue, and projecting through the lips of the incision ; this gland is filled with chancroidal matter, and as long as it remains will keep up the specific nature of the sore ; and though it will in time undergo spontaneous disintegration, other glands will by that time have been infected, and the disease will thus be perpetuated. Such a chancroidal lymphatic gland should therefore be removed ; this may be accomplished by repeated applications of caustic, but is much more conveniently effected by enucleation, which consists simply in seizing the gland with forceps, and dissecting it from its attachments. Before proceeding to cauterize an opened chancroidal bubo, the patient should be thoroughly anaesthetized, as the operation is usually both tedious and painful. The first step consists in tracing out and slitting up every sinus that can be detected, with a grooved director and probe-pointed bis- toury ; the flaps of undermined and unhealthy-looking integument are next to be clipped away with scissors, enlarged glands to be carefully enucle- ated, and finally the strong nitric acid to be thoroughly applied "to every portion of the surface, and even a short distance beyond the incisions, with the same precautions as in the cauterization of the original chancroid. A large slough is thus formed, the detachment of which is the work of some time; water-dressing may be applied after the cauterization, the subsequent treatment being conducted on general principles. The management of a chancroidal bubo is thus seen to be a much more serious affair than that of the chancroid itself; hence the importance of prompt and effectual treat- ment of the original sore that absorption may, if possible, be prevented. Warts—The treatment of venereal warts "does not differ from that of vegetations on the generative organs arising from other causes, and will be described in a subsequent chapter. Phimosis—A troublesome complication of chancroid on the prepuce or glans penis, is phimosis, which may be congenital, or the result of inflam- matory action. A great objection to any cutting operation, in these cases, is that the cut edges themselves will almost certainly be inoculated with the chancroidal virus; hence, if the phimosis be the result of inflammation, K. Taylor recommends interstitial injections of carbolic acid (gr. iv-fgj). 494 VENEREAL DISEASES. it is better to attempt to subdue this by the use of cold washes, and by the injection of detergent lotions beneath the prepuce, when it will often be possible to draw back the latter and make the necessary applications to the glans. Another plan, which may be occasionally useful, is to pack the preputial fold with lint saturated with a solution of nitrate of .-ilver, as recommended in cases of balanitis. If the phimosis do not yield, or if it be congenital, it will probably be necessary to slit up the prepuce, or, if the chancroid be seated near the orifice of the latter, to perform circum- cision ; if the cut edges in either case become inoculated, they must be freely cauterized with nitric acid. Paraphimosis occurs as the consequence of the patient drawing backthe prepuce and then being unable to return it; the necessary applications having been made to the chancroid, the prepuce may be restored to its place by the manipulation which will be described in the chapter on Dis- eases of the Generative Organs ; the after-treatment consists in the use of cooling applications to relieve inflammation of the part. Gangrene of the Prepuce is an occasional result of inflammatory phi- mosis, and is a very serious complication of chancroid. If, in any case of phimosis, the foreskin become much swollen, and of a dark-red or purple hue, the surgeon may fear the occurrence of gangrene, and should lose no time in relieving the tension of the part by freely slitting up the constrict- ing prepuce. If gangrene, however, have actually occurred, the surgeon's efforts must be chiefly directed to limiting its extension by the use of fer- menting poultices and detergent injections, and by the internal administra- tion of opium. Hemorrhage, occurring during the separation of the .-dough, may be checked by the use of the actual cautery. The patient may escape with the loss of a small portion of the prepuce, but occasionally the whole extent of this structure will perish, when it may be detached en masse, and leave the patient as effectually circumcised as by an operation. After the separation of the mortified part, the chancroids, which will now be fairly exposed, must be treated in the manner already described. Phagedaenic Chancroid.—In this serious affection, no time should be lost in detaching the slough, and in applying the strong nitric acid to the whole ulcerated surface in the manner already directed, the patient having been previously etherized if necessary. The subsequent dressings maybe made with a solution of the potassio-tartrate of iron (a favorite remedy with Ricord), with one of chlorinated lime, with iodoform, or with an opium wash, if the part be inflamed and very painful. E. Vidal employs pyrogallic acid. The application of a constant current of electricity is recommended by Schwanda, and the use of the continuous warm bath by Simmons. Opium should be administered internally in such doses as to relieve pain without disordering the digestion, and alcoholic stimulants may be given in quantities proportioned to the age and strength of the patient. Tonics are usually required, the best being, probably, the potassio-tartrate or muriated tincture of iron, either of which may be given pretty freely. The diet should be nutritious but unirritating. The nitric acid should be reapplied as often as any tendency to a recurrence of phage- daena is manifested. Serpiginous Chancroid.—In the treatment of this most intractable affec- tion, free and repeated cauterization of the whole ulcerated surface and surrounding integument is the only remedy worthy of much confidence. The actual cautery is probably the best application in these cases, the sub- sequent dressings being made with chlorinated washes. The strength of the patient must be maintained by the use of tonics and the administra- tion of suitable nutriment; opium may be given as often as required to HISTORY AND CAUSES OF SYPHILIS. 495 relieve pain. Cases have been reported in which both phagedaenic and serpiginous chancroids have been cured by the use of mercury or iodide of potassium, but there is every reason to believe that in these instances the affection was really syphilitic, phagedenic and serpiginous ulceration being occasionally, though rarely, met with as complications of both primary and tertiary syphilitic sores. Primary Bubo or Bubon d'Emblee — Under this name has been described an acute or subacute inflammation of an inguinal lymphatic gland, occasionally met with after coitus, and not connected with either gonorrhoea, chancroid, or syphilis. It is, in fact, a simple adenitis, result- ing from mechanical irritation, usually in a patient of strumous constitu- tion ; and its symptoms and treatment differ in no respect from those of ordinary adenitis, an affection which will be considered in its proper place. CHAPTER XXVI. VENEREAL DISEASES.—Continued. Syphilis. Syphilis is a constitutional disease, resembling in many respects the specific fevers, such as variola, etc., but differing from them in its much slower course, in its communicability only by direct or indirect inocula- tion, and in the possibility of its being inherited as well as acquired. History. The origin of syphilis has not been positively determined. The limits of this volume will not permit any discussion of the evidence which has been adduced by various authors as bearing upon the history of this dis- ease (although the subject is one of very great interest), and I will there- fore invite the reader to refer, for information upon this matter, to the various excellent monographs upon Venereal Diseases which have been published from the days of Astruc down to our own time. It may, how- ever, be stated that (1) the disease does not appear to have been known to the ancients, though both the simple venereal ulcer (or chancroid) and gonorrhoea were unquestionably familiar to them ; (2) there is no sufficient proof that syphilis originated in this country and was hence imported to Europe; and (3) although the disease certainly first attracted public attention in the latter part of the fifteenth century, during the campaigns ot Charles VIII., of France, it is impossible, in view of existing evidence, to hx any particular date as the precise period at which syphilis originated. Causes. ^ Syphilis may be inherited or acquired. Hereditary syphilis, in the great majority of cases, depends upon previous infection of the mother, tnougn it is believed by Diday and others that the disease may be trans- mitted from a father to his offspring, the mother being only secondarily nected. Examples of hereditary syphilis are unfortunately not rare, and is even believed by Hutchinson that the disease may be transmitted to 496 VENEREAL DISEASES. the third generation. Acquired syphilis can only arise from contagion which may be either immediate or mediate. Immediate or Direct Contagion results from contact with a chancre (the primary lesion of syphilis), or with certain secondary lesions —particularly that which is known as the mucous patch—or from inocula- tion with the blood of a syphilitic person. It was formerly believed that syphilis was transmissible through the various secretions, especially the saliva, milk, and seminal fluid ; through contact with cutaneous surfaces of which the skin happened to be thin, as the lips; or even through the medium of the atmosphere. It soon became evident, however, that the assertions of patients upon these points were, for obvious reasons, not trustworthy, and a natural reaction ensued in medical opinion, which finally culmin- ated in the axiom of Hunter, which, for a long time, was generally received as cor- rect, that the primary sore alone was contagious, and that hence syphilis could only be required by contact with a chancre. But it has now been repeatedly established, by both clinical observation and direct experiment, that certain secondary mani- festations of syphilis are contagious, while it has, on the other hand, been rendered almost equally clear, that supposed in- stances of contagion through secretions are really examples of contagion from se- condary lesions; thus where the saliva has been supposed to convey the disease, there have been mucous patches in the mouth of the infecting person, and Culler- ier has shown, at the Lourcine Hospital, that it is not the milk of a syphilitic woman that infects her nursling, but the secondary lesions which are found upon her breast. The only possible exception is in the case of the semen, and even here there is no positive evidence that a woman can receive syphilis from the seminal fluid, unmixed with the product of urethral sores or with blood, while negative evi- dence has been furnished by experimental inoculations practised by Mireur, of Mar- seilles. That the blood of a syphilitic per- son may prove the source of contagion, has been demonstrated by both experi- ment and clinical experience, as well as by observation of the fact that syphilis may be transmitted by vaccination, when blood is mixed with the lymph obtained from a syphilitic child, while vaccine matter does not ordinarily appear to be capable of conveying syphilitic infection, if care be taken to exclude the admixture of blood.1 The menstrual discharges of syphilitic 1 Dr. Cory has succeeded, however, in experimentally syphilizing himself with unmixed vaccine lymph from a syphilitic subject. Vaccination with pure vaccine matter may, moreover, hasten the development of latent syphilis. It has been suggested that syphilis may be conveyed in vaccination by the admixture with the vaccine lymph of epidermic scales, or of pus, as well as of blood. Fig. 250.—Multiple chancres inoculated by tattooing. PRIMARY SYPHILIS. 497 women are, as pointed out by Hyde, probably not unfrequently a source of contagion. Mediate or Indirect Contagion—The contagious matter from a syphilitic sore may be transmitted to a previously healthy person by means of spoons, drinking-cups, sponges, dental instruments, catheters, etc. Rollet has recorded a number of cases of this nature, and similar cases have been published by Cullerier, Barton, and others. Hence, though surgeons may justly look with suspicion upon the statements made by patients, that their disease has been acquired in water-closets, etc., it should be remembered that such an occurrence is at least possible, and care should be taken not to wound the feelings of others, and perhaps cause domestic unhappiness, by expressing an unguarded opinion, which, after all, may be erroneous. Tardieu, Hutin, Simonet, Maury, Robert, Barker, and Trotter have observed cases in which syphilis has been trans- mitted by tattooing, the coloring-matter having been mixed with saliva from the mouth of a person affected with mucous patches. (See Fig. 250.) Course or Natural History of Syphilis. (Including its Morbid Anatomy.) The course of syphilis varies according as the disease is hereditary or acquired. The latter form of the affection will be first considered. The natural history of a typical case of acquired syphilis is usually described as going through three stages, known respectively as primary, secondary, and tertiary syphilis; and this convenient and time-honored division is that which 1 shall adopt. Ricord's classification subdivides the second period by making a late-secondary stage, while Lancereaux adds a pre- liminary stage, or that of incubation. Barton modifies Ricord's division by omitting the late-secondary stage, and subdividing the tertiary into the period of sthenic or lymphy deposits, and that of asthenic or gummy deposits—a subdivision which seems unnecessary, as both these forms of deposit frequently coexist in the same case. The classification of Virchow and other German writers, based strictly upon the pathological changes produced by syphilis, though scientifically correct, is less convenient than that which is founded on its clinical characters. Syphilis is then to be studied in its first stage, or that of primary symptoms—chancre and syphilitic bubo ; second stage, or that of secondary symptoms—early erup- tions and sore-throat, the period of general superficial lesions ; and. third stage, or that of tertiary symptoms—the period of late eruption, ulcera- tion, and deposit. Primary Syphilis. Incubation—A variable period of incubation intervenes between exposure to contagion and the appearance of a chancre. This period has been estimated by different observers at from one to seven weeks, and it is probably safe to say that the average is from two to three weeks. Cases have been recorded by Hammond, R. W. Taylor, and others, in which the period of incubation has been but one or two days, while in other instances a much longer period than the average—as much as ten or eleven weeks— has intervened between exposure and the development of the chancre. The period of incubation is, according to F. N. Otis, directly proportional to the distance between the point of inoculation and the proximal lymphatic vessels. Whatever be the source of acquired syphilis, whether from a pri- 498 VENEREAL DISEASES. mary or secondary lesion, the first symptom is invariably a chancre.1 This fact is of great importance, and may be considered as an axiomatic truth. Varieties of Chancre—The chancre assumes various forms, and there appears to be some relation between these and the severity of the subsequent symptoms; thus what is known as the " Hunterian" or "deep chancre" is commonly the precursor of a severer case of syphilis than a " superficial erosion." We may recognize two principal forms of chancre, the superficial and the deep, and either of these may assume a phage- daenic form, constituting a third variety, the phagedaenic chancre. 1. The Superficial Chancre, Chancrous Erosion, or Superficial Ero- sion, is by far the most common form of chancre, and is that which usually results from contact with secondary lesions. Of 170 cases tabulated by Bassereau, no less than 146 were of this variety. It has a long period of incubation—from three to five weeks—and appears as a reddish-brown papule (rarely, if ever, as a pustule), usually with an ulcerated spot in the centre, but sometimes (particularly if seated on an exposed surface) covered with a dry, brownish scab. The ulcer is commonly circular or irregularly elliptical in shape, slightly if at all excavated, and red in color, furnishing a thin serous exudation, without pus, unless as the result of extraneous irritation. When taken between the thumb and finger, the margin and base of the ulcer present a cartilaginous or membranous hardness, known as parchment-like induration. This induration is of variable persistence, and sometimes disappears before the ulcer has healed. It is much less evident when the chancre is situated in mucous than when in cutaneous tissue, and hence in certain situations, as in the male urethra or upper part of the vagina, this form of chancre may readily escape detection. 2. The Deep Chancre (commonly known as the Hunterian Chancre) has a comparatively short period of incubation—from a week to ten days —and is apparently of rarer occurrence at the present day than formerly. It presents a deep excavated ulcer, with elevated sloping margins and a foul surface, furnishing a serous exudation often tinged with blood. The base of this chancre is deeply indurated, the sensation communicated to the fingers being frequently compared to that given by a split pea, a term originally used by Benjamin Bell in illustration of the size of the chancre itself. The induration of this form of chancre is very persistent, some- times remaining long after the cicatrization of the ulcer. This form of chancre usually, though not necessarily, arises from a primary lesion of the same variety. 3. The Phagedaenic Chancre is nothing more than either the superficial or deep chancre attacked by phagedenic ulceration. If this extend so far as to pass the limit of induration, the case may be mistaken for one of phagedaenic chancroid. Characteristics of Chancre.—Induration is a characteristic feature of all forms of chancre, but I am hardly prepared to say that it is univer- sally present. In the case of deep chancre it is very evident, and in the parchment-like form could probably be detected at some period in almost every case of superficial chancre, if the patient were constantly under ob- servation. It may, however, in this form of chancre, be quite evanescent, and may, in either variety, disappear under the influence of phagedenic action. It must be distinguished from the inflammatory thickening and 1 This remark, of course, applies to syphilis acquired in the ordinary way; it is possible that were the syphilitic poison carefully introduced directly into a lymphatic vessel, or into a vein, a chancre might not result, but that in the former case a syphi- litic bubo, and in the latter constitutional syphilis, might occur as the primary lesion, as it does in the case of the hereditary form of the disease. CHARACTERISTICS OF CHANCRE. 499 hardness which occasionally surround the chancroid, and this can usually be done by observing the sharply defined limitation of the true syphilitic induration (which gives exactly the sensation of the presence of a foreign body), and by observing the absence of the ordinary signs of inflammation. The microscopic characters of syphilitic induration are not very distinctive. Robin found fibres of areolar and elastic tissue, with fusiform cells, free nuclei, and amorphous granules, while Ordonez observed hypertrophy of the normal structures, with inflammatory lymph, hemorrhagic effusions round or oval nuclei, fusiform cells, and bundles of fibres in different stages of development. According to Auspitz and Unna, the epidermis under- goes a peculiar development, growing downwards in processes which send out lateral projections, these being frequently isolated by the growing connective tissue. Induration is usually developed within a few days after, and, occasionally, even before, the appearance of a chancre; it is rarely if ever manifested for the first time after three weeks. Sigmund found that in 231 out of 261 cases, induration appeared from the°9th to the 14th day after contagion. The period during which induration persists is ordinarily from two to three months, and in some instances it lasts for many years. A chancre is in most cases solitary, thus differing in a marked manner from the chancroid, which is commonly multiple. When two or more chancres coexist in the same patient, it will be found that they have arisen from multiple but simultaneous inoculation, and usually by contagion from secondary lesions. The chancre is, under ordinary circumstances, not auto-inoculable ; if, however, as is done by the advocates of syphilization, the chancre be irri- tated by savine ointment, etc., until its secretion becomes purulent, an ulcer may be indeed produced by auto-inoculation—but it is not proved that this ulcer is a chancre.1 This fact (non-auto-inoculability of chancre) ap- pears to be owing to a property which syphilis shares with smallpox and many other affections, viz., that one attack of the disease protects a patient, for a time at least, from any subsequent infection. This protective influ- ence extends through all the stages of syphilis, so that a second attack of syphilis, though possible, is very rare. Cases have been, indeed, recorded in which a chancre has apparently arisen after impure coitus, in a person at the time actually suffering from general syphilis; but, as shown by Fournier, the suspected chancre in these cases is really but a reulceration in the seat of the original primary lesion, which may be caused bv any irri- tation, either constitutional or local—sexual intercourse being but" one form of local irritation, though one which may easily give rise to confusion, par- ticularly if the patient's partner in the venereal act should happen to be affected with any disease of the generative organs, whether syphilitic or otherwise. 1 It has been suggested that the ulcer which results from the auto-inoculation of a chancre is a. chancroid, and that this tends to confirm the view of Clerc, that the latter lesion is a derivative of the chancre, or, in other words, the result of chancrous contagion in a person already syphilitic, just as varioloid is the result of the variolous poison act- ing upon a person alrealy protected against smallpox ; bat the analogy fails, because varioloid is just as much a constitutional disease as variola itself, while the chancroid is a purely local lesion, and because the contagion of varioloid will communicate to ," jnpro.tec^ed Pers°n not varioloid but smallpox, while the chancroid can only re- raniw Moreover, if the chancroid be a derivative of the chancre, the latter m no. ot course syphilis generally) must have existed before the affection which is its hut ™0(11ncation—an hypothesis which is contradicted by all that is known of the isiories of the two affections. A.s a matter of observation, the ulcer derived from w-iiioculatioii of a chancre appears to be precisely such a sore as can be produced >7 inoculating a syphilitic subject with non-venereal matter. 500 VENEREAL DISEASES. The duration of the chancre is self-limited ; it heals without treatment in a period varying from a few weeks to several months, the only exception being probably in the case of the phagedaenic variety. The primary and secondary periods of syphilis usually overlap each other, syphilitic erythema occurring, according to Bassereau, in about three out of four cases, before the chancre has completely healed. The cicatrix of a chancre is more or less depressed, according to the depth to which ulceration has extended. It is at first discolored, but subsequently becomes whiter than the surround- ing skin. It is usually very persistent, and can often, though not always, be distinguished from the scar of chancroid. Ricord first pointed out that a chancre, instead of undergoing cicatrization, might become converted into a mucous patch. This change may occur in any situation, but is most often seen where mucous tissues are habitually in contact, as the inside of the lips, the tongue, the inner surfaces of the labia, the folds of the anus, or the lining surface of the prepuce. The change occurs when the repair of the chancre has been nearly completed by granulation, and consists in the formation of a white membranous pellicle, which gradually spread.- from the circumference of the sore to its centre. It is from inattention to this fact that a mucous patch has been in some cases supposed to be really the initial lesion of syphilis, the patient not being seen until the transfor- mation has occurred, and the previous existence of a chancre thus escaping recognition. Mixed Chancre.—It has already been stated that chancroid and syphilis may exist in the same patient. They may likewise be acquired at the same moment. Hence a patient, a few days after impure coitus, may present several venereal ulcers, not indurated and evidently not syphilitic —and yet in a few weeks, without further exposure, one of these may become indurated and be followed by* secondary symptoms. The syphi- litic has been inoculated simultaneously with the chancroidal poison, just as it may be inoculated with the poison of cowpox, the vaccine disease disappearing at the usual time, and syphilis following after its own proper period of incubation. Again, syphilis may be inoculated upon a previ- ously existing chancroid, a chancre being the result; or conversely, if a person with chancre have sexual intercourse with a woman affected with chancroid, he may acquire the latter disease, his chancre serving as a point of inoculation. The term mixed chancre is. perhaps, an unfortunate one, as seeming to imply that the venereal ulcer to which it refers is interme- diate between chancre and chancroid; the fact being that it is not in any degree intermediate, but the result of the accidental coexistence of two separate diseases. Syphilitic Bubo—Induration and chronic enlargement of the neigh- boring lymphatic glands are almost, if not absolutely, constant sequels of chancre. As in the large majority of cases the latter is situated on the genital organs, it is the inguinal glands that are usually affected, consti- tuting the ordinary syphilitic bubo; but induration will attack the facial and submaxillary glands if the chancre be cephalic, and those of the elbow and axilla if the initial lesion occupy the finger. Cases have been recorded by H. Lee, and others, in which a chancre is said to have been followed by secondary symptoms, without the intercurrence of a bubo, and the possibility of such an event must therefore probably be acknowledged: such cases must, however, be extremely rare, and in no instance can it be fairly claimed that this has happened, unless the patient has been continuously under the notice of a skilled observer, as syphilitic bubo is often unper- ceived by the patient himself, and may, like the induration of a chancre, pass off in a comparatively short time. SECONDARY/ SYPHILIS. 501 The development of a syphilitic bubo coincides pretty closely with that of induration in the chancre which precedes it; it is poly ganglionic and usually bilateral, or, in other words, involves the whole chain of superficial glands, and commonly invades both groins at once. The glands are hard, movable upon each other and beneath the skin, usually painless, and about the size of almonds (amygdaloid enlargement); one is frequently larger than those which surround it, the group being fancifully designated bv French writers as the "pleiade ganglionnaire." The syphilitic bubo has in itself no tendency to suppurate, and when suppuration occurs it is due to the influence of some external irritant, to the patient's being of a scrof- ulous diathesis, or to the coexistence of a chancroid. In the latter case, the suppurating bubo will be chancroidal, and its pus, of course, auto- inoculable. The duration of a syphilitic bubo is variable, lasting usually longer than the induration of the chancre, and being in many cases quite distinct for six months or a year after infection. Cases have even been recorded, by Venning and others, in which the amygdaloid condition of the inguinal glands persisted twenty years or longer; and it is believed by the above-named writer that the disappearance of this condition may be considered an evidence that the disease has worn itself out, and that the patient is susceptible of re-infection. The syphilitic bubo is often attended by induration of the lymphatics running from the chancre to the affected glands; resolution usually occurs about the time that indura- tion disappears from the chancre, but, occasionally, suppuration has been observed, a number of fistulous openings being formed in the course of the vessel It is believed by some surgeons that a syphilitic bubo may occur with- out any pre-existing chancre, and this has been spoken of as a form of the Bubon d'Emblee. Such cases are, however, really instances of defective observation, or of voluntary deception upon the part of the patient. A superficial chancre may readily be unnoticed by a patient, or even by a surgeon, particularly if situated in the urethra, or neck of the uterus, or if unaccompanied by induration : there is no sufficient evidence to throw doubt upon the truth of the axiom, that the initial lesion of syphilis is invariably a chancre. Secondary Syphilis. Between the time of appearance of a chancre and the period at which secondary symptoms ate developed, there is an interval which is sometimes called the period of incubation or latency. The former term is better ap- plied to the interval between the date of contagion and that of the appear- ance of the chancre, while in many cases the disease cannot properly be said to be latent, as the chancre and attendant bubo frequently continue after the appearance of general syphilis, the primary and secondary stages often, as already remarked, overlapping each other. The shortest period in which an untreated chancre is known to have been followed by secon- dary symptoms is twenty-five days, while the average period, as shown by an analysis of nearly 500 cases, is about six weeks. Secondary syph- ilis rarely appears after the first three months, and almost never later than six months, unless the natural evolution of the disease has been interfered with by treatment. Secondary syphilis cannot occur without primary syphilis having preceded it;1 the apparent exceptions are due to the pri- mary symptoms having escaped detection, an event which, as already seen, may readily occur under various circumstances. 1 This remark does not, of course, apply to hereditary syphilis. 502 VENEREAL DISEASES. Premonitory Signs.—Certain premonitory symptoms usually pre- cede the development of secondary syphilis, lasting from a few days to a week or more, and consisting in febrile disturbance, with languor and gen- eral discomfort, vague pains of a neuralgic character, headache, sometimes apparently neuralgic, but sometimes due to inflammation of the pericra- nium,1 and (particularly in women) anaemia. With the exception of the pericranial headache, these symptoms usually disappear upon the occur- rence of the eruption and other secondary symptoms. The most charac- teristic and usual manifestations of secondary syphilis are cutaneous erup- tions, sore throat, mucous patches, and general enlargement of the lymphatic glands. More rarely we find falling of the hair, certain affections of the eyes and ears, paralysis, and other symptoms referable to the implication of the nervous system. Cutaneous Eruptions—There is no definite syphilitic eruption. On the contrary, a large number of skin diseases may occur as manifestations of syphilis, and several of them are not unfrequently found coexisting in the same case. The limits of this work will not permit any extended de- scription of the various syphilitic eruptions, or, as they are often called, Syphilo-dermata or SyphHides, for a full account of which I would re- spectfully refer the reader to the numerous excellent works on Venereal Diseases which are now readily accessible, and more especially to those of Cullerier, Lancercaux, and Belhomme and Martin, in France, of H. Lee and W. J. Coulson, in England, and of Bumstead, Taylor, and Keyes, in this country. A good account of these lesions, too, will be found in Dr. Van Harlingen's article on Syphilis, in the International Encyclopaedia of Surgery. Cazenave's classification is that usually adopted, those eruptions which belong to the secondary stage of syphilis being the ex- anthematous (erythema and roseola), the papular (syphilitic lichen), the vesicular (herpes, eczema, syphilitic varicella, etc.), the bullous (pemphigus and superficial rupia), and the pustular (ecthyma, acne, and impetigo). Syphilitic erythema is usually the earliest of the eruptions, and is frequently so slight as to escape the attention of the patient. Ecthyma is likewise an early manifestation of secondary syphilis, and is very often met with in the scalp. There are certain features which habitually mark all forms of syphilitic eruption, and which have a certain diagnostic value. These are (1) the so-called protean character of the eruption, or the appearance simultaneously, or in quick succession, of more than one variety; (2) the peculiar reddish-brown or copper-colored hue of the eruption in its declin- ing stage; (3) its symmetrical character; and (4) the absence of itching. Fournier has lately pointed out a peculiarity of the skin in syphilis which he considers quite significant. This is cutaneous anaesthesia, of which he describes three varieties, viz., anaesthesia as regards pain, or analgesia (by far the most common), anaesthesia of general sensibility, and anaesthesia as regards changes' of temperature. Sore Throat—The sore throat of secondary syphilis may consist merely in erythematous efflorescence of the part, or in a superficial aphthous ulceration. This may affect the fauces, tonsils, palate, cheeks, or tongue. Occasionally, in this stage, the tonsil may present an excavated ulcer, with sharp-cut edges and sloughy surface, which somewhat resembles a chan- croid, and has been incorrectly called an amygdaline chancre.' The 1 According to Mauriac, periostitis, whether of the cranium or other parts, is much more common as an early manifestation of syphilis among the Arabs in Africa, ana the inhabitants of South America, than among the residents of other countries. 2 True chancres of the tonsils have, however, been observed by Lindstroem, Szadek, Belousoff, Bumstead, Taylor, and several other writers. SECONDARY SYPHILIS.' 503 severer forms of syphilitic sore throat, with the concomitant affections of the larynx and oesophagus, belong to the tertiary period of the disease Mucous Patches—These, which are also called Condylomata, Moist Papules, and Mucous Tubercles, are particularly interesting as beino- the manifestation of secondary syphilis which is chiefly concerned in the trans- mission of the disease, though it is probable that any of the moist forms of eruption may occasionally prove the source of contagion. Mucous patches occur on mucous membranes, or where the skin is thin, and particularly 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 Fig. 251.—Mucous patches. (Miller.) rarely between the toes, on the inside of the thighs, and on other parts of the body. J. S. Barnes has seen a mucous patch on the conjunctiva. On the skin they appear as flat, slightly elevated papules, about half an inch in diameter, and covered with a slimy, fetid exudation. This appears as a kind of false membrane or pellicle, which covers a raw surface from which the cuticle has been previously removed. On the mucous mem- branes they are less elevated, and, in the mouth at least, the exudation 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, thev 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 verv 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, 504 VENEREAL DISEASES. 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 involved. The cervical engorgement is most marked when a pustular eruption exists upon the scalp; this form of glandular enlargement is very different from the glandular induration observed in the primary stage, though, like that, it usually ends in resolution. The period of develop- ment of this characteristic symptom 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 syphilis. It is sometimes so slight as to be scarcely recognizable, and is most marked when the scalp is the seat of an abundant eruption. Beside the hair of the head, the eyebrows may be affected, and more rarely the eyelashes and beard. 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 byr 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 different 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 comparatively 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 synechiae to the capsule of the lens, but there is little photophobia. Both eyes are attacked in probably7 two-thirds of the cases, though not usually simultaneously. According to Nettleship, re- lapses in the iritis of secondary syphilis are rare. This form of the disease is much less intractable than the parenchymatous variety which occurs in tertiary syphilis. Retinitis and Choroiditis, often seen together, but occa- sionally 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 infection, but their appearance has occasionally been de- layed as late as ten years. Next to the iris, the choroid is affected more fre- quently by syphilis than any other portion 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. Photo- phobia is usually but not invariably absent. It is sometimes possible, according to Wells, to distinguish these affections from those which are not syphilitic by their ophthalmoscopic appearances, even if no other symptoms of syphilis are present. Hutchinson has, however, pointed 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 symp- toms should not be entirely relied upon, unless supported by other facts TERTIARY SYPHILIS. 505 Syphilis is, according to Cowell, by far the most frequent cause of diffuse neuro-retinitis and exudative 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 inherited syphilis, is of extremely rare occurrence in the acquired disease, but occasionally appears in the secondary stage. Syphilitic affections of the lachrymal apparatus have been described by R. W. Taylor. Affections of the Ear.—Acute myringitis, or inflammation of the membrana tympani, sometimes occurs in secondary syphilis, and may cause permanent deafness from inflammatory thickening of the part. Sturgis has reported two cases of inflammation of the middle ear due to secondary syphilis, and syphilitic disease of the internal ear has been observed by Roosa and by Moos. Affections of the Nervous System.—Hemiplegia, with or with- out loss of consciousness, often preceded by persistent headache, mydriasis, and perhaps ptosis, 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 Keyes, who has paid particular attention to the subject, that the paralysis is due to general or partial congestion of the brain, analogous to the congestions of the skin and mucous membranes which occur in secondary syphilis. Affections of Joints and Bursae.—These may, according to Keyes, be affected in secondary syphilis, becoming congested and sometimes painful, though in other cases the congestion is painless and followed by effusion. The various manifestations of syphilis which belong to the" secondary stage occur with a certain degree of regularity (the exanthematous, for instance, usually preceding the papular eruptions), and last, with occasional 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 or^an of the body, and the symptoms of this stage are developed with such irregularity as to render it impossible to classify them chronologi- cally. 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 cica- cf/.or °f 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 uoercular and squamous eruptions, together with a destructive form of 506 VENEREAL DISEASES. 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, aud 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. 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 Fig. 252.-syPhiiitic ulceration of face. 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 ex- tends. In this stage a severe form of Alopecia is occasionally seen, in which the hair-follicles all over the body may be destroyed, the affection being, of course, incurable; this variety of alopecia usually occurs in con- nection with the tubercular eruption already described. Syphilitic Fig. 253.—Syphilitic rupia. (Druitt.) Onychia, or ulceration in the matrix of the nails, which become dry and distorted, and are finally thrown off, is a concomitant of the squamous eruptions, and affects the hands more often than the feet. Mucous Membranes__The tongue is often affected in tertiary syph- ilis ; it may present white patches upon its surface, apparently due to lymphy deposit and opacity of the epithelium—upon the detachment of which a smooth and slightly depressed spot remains—or there may be a tubercular condition of the tongue, analogous to that described as affecting the skin, which may end in ulceration, or may assume the form of a deep- seated lymphy deposit, causing stiffness, contraction, and distortion of the TERTIARY SYPHILIS. 507. 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 partic- ularly the side of the tongue, is solitary, and involves the submaxillary ganglia; while the lingual syphilitic tubercle is commonly multiple, oc- cupies the dorsum and base of the tongue, and is not attended bv enlarge- ment of the lymphatic glands. The syphilitic gumma may, however, occupy any part of the organ. The tonsils, fauces, and palate suffer in tertiary syphilis from ulcera- tion, which may be circumscribed or phagedaenic. 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 vertebrae. The larynx and trachea may be affected with a deposit of syphilitic tubercle, which may undergo ulceration, causing dyspncea, often of a par- oxysmal character, and perhaps 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 part. 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 at- tacked", but in an insidious and almost painless manner, becoming the seat of a deposit 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 margin, but occasionally at the periphery ; from one to four may be present. Cyclitis of a severe type may appear in acquired syphilis, and may lead to detach- ment of the retina. Gummata involving the ciliary body are compara- tively rare; Ayres has reported six cases. The deeper seated structures are occasionally involved, and permanent disorganization may then occur. Optic neuritis, as an indirect result of syphilitic disease of the eye and of the nervous system, 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 syph- ilitic diseases of the eye, such as retinitis and choroiditis, or is consecutive to a papillitis caused by coarse tertiary syphilitic intracranial lesions. Kankin 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 paralysis of the ocular muscles as a result of syphilis. Progressive atrophy of the disks and 508 VENEREAL DISEASES. external ophthalmoplegia of syphilitic origin, associated with locomotor ataxia, are not unfrequently recorded. R. W. Taylor reports cases of ter- tiary as well as of secondary syphilitic disease of the lachrymal apparatus. Solid Viscera.—Visceral syphilis has, until recently, not attracted as much atteution 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 glands, lungs, and heart. The limits of this wrork will not permit a de- scription of the changes produced by syphilis in any of these viscera except the testis ; and, indeed, syphilis of the internal organs is habitually treated by the physician rather than by the surgeon. For a full account of these affections I would refer the reader to the work of Lancereaux which has been translated for the New Sydenham Society, and which gives a very complete account of visceral syphilis. Syphilitic Sarcocele, or Syphilitic Orchitis, appears under two forms, the interstitial and the circumscribed or gummy. Interstitial Orchitis occurs in the early part of the tertiary stage, and is attended with the 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 by 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 iarge 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 lymphy 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 Alison has collected four cases), Mental Perturbation, or, as pointed out by M. II. Henry, absolute Dementia. Diabetes is said to have resulted from syphi- litic disease of the base of the brain. The credit of first distinctly recog- nizing the existence of syphilitic lesions of the central nervous system is due, I believe, to Reade, 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 syphilis has long been recognized, but the change has been supposed to be identical with atheroma. According to Heubner and E wald, 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 TERTIARY SYPHILIS. 509 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 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 place, and, after the extrusion of a slouch 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 nuciei, 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; Bursae__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 bursae, either primarily or by ex- tension from other tissues. In the fingers and toes, in which situation they may involve either the super- ficial tissues or the perios- teum 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. 254), or Syphilitic Dactylitis, the latter name being preferred by R, W. Taylor, who has given an excellent account of toe attection. 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 appears in some cases to be a syphilitic lesion Bones and Periosteum—Periostitis is of frequent occurrence in imiary syphilis, and the periosteum of those bones which are subcutane- radi 8 m°*Z °i affected> as of the tibia> cranial bones, clavicle, sternum, nius, and ulna, Osteocopic (literally, bone-tiring) pain is often observed npnni- !Fe ?L °ther symPtom, and, in a large majority of cases, has the pecunanty o being aggravated by the warmth of bed. Syphilitic perios- us is usuay circumscribed, and gives rise to the formation of oblong to lvn h ™lled J10**™, which are commonly hard and indolent, being due ivmpny deposit m and beneath the periosteum, but which in other cases Fig. 254.—Syphilitic panaris. (From a dren's Hospital.) patient at the Chil- 510 VENEREAL DISEASES. are fluctuating and tender, and apparently due to the deposit of gumma- tous material. They may often be dispersed by treatment, but occasion- ally persist, 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 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 Virchow, 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 Fig. 255.—Syphilitic permanent teeth. (Hutchinson.) offspring; and (4) the father may transmit the disease to the foetus, without directly in- fecting the mother, who, however, may in turn be infected by the embryo. The latter mode of transmission is denied by many au- thors, and is certainly of rarer occurrence than the others. The syphilitic embryo very often dies before the full term of intra-uterine life is accomplished, and abortion then follows. 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 year. It is very doubtful whether the first manifesta- tion of hereditary syphilis ever occurs at a later period, the apparent ex ceptions which have been reported being probably cases of acquired syphilis Fig. 256.—Bone-disease in hereditary syphilis. diagnosis of syphilis. 511 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. Laryngitis may also occur in this stage, with inflammation of the buccal mucous membrane, or syphilitic stomatitis. If the latter exist, the temporary teeth are apt to be ill-formed and carious, and often drop before the usual time. The child becomes sallow and withered, and seems prematurely old. If death do not occur from malnutrition during this stage of the disease, there is usually a lull in the symptoms, the later manifestations (which belong to the tertiary period) not being de- veloped 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. 255), particularly of the upper central incisors, first pointed out by Hutchinson.' Interstitial keratitis usually affects both eyes, and is attended with a formation of lymph between the laminae of the cornea?, which often remain permanently opaque in spots. (See Chap. XXXVI.) Iritis is much rarer in the hereditary than in the acquired form of the disease. Inflammation of the choroid,1 retina, and optic nerve, and deafness, are also sometimes ob- served as a result of hereditary syphilis. The viscera affected in these cases are chiefly the liver and lungs, the brain and thymus gland being very rarely involved. The bones may be affected in hereditary syphilis, the lesions particularly deserving attention being the syphilitic panaris or dactylitis (p. 496), and a peculiar inflammatory condition of the epiphy- seal 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, it ordinarily intelligent, can usually give a more or less complete history ot his own case; but in syphilis, very little reliance can be placed upon the statements of the patient. Apart from wilful deception, or concealment, jo wnicb there is of course unusual temptation in many cases of syphilis, tbere is another difficulty, which is that, the symptoms'being spread over a term of years, and often in themselves trivial, the patient either does not notice them, or subsequently forgets their existence, and thus with every birt?^0' « B."11 hf seen 8yPhilitic iritis and irido-choroiditis within a few hours of Dinn, the affection then being properly called congenital. 5 IS VENEREAL DISEASES. 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 symptoms presented at any one period. The diagnostic marks between chancre and chancroid may be conveniently presented in parallel columns :— Chancroid. No period of incubation ; the sore is fully developed from four to six days after ex- posure. Usually multiple, if not at first, becoming so subsequently by auto-inocu- lation. An excavated ulcer, with sharply cut, punched-out edges, a gray sloughy 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. 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 phagedajnic. 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. Besides the information derived from observation of the patient, valuable aid in forming a diagnosis may be sometimes derived from confrontation and inoculation. Confrontation consists in examining the person from vyhom the disease has been contracted, and its value depends upon the fact that chancroid can only produce chancroid, while syphilis can only be imparted by a syphilitic lesion. It is in many cases, from obvious reasons, impossible to make use of confrontation, but, when available, it is a 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. 499). 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 PROGNOSIS. 513 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. Chancre may occasionally have to be diagnosticated from cancer, epi- thelioma, or similar affections. This is particularly the case when chancre occurs in unusual situations, as on the fingers, lips, 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 antisyphilitic 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 except chronic scrofulous adenitis. If there be no concomitant signs by which the nature of the case may be revealed, the surgeon should avoid givin°- 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 develop- 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 eruptions of various forms, post-cervical engorgement, alopecia, and occasional development of mucous patches ; or from osteocopic pains, indolent nodes, and gummatous tumors of the areolar tissue—even though such a patient should appear as virtuous as Joseph, or as wise as Penelope —the surgeon might reasonably conclude that he had to deal with a case of syphilis, and should direct his remedies accordingly. The diagnosis may often be assisted by observing the traces of past manifestations of the disease, such as induration of the genital organs, or of the inguinal glands, or the depressed white cicatrices of syphilitic ulceration. The seat of ulcer- ation 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 A familiar example is the vaccine disease, which is more violent when produced y matter fresh from the cow, than when transmitted from arm to arm with humanized virus. 33 514 VENEREAL DISEASES. considerable number of persons—more than is commonly supposed—are besides, at least partially protected by inheritance. Moreover, as surgeons more generally understand the natural history of the affection, their treat- ment has become more judicious; and the reckless use, or abuse, of 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- stances. Infection from a deep (Hunterian) or from a phagedienicchancre, 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 superficial erosion. If a patient be of a strumous constitution, or broken down by previous illness, or of dissipated habits, the prognosis will, other things being equal, be less favorable than in the case of one who is robust, and who will probably take due care of his health during the course of treatment. The effect of intercurrent at- tacks of erysipelas is regarded by Neumann as favorable. According to Sigmund, syphilis acquired in advanced life runs a milder course than in younger persons. Secondary symptoms will almost invariably occur in every case of syphilis, but in a mild case will probably declare themselves at a later period, will be less intense, and will be more evanescent, than in one which is severe. Again, the form of the first eruption is of prognostic value, an erythema, or roseola, indicating a milder form of syphilis than one of the other varieties. When the tertiary stage has once appeared, the chances of complete recovery become very doubtful; though the dis- ease, however, can rarely, under these circumstances, be entirely eradicated, its manifestations 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 of 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. 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 1 The modus operandi of these drugs is still a matter of dispute ; perhaps we may come nearest the truth in saying that they probably act by promoting elimination and absorption—the elimination of the syphilitic virus, whatever that may be, and ab- sorption of the lymphy and gummy deposits which characterize the later manifesto tions of the disease. TREATMENT OF SYPHILIS. 515 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 sali- vation, and discontinuing the remedy if it appear to irritate the patient's system. If, however, there be the slightest doubt as to the nature of the sore, or if the general condition of the patient be such as to contra-indicate the use of mercury, it is much better to rely upon local measures, giving only tonics or such other medicinal agents as may be required by the particular exigencies of the case. For primary syphilis, mercury is", per- haps, best given by the mouth, and the preparation which I prefer is the protiodide (hydrargyri iodidum viride of the U. S. Pharmacopoeia), which may 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 prepuce, circumcision would be justifiable, though it could hardly be expected 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 phagedaena, advantage may be derived from the use of opium, and of the potassio-tartate of iron, both locally and generally, with free stimulation, if the condition of the patient require it. Mercury may be given cautiously, and, as it were, tentatively, being discontinued if the phagedenic action continue to spread under its employment. Cauterization with nitric acid, which, it will be remembered, is the great remedy for phagedenic chancroid, is rarely needed in the treatment of phagedaenic chancre. If the surgeon suspect the existence of a mixed chancre, he should treat the case as one of simple chancroid, until the syphilitic nature of the affection becomes evident. Cauterization with nitric acid will, in such a case, be required under any circumstances, and little or no harm will result from delaying the use of mercury until the diagnosis has been rendered positive. But little can be done for the treatment of Syphilitic Bubo: attempts may be made to promote resolution by pressure, or by the employment of mscutient applications, though the latter should be used with great caution, lest they induce suppuration. Pressure may be conveniently applied by means of a compressed sponge and spica bandage, or by means of a 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 application of tincture of iodine, 516 VENEREAL DISEASES. around, but not over, the enlarged glands, in the way recommended by F. Jordan. Jakubowitz recommends injections with a hypodermic syringe of a solution of iodide of potassium (R. Potass, iodid. gr. xv, Tinct. iodi gtt. v, Aquae f^j. M.). If suppuration occur, troublesome sinuxs will probably be left, which must be treated on the general principles laid down at page 438 ; while if, as is often the case, the patient give evidence of struma, mercury must be abandoned, and iodine and cod-liver oil sub- stituted. Secondary Stage.—By the course of treatment above described, it im- possible, though not probable, that the development of secondary symp- 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 j-ys- 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 per cent, of the oleate of mercury, may be slowly rubbed into the inner part of the thighs, once a day (the hand being covered with a soft leather glove, soaked in fat to prevent absorption, if the treatment be carried out by an attendant), or into the soles of the feet, as recommended by Coulson, in which case woollen socks should be constantlyr worn. In infantile cases, a few grains of the ointment may be smeared upon a strip of flannel, which is then ap- plied as a belly-band. In many cases the use of inunction is objected to by the patient, and, under such circumstances, various preparations of mercury may be given by the mouth, the best probably being the corrosive chloride, in doses of from one-sixteenth to one-eighth of a grain, three times a day, after meals. It is best given in solution, much diluted, and may be conveniently combined with the bitter tonics, with the muriated tincture of iron, or (dissolved in ether) with cod-liver oil. The following formula?, the second and third of which are imitated from Bumstead, will usually prove satisfactory':— $.. Hydrarg. chlorid. corrosiv. gr. j; Tinct. gentian, comp. f.5ij; Syr. zingiberis fgj ; Aquae fgv. 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. $.. Hydrarg. chlorid. corrosiv. gr. j-ij ; iEtheris f3j ; 01. niorrhuse f3viij- 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. The tannate of mercury, in one or two grain doses, is highly commended by Lustgarten and C. W. Allen. 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 1 Keyes has shown, by actual counting, that small doses of mercury increase the number of red corpuscles both in healthy persons and in the subjects of syphilis- TREATMENT OF SECONDARY SYPHILIS. 517 means of a tin plate heated with a spirit-lamp, or, which is perhaps better by means of the ingenious apparatus devised by T. F. Maury (Fig 257)' The use of mercury by hypodermic injection has been of late success fully resorted to, in cases of syphilis, by Lewin, R. W. Taylor 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 e«-g ' may be injected once or twice daily; or Bamberger's peptonized solution, Which contains the bichloride and common salt; or, which is preferred by Raggazzoni, half a grain of the biniodide, dissolved with a little iodide of potassium in half a flui- dracbrn of distilled water. Pick and Streitz employ a preparation known as "iodo-pepton," 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 Pirochi and Porlezza. Should Salivation occur during the administration of mercury, the remedy must be stopped, and astringent and detergent mouth-washes freely employed. The treatment may subsequently be cautiously resumed, or the iodide of potassium may be used instead Ine 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 mav 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 ot metallic zinc. 1 Staub's solution may be made according to the following formula :— ft. Hydrarg. chlorid. corrosiv., Ammonii chlorid. aa 3j ; Sodii chlorid. 5j ; Aq. aest. tgm Misce et cola, deinde add. Ovi alb. no. j, Aq. dest. q. s. pro f'Siv. u this solution 15 minims, containing about T* grain of the sublimate, may ue injected twice daily. Fig. 257.—Maury's fumigatiDg apparatus. 518 VENEREAL DISEASES. Syphilitic Sore Throat may be treated with chlorate of potassium gar- gles, or with caustic applications, if there be any phagedaenic 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 employed to relieve the pain. Mercury, preferably by inunction, may be freely used, or, which is sometimes better, 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:— $.. 01. terebinth, f^iss ; Tinct. opii f5ss ; Acacise, Sacch. alb. aa 5'j ; 01. gaul- theriae, gtt. iv ; Aquae fgiv. 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 cantbarides. 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 moder- ate amount of alcoholic stimulus may be given if the patient is used to its employment. The clothing should be sufficiently warm, and prefer- ably of wool, and great care should be taken to avoid all exposure to wet or cold. The mercurial course should, as a rule, not be begun until the disappearance of the premonitory signs, but should then be continued reg- ularly, 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 mildness, will exhaust its virulence in this stage, arid 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 re- move the pigmentary stains left by syphilitic eruptions, Langlebert applies small blisters kept open for a few days, so as to substitute white for cop- per-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- 1 The following formula will be found satisfactory :— 1£. Hydrarg. iodid. rubr. gr. j ; Potassii iodid. 5j ; Aquae fgj ; Syrupi f3v- M' Sig. From a dessertspoonful to a tablespoonful, thrice daily, after meals. TUMORS. 519 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, iodide of potassium, with tonics, and especially iron and quinia, wilf be found of service. The saccharated 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 Colles, 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, both as a prophylactic and as a rem- edy for syphilis, and has been extensively used in the'treatment of the dis- ease by Boeck, of Christiania. This mode of treatment has been thor- oughly tested by surgeons in different parts of the world, and the opinion of the profession is almost unanimously opposed to its employment. Its use as a means of prophylaxis is clearly unjustifiable, for there is no evi- dence that the artificially inoculated disease is more tractable than that which is acquired in the ordinary way; and as to the curative effect of syphilization, the testimony of most unprejudiced observers tends to show that (1) it is very doubtful whether it exercises any beneficial influence, and that (2) if it do any good, it is probably merely as a means of pro- ducing 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 impression that the chancroid is a syphilitic lesion) is quite unjustifiable, as merely adding another disease to that from which the patient is already suffering. I do not recommend a resort to syphilization under anv cir- cumstances, and have mentioned it simply as a matter of historical interest. CHAPTER XXVII. 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 restricted 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 520 TUMORS. region of the body. Though originating in and deriving their nourish- ment 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 mayr 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), always, however, pre- serving 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 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 simultaneously, 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 sys- tem (as in the process of embolism1), or otherwise, between the first, which is then called primary, and the secondary tumors, or those which are sub- sequently formed. The origin of secondary cancerous tumors is, in the large majority of cases, traceable to absorption from the primary tumor, through the medium of the lymphatic system. Causes.—The causes of the development of tumors are sometimes suffi- ciently obvious; as where a cystic tumor results from obstruction of an excretory duct, or where the occurrence of a fatty tumor, or of an adventi- tious bursa, is directly traceable to the effect of pressure. In most instances, however, no direct cause of the occurrence of a tumor can be detected, 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 functional activity of any 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 system ; 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 wrhich 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- riant. This general division, founded upon the clinical characters of mor- 1 A remarkable case has, however, been recorded by Hayem and Graux, in which a fibro-plastic tumor of the ligamentum patella' was followed by a similar growth in the lung, directly traceable to embolism. Other examples of transference of non-cancer- ous tumors have been recorded by Virchow, Moore, Bryant, and Heitzmann. CLASSIFICATION OF TUMORS. 521 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 Vir- chow and other authors, and would doubtless have been generally adopted by surgical writers as well as by pathologists, but for the fact that a knowledge of the microscopical characters of a tumor does not always sometimes in undulating bundles which inter- ann t u °ther' and sometimes a£ain matted closely together, so as to ' wear to the naked eye as a nearly uniform, white, glistening mass. The 532 TUMORS. tumors are more or less lobed, and divided by septa of areolar tissue, the vascularity of the growth being greatest in those tumors which are most loosely arranged. Besides 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 (Virchow). the Muscular Tumor of Yogel. The Fibro-cystic and Fibro-calcareous varie- ties are the result of secondary degeneration, and mayr 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. 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 tis>ue, 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, subperitoneal 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 appearance. The diagnosis of fibrous tumors may usually be made by observing their smooth and regular outline (unless distorted by compression), their uniform firmness, their mobility' (when iu 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 impossible, 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 osse- ous 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 ana- logies 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 Fibrous Cancers, but Malignant Fibroid Tumor would seem to be a better name. 1 Or the false neuroma. (See Chap. XXIX.) CARTILAGINOUS TUMORS. 533 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 lobnlated, and (in parts unconnected with bone) invested with a dense connective-tissue capsule, from which proceed septa which divide the lobules from each other. On section, these tumors present a glistening, bluish, or pinkish-white appearance, 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 Fibro-cartilaginous appropriate. The cells vary greatly in number, size, shape, and mode of arrangement, and are sometimes so fused with the basis-substance that the nuclei alone are perceptible. The nuclei themselves vary in different spe- cimens, 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 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. Enchondromata usu- ally occur at an early period of life. These tumors are most frequently seen in connection with bones (when they may grow beneath the periosteum, or in the medullary cavity), but cartilages^ met with in joints present certain analogies to enchondro- be more conveniently considered in another part of the volume. 534 TUMORS. Fig. 268.—Multiple enchondromata ol hand. (Druitt.) 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 suppurating and offensive cavity, and death may occur from exhaustion under these cir- cumstances. 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, enchondromata may contain cysts, glandular tissue, or myeloid structure—and may even be apparently mingled with encephaloid, in the same general mass. Cartilaginous tumors are usually solitary, except when occurring in the bones of the hands, where they are commonly multiple. The bones most frequently affected, after those of the hand, are the femur and tibia, and, next to these, the humerus, ribs, pelvis, and last phalanx of the great toe—though enchondromata have been occasionally- seen in almost every bone of the body. When growing near the articular extremity of a long bone, a cartilaginous tumor is usually seated between the periosteum and bone, gradu- ally eroding the wall of the latter, and involving it in its own mass. The arti- cular extremity itself is probably 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 gradually expand; but in the rare cases of single enchondromata in this situation, the tumors are subperiosteal, as in the long bones The diagnosis may usually be made by observing the various characters which have been described as belonging to the enchondroma, especially its hardness combined with elasticity ; but when occurring in certain situa- tions, as within the jaw, the diagnosis from other innocent tumors maybe 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 wiien 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 normal bone, from the periosteum or other fibrous tissue. They are usually solitary, and when multiple are often symmet- rical and hereditary. Two varieties of bony tumor may be recognized, the cancellous (consisting of a thin layer of compact substance, with cancellated structure and marrow internally), and the compact, hard, or ivory-like, bony tumors, which consist, as their name implies, of hard and solid bone. OSSEOUS TUMORS AND OUTGROWTHS. 535 The cancellous tumors usually constitute the ultimate sta^e of the cartilaginous tumors already described; they are indolent, and when thoroughly ossified rarely grow; they are situated outside of the bones with which they are connected, and in suitable cases may be treated by excision. A favorite locality of this form of bony ;x Fig. 270.—Ivory-like exostoses of the skull. (Miller.) 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 re- move, 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 s rare, except in connection with the cranial bones (Fig. 210), where they may be small, superficial, and per- haps pedunculated, or may origin- ate in the diploe or frontal sinus,1 etc., where they may grow both in- wardly and outwardly, in the form of large nodulated masses, involv- ing the orbit, causing protrusion of the eyes and great deformity, and perhaps inducing fatal compression of the brain For the superficial variety, excision may occasionally be attempted, though the operation is sometimes rendered impossible by the hardness of the tumor. For the deep orbital growths, attempts at ex- cision are not to be recommended, but as a cure has sometimes followed necrosis and spontaneous separation of the mass, it may be proper to expose the most prominent part of the tumor, and apply nitric acid or Fig. 269.— Cancel- lous exostosis, growing from the lower part of the femur. (Druitt.) Fig. 271.—Multiple osteomata of the bones oi the head and face. (From a patient in the University Hospital.) 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 attachments o surrounding parts are then very slight, and their enucleation comparatively easy. o ignon reports a case in which such a growth was successfully removed by Demar- quay from the maxillary sinus. 536 TUMORS. caustic potassa, as recommended by Stanley, in hope of inducing exfo- liation. Those exostoses which are not pedunculated, and which, therefore, are properly called Outgrowths (Osteomata), 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, bv inter- ference with the brain. If limited to the jaw, and to one side, excision of the bone might properly be tried; but if bilateral, or involving neighbor- ing parts, no operation should be attempted, except, perhaps, the applica- tion of caustics, as in the frontal and orbital growths already referred to. Fig. 271, 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 princi- pal localities of adenoid tumors are iu or near the mammary, the prostate, the thyroid, the labial, and the lymphatic glands, though they also occur in the parotid, sebaceous, and sudoriferous ylands. Glandular structure, moreover, forms an important part of the submucous fibro-cellular tumors which constitute mucous polypi, as well as of the complex ovarian cysts. The mammary, and probably some other glandular tumors, sometimes ap- pear 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 lobated, and may be flattened by pressure. They have commonly a distinct investing capsule of connective tissue, and are but slightly vascular. On section, they appear of a gray or yellowish-white hue, of variable density and 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, tt„ 070 k* ^ <■ tv. v/,„n glandular tumors, especially Fig. 272.—Adenoma of the mamma. X 300. <• i • • n (Riudfleisch.) 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 Turner as equivalent to the Lymphoma of Virchow, "to express 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 lymphatic glands." In most cases these lymphoid tumors occur in parts where lymphatic glands are known to exist, but in other instances they have. NEURALGIC TUMORS. 537 been met with as entirely independent formations. Thev are frequently multiple. They have been observed by Virchow in the liver and kidney, by Church in the mesentery and extra-peritoneal tissue, and by Mur- chison in all these organs, as well as in the intestine and heart. The Fig. 273.—Lymphoma.—a, a thin section of a lymphoniatous 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 201). (Greek.) treatment recommended by Billroth and Czerny is the use of arsenic both internally and by parenchymatous injection ; excision is occasionally justifiable. Vascular or Erectile Tumors (Angeiomata) are of most fre- quent occurrence in the skin and subcutaneous tissue, though they may also be found in any structure which is itself vascular. They are 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 Naevi. The diagnosis and treatment of these affections will be considered in the chapter on Diseases of the Vascular System. 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- Ivmoh iustead of blood. & J r- > 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- branes, 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 mav occur in serous tissues, particularly the arachnoid; the "'Pacchionian bodies are, according to Von Luschka, merely enlargements of the villi normally existing in this part. The papillary tumors above described are of a non-mahgnant 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. ,v-ffeUralgic Tum°rs—This is a group embracing such tumors as are, uunout any perceptible reason, the seat of intense neuralgic pain. They 538 TUMORS. 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. XXIX.), 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 realty a painful subcutaneous tubercle, though occasionally a simple adenoma. The pain in all of these cases is of a paroxysmal character, and is often compared to an electric shock. During the paroxysm, the tumor itself commonly becomes sensitive and swollen. Fig. 274.—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 their place and float away, as it were, under the surgeon's manipulations. They consist in some cases of movable kidneys, but are probably sometimes SEMI-MALIGNANT OR RECURRENT TUMORS. 539 loosely attached ovarian cysts, portions of thickened omentum, etc., or even fecal accumulations. Phantom Tumor is the name given to an apparent tumor which vanishes spontaneously, and which usually consists of a partially and spasmodically contracted muscle. In other cases an accumulation of gas, or a thickened or fatty omentum, has been known to simulate an ovarian tumor, and laparotomy has actually been performed under these circum- stances. The usual seat of phantom tumors is in the abdomen, though 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 occasionally 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 ma- jority (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 granulation or fibro-plastic cells, and correspond to what Virchow calls the " Spindle- celled Sarcoma." Fig. 276.—Recurrent fibroid tumor of thigh (spindle-celled sarcoma) contain- ing a large cyst. (From a patient in the University Hospital.) These recurrent tumors differ in general character from the non-recurrent growths of the same varieties, in being softer and more friable, rather more juicy, and somewhat more glistening on section. Under the microscope they exhibit a large proportion of cells, and fewer formed fibres, with large and often free nuclei and nucleoli. Under the name of Fibro-nucleated Tumor is described by Bennett a torm of recurrent tumor which is very analogous to the recurrent fibroid Fig. 275.—Recurrent fibroid tumor, or spindle- celled sarcoma. (Green.) 540 TUMORS. 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 mi- croscopic characters resemble foetal marrow. The characteristic myeloid cells are round, or irregularly oval, clear, or slightly granular, from 16XSJS to 3^ff 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- shaped, caudate, or spindle-shaped (fibro-plastic) cells, whence the name sometimes used of Fibro-plastic Tumor, though this is more appropriate to the recurrent fibroid variety. These tumors are rarely found except in the bones, 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 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. 277.—" Giant-celled sarcoma," or myeloid tumor, a points to 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 point;1 as a 1 Successful cases of excision of tbe lower ends of the ulna and radius for myeloid tumors of those parts have been reported by Lucas and Morris. ROUND-CELLED AND OTHER SARCOMATA. 5-41 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 lymph- atic 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 Virchow 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." (Virchow.) 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." (AHrchow.) The following are Virchow's subdivisions of sarcomata according to their cellular structure:— (a) Reticulo-cellular Sarcoma; like the typical connective-tissue (fibro- cellular) tumor, but with a larger proportion of cells. (6) Spindle-celled Sarcoma; containing fusiform or fibro-plastic cells; corresponds with fibro-plastic, recurrent fibroid, and fibro-nucleated tumors. Cells often arranged in lamellae, bundles, or trabecular (lamellar, fasciculate and trabecular sarcomata). Fig. 278.—Several varieties of sarcoma. (Bryant.) (c) Globo-cellular or Round-celled Sarcoma; often mistaken for medul- ry carcinoma, but can be distinguished by observing that the cells of the rcoma are m constant relation with an intercellular substance, whereas ose of carcinoma are intimately connected with other cells alone. Glioma is a variety of round-celled sarcoma, originating in the neurog- * or delicate connective tissue of the brain, auditory nerve, or retina. 542 TUMORS. Under the microscope, the tumor is found to consist of round or oval, and sometimes 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 in- creased intra-ocular tension. They may prove fatal by extending backwards within the cranium. Complete and early extirpa- tion of the eyeball is the only treatment to be recommended, though even this will not always prove successful. (d) Colossal-celled, Giant-celled, or Gi- gantic-celled Sarcoma; contains very large cells, with numerous nucleolated nuclei; corresponds with the myeloid or myeloplaxic tumor. Billroth also describes an alveolar sar- coma, 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 va- riety 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 the name of endothelioma); a hemorrhagic sarcoma; and a myxosar- coma or net-celled sarcoma. 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 variety of tumor results, which might properly be called Carcinomatous Sarcoma. Fig. 279.—Multiple round-celled sar- coma of leg. (From a patient in the University Hospital.) Fig. 280.—Alveolar sarcoma. (Billroth.) The intercellular substance in sarcomata usually contains albumen, casein, or mucin (whence another subdivision might "he made into albumi- MALIGNANT TUMORS OR CANCERS. 543 nous, caseous, and mucous sarco- mata), and, under the micro- scope, appears homogeneous, granular, or fibrillar. Finally, sarcomata are distin- guished by the vascularity upon which depends their characteris- tic succulence. They are often the seat of parenchymatous ex- travasations, these "hemorrhagic infarctus" sometimes giving rise to new productions of pigment- matter. According to J. Jackson Clarke, sarcoma, like carcinoma, is causally connected with the presence of psorosperms. The treatment of sarcoma consists in excision, but the growth almost invariably recurs, and ultimately leads to a fatal termination. Arsenic is sometimes adminis- tered internally, and Fehleisen, Brune, Coley, and others have observed temporary benefit from inoculations of the micro-organ- ism found in erysipelas. Lees advises interstitial injections of corrosive sublimate in oil (1- 2000). For further information upon the subject of sarcomata, the reader is referred to the nineteenth lecture of Virchow's work on Tumors, from which this account has been principally taken, and to Mr. Butlin's excellent article in the fourth volume of the International Ency- clopaedia of Surgery. Malignant Tumors or Cancers ; Carcinomata and Epitheliomata. 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 malig- nant course than Epithelioma. The terms Malignant Tumor and Cancer are used by Paget, Moore, Pemberton, and other writers, as synonymous *tth Carcinoma, and Epithelioma is by them considered to be merely a vanety of that disease. It is, however, upon the whole, better, I think, to separate epithelioma from carcinoma (from which, indeed, it differs in a gooa many points), though its clinical characters are such as to make it pioper to retain it among malignant tumors. Carcinoma — There are two principal forms of carcinoma, the hard i scvrhous, and the soft or medullary—the terms melanoid, haematoid, MPn'rio 1¥ aPPll(lable t0 varieties of these, rather than to distinct and inde- Lm7n ;-°TS ofJd,sease- Hard and soft carcinoma may coexist in the alde-Sh T ' 6Ven iQ the Same tumor5 but they are not interchange- nnr w 1S t0 Say' a mass of scirrhous tissue never becomes medullary, uor uce versa. Fig. 281.—Sarcoma of arm and shoulder. (From a patient under the care of Dr. Massey, of West Chester.) 544 TUMORS. 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 usually supposed that the development of scirrhous carcinoma is in some way connected with the cessation of the menstrual flow, but statistics do not support such a view. Scirrhus is sometimes predisposed to by inheritance, and its development is sometimes directly traceable to the reception of an injury, or other local cause. It appears to be proportion- ally more common among married than among single women. Scirrhus usually occurs in persons who are otherwise healthy, and is at first unat- tended with much pain ; so that it may frequently exist for some time be- fore its presence 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 appear quite healthy, the microscope may reveal the presence of cancer elements, so that scirrhus is said to be often surrounded with ahalo 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, Fig. 282.—Section of scirrhous breast, showing retraction of the nipple. (Liston.) by inducing contraction of the neighboring tissue. Even in its earliest stage, however, scirrhus has usually its char- acteristic hardness, a peculi- arity which is so marked as to have given the disease its Fig. 283.—Scirrhus of breast in stage of ulceration. a patient in the Episcopal Hospital.) (From 1 Cullingworth has, however, reported a remarkable case of mammary scirrhus which was completely surrounded by a distinct fibrous capsule. A case of enc lated scirrhus has also been reported by Wheeler. SCIRRHUS, OR SCIRRHOUS CARCINOMA. 545 name. As a scirrhous tumor grows, it becomes painful, the pain com- monly being of a lancinating, " electric" character. Though the growth is in itself not sensitive to the touch, the pain in the tumor is aggravated by handling. As the scirrhous mass in its growth approaches0the skin the latter becomes adherent, the shortening of various subcutaneous fibres giving a dimpled or pitted, somewhat brawny or lardaceous (Fig. 284) appearance to the part, and, in the case of the breast, inducing retraction of the nipple. After a time ulceration occurs, either (1) superficially, when the adherent skin, having become infiltrated and congested, becomes excoriated or cracked, a small, superficial, indolent ulcer resulting (Fig. 283); 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 evacuated, 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 ulceration has certain features, such as elevated, knobbed, and everted edges, a hard and nodular base, cancerous walls, and a peculiarly offensive discharge, which, when combined, serve to characterize the so-called Can- cerous Ulcer (Fig. 284). The ulceration of a scirrhous tumor may persist for a long time, and even cicatrization may occasionally occur, the cicatrix being thin, red or livid, with an irregular surface, and much'disposed to Fio. 284.-Carcinoma of both breasts; ulcerated on left side; on right side showing lardaceous appearance of skin. (From a patient in the University Hospital.) reulcerate. More commonly, the ulcer, as has been said, constantly en- arges, though not as rapidly as the tumor itself; considerable portions of jne growth may become, from time to time, inflamed, and slough, and Hemorrhage may occur from the fungous granulations, or from the ulcera- tei invading neighboring vessels, until finally the patient dies, exhausted uyine profuse and fetid discharge, pain, and loss of blood. in wt"k? (jhlch is at first usually solitary) not only grows in the locality wnich it first occurs, but becomes diffused, by multiplication in other 00 546 TUMORS. parts of the body.1 The most frequent seat of secondary deposits is 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. Nunn believes that in cases 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 par- 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 important 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 Bell's vivid picture is that usually referred to, and the continued emaciation, leaden hue of countenance, pinched features, and livid lips and nostrils, of which he speaks, are undoubtedly seen in cases of scirrhus, but probably not more often than in other exhausting and painful diseases; in fact, 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 yrears, or even longer, and, the tumor ceasing to grow, and perhaps cicatrizing if ulcerated, the patient may at last die from some other cause. I have myself operated upon persons in w'hom 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. Fig. 285.—Secondary growths of scir- rhus. (Miller.) 1 It is often said that the secondary growths in cases of scirrhus are of an encep 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. SCIRRHUS, OR SCIRRHOUS CARCINOMA. 547 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 purple 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^ to 7^ of an inch in diameter, the most usual size being about y^o-o or t(Too of an inch ; the average length of the nucleus is about s^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. lie 286.—Cells from a scirrhus of the mamma. X 250. (Green-.) Fig. 287.—Microscopic appearance of scirrhus. (Green.) Beside these, which may be regarded as the normal elements of scirrhus, cells are often seen which are withered, or in various stages of degenera- tion; the cells may be 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 audition to the carcinomatous elements themselves, a scirrhous tumor j;nows, under the microscope, various structures, glandular, muscular, n^rous, areolar, etc., which belong to the tissues in which the neoplasm appens to be growing, and which are present in varying quantities, being 'east apparent when the cancer-structure itself is most abundant. 548 TUMORS. The anatomical characters of scirrhus, when occurring as a secondary deposit, as, for instance, in the lymphatic glands, do not differ in any- essential respect 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 spreading, comparatively superficial affection, rather than as a tumor; it is thus met with on the surface of the thorax, sometimes originating in the skin itself, at other times in the mam- mary7 gland, or as tubercles in the deeper planes of tissue, but always at last involving both superficial 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 implies, 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 medullary 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 marked in medullary as in scirrhous carcinoma, while the proportion of cases in which previous 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 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 pre-nre of the skin, appears to grow with increasing rapidity, and soon protrude- MEDULLARY OR SOFT CARCINOMA. 549 Fig. 288.—Medullary carcinoma in stage of ulceration, tumor protruding. (Dkuitt.) through the opening—the exuberant mass usually becoming inflamed, slough- ing, and bleeding, and constituting the bleeding fungus, or Fungus Haematodes, of the older writers. Medullary carci- noma occurring in bone is sometimes attended with a distinct pulsation (see p. 538). The course of medullary carcinoma is commonly towards an early death, but occasionally—even after ulceration —large masses of encephaloid matter may slough away, cicatrization follow- ing, and thus leading to at least a tem- porary recovery. Medullary carcino- mata sometimes wither, becoming shrivelled and concentrated, and finally temporarily disappearing; in other cases they undergo fatty degeneration, ceasing to grow, and becoming "obso- lete." Usually, however, while this change occurs in one tumor, others continue to increase. Calcareous degeneration is a rare occurrence, and, when seen, is usually combined with the fatty change above referred to. The occurrence of hemorrhage and of sloughing in medullary carcinoma has already been mentioned More rarely, inflammation of such a growth ends in suppuration and in this way, too, temporary disappearance of the tumor may be effected Medullary, like scirrhous 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 thev 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, tor it often rapidly disappears when the morbid growth is removed the patient quickly regaining flesh and strength. The average duration of medullary carcinoma is decidedly less than that of scirrhus, more than hree-fourthsof those affected dying within three years, and the expecta- mtL°f lye 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 comparatively firm and elastic, approximating in character to the acute variety of scirrhus. The tumor has a rounded n n« i ° «Vne' is °ften markedly lobulated, the lobes extending through uscuiar, horous, or bony interspaces, to a considerable distance from the Lnl? i PruiciPal mass. These outlying projections are apt to tmL« ?P attachments. or may surround and inclose important struc- snnifiSUCi a" e Car0tid artery- J^Iar vein, or phrenic nerve. The " Wh Vei"s> over a soft carcinoma, are usually enlarged and tortuous. whiehT \™;dullary carcinoma is surrounded with a capsule, the latter, thp lnhl Vu U connective ^ssue, often sends in septa, which may separate tones of the tumor, or, if it be not lobated, merely traverse its substance. 550 TUMORS. Fig. 289.—Microscopic appearance of me- dullary carcinoma. (Green.) The capsule is vascular, tense, and may or may not be adherent to surrounding structures. When cut into, the con- tained tumor protrudes, or, if very soft, oozes out like a thick fluid. When laid open, a medullary carcinoma has com- monly a lobated appearance, the various lobes, with their investing septa, bein" often distorted by mutual compression, and having the appearance of a mass of cysts filled with intra-cystic growths. The substance of a medullary carcinoma varies in color, being usually gravisb- white, but sometimes tinted with yellow, pink, or violet. In the softer tumors it has but little consistency, being friable or pulpy, like softened brain- matter, or grumous and shreddy ; while in the firmer varieties it is com- pact and resisting, is somewhat glistening on section, and occasionally presents a fibrous appearance. By pressing or scraping a medullary car- cinoma, 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 appearing 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, ,jg'0o- to ^soo" °^ an inch long, bright, well-defined, and containing large and often double nucleoli; (2) large elongated or caudate nuclei, containing granular matter, or one or more large nucleoli; (3) large round or oval nuclei, resembling lymph-corpuscles, and containing numerous shining granules, but no dis- tinct nucleoli; (4) very numerous elongated and caudated cells, resem- bling those of the recurrent fibroid tumor, and giving the mass a fibrous appearance on section; (5) large round cells, containing granules, and either no perceptible nucleus, or one which is smaller and more granular than that of the ordinary 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 521 I shall say but little, as OTHER VARIETIES OF CARCINOMA. 551 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 pigment 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. 542) Fig. 290.—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, nucleus-like corpuscles;_ it corresponds with the normal pigment of the choroid coat of the eye, with that of the rete mucosum in the black races, and with that found in the lungs and bronchial glands of old people. The course and natural history of melanotic cancer are very much those of encephaloid ; it has, however, a still greater tendency to spread, by multiplication, in the subcutaneous tissue, as w^ell as to involve internal organs. It is peculiarly apt to grow beneath pigmentary cutaneous moles. Esematoid 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 Hee- matodes of Hey, Wardrop, and other writers (Fiir. 291). k b Osteoid Cancer.—" I be- lieve," says Paget, "the most probable view of the nature of osteoid cancers would be expressed by call- ing them ossified fibrous or medullary cancers, and by regarding them as illus- trating a calcareous or osse- ous degeneration." Osteoid cancer usually occurs in bone (particularly m the lower part of the femur), but is also seen in the inter-muscular spaces tol 'Whatic glands, etc! When met with in bone, it may occupy either the in- Fig. 291.—Haematoid cancer of breast. (Millee.) 552 TUMORS. terior or exterior, or both, and has usually an elongated oval or biconvex shape, according to the nature of the bone in which it occurs; it has a smooth surface, is hard, nearly incompressible, painful, and often tender when touched. The bonyr 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-corpuscles, in containing no medulla (its interspaces 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 lamella?, with edges directed out- wards. The unossified part of the tumor is very hard, tough, and incom- pressible, 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 car- cinoma-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 ofteu 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 the removal of the primary growth, life was pro- longed for twenty-four and twenty-five years, respectively. 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 page 537), 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. Fig. 292—Colloid carcinoma. Showing the large alveoli, within which is contained the gelatinom colloid material. X 300. (Rindfleisch.) 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 NATURE OF CARCINOMA. 553 of a stroma of more or less delicate white fibrous tissue, forming alveoli or cysts 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 (EJ}\jj to ^„ 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, 5-^ to ^ of an inch in diameter, sometimes with a lamellar surface, and containing one or more nuclei' with granules, and sometimes complete nucleated cells: and (3) large laminated spaces, T^ to -6\ of an inch in diameter, with elongated nuclei between the lamellae of their walls, small nucleated cells and nuclei in their interspaces, and brood-cells in their internal cavities. The diversity in structure between colloid and other carcinomata is attributed 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 for those rare cases of fibrous tumor which run a malignant course, and which have already been referred to under the name of Malignant Fibroid (p. 532). Nature of Carcinoma—I do not purpose to enter into any 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, 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 patient's part, give rise to the formation of a cancer, it is hard to believe; at the same time, cancer may undoubtedly (from a practical point of view) be looked upon as, at first, a local affection—its early manifestations being of a local nature, and the only applicable treatment being of a topical character; even when "cachexia" precedes the appearance of a cancerous tumor, the removal of the latter may relieve, at least temporarily, the cachectic condition. With regard to the anatomical origin of 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 Waldeyer, who maintain, on the other hand, that carcinoma can only originate in a tissue of an epithelial type ; (3) that of Maier, who holds an intermediate opinion, believing that fibrous growths may be transformed into sarcomata, and these in turn into carcinomata;2 (4) that of Koester, •See also the works of Virchow, Billroth, and Rindfleisch, Dr. J. J. Woodward's w"tf a cture" 0873), and an interesting paper on the Development of Cancer, published by Waldeyer in Virchow's Archiv, and analyzed in the Archives Generates ae Medeane for October, 1873. ,. ^cc<)rding to Maier and Creighton, the essence of carcinoma consists in its property oi injecting 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 kin and its appendages which require surgical manipulations in their treat- ment, and which may, therefore, be here appropriately referred to. Verrucae or Warts.—Wart- consist of by pertrophied cutaneous papillae, which may project, each papilla by itself, or, as is more usual, ensheathed by a common in- vestment 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 appear upon the hands and face come without any apparent cau>e, 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 growth- known as moles. The treatment consists in the application of nitrate of silver in substance, nitric or chromic acid, a saturated solution of the bichromate of potassium, or the muriated tine- Fig. 301.-Warts around the anus. (Ashton.) ture of iron—Or in ligation or ONYCHIA. 563 excision, if the wart be pedunculated. Warts occasionally have a moist, muco-cutaneous covering, and are irritable and disposed to bleed ; the gly- cerite of tannic acid will often be found a useful application in this form of the disease. Warts not unfrequently occur upon the muco-cutaneous surfaces of the anus, or of the genital organs in either sex, and in the latter situation are often spoken of as venereal warts or vegetations ; thev are not, however, necessarily of a venereal origin, but may be pro- duced simply by the irritation of frequent sexual intercourse, or may even result from the 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. According to Kiih- nemann, the common wart presents a peculiar bacillus not found in other tissues. 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. Bursae 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 part from pressure by the use of suitable shoes or the application of a perforated plaster, in shaving off the surface of the corn and applying the solid stick of nitrate of silver to its base, or in excising the centre of the indurated part with a sharp knife, or scissors, after the whole has been softened by the use of a warm water-dressing. Soft corns may be dusted with powdered oxide of zinc, or touched with nitrate of silver or glacial acetic acid, the toes being kept apart by the interposition of scraped lint or raw cotton. Suppuration occurring beneath a corn requires poulticing and the evacuation of the pus after shaving down the part with the point of a sharp lancet. Onychia is an affection of the matrix of the nails, of which we may recognize two varieties, the simple and the malignant. Simple Onychia, or, as it is vulgarly called, "run-around," consists in an inflamed condition of the matrix of the nail, usually resulting from slight injury, and attended with suppuration and loosening of the nail, which becomes shrivelled and discolored, and is eventually cast off—the new nail which forms being commonly thickened and distorted. This affection occurs chiefly in the hand, and is almost exclusively 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 application of an adhesive strip or a layer of wax. 564 SURGICAL DISEASES OF THE SKIN. 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 occupied by fungous granulations. The disease has little or no tendency to a spontaneous cure, and sometimes leads to necrosis of the ungual phalanx. The treatment may consist in avulsion of any portion 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 applying powdered nitrate of lead, as advised bv Moerloose, Yanzetti, and MacCormac ; the nitrate forms a thick crust Fig. 302.—Malignant onychia. Fig. 303—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 Vanzetti recommends the employment 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 506 : it requires the application of black or yellow 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, w-hich 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 sharp-pointed scissors beneath the nail up to its root, when the whole nail may be divided at a single stroke; the segment to be removed is then grasped with forceps, and torn away from the matrix, this process being repeated on the other side, if necessary, and the part then simply dressed. 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. RODENT ULCER. 565 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. 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 consid- erable pain. In their structure they correspond with the fibro-cellular outgrowths described in the last chapter. The Keloid of Addison begins as a " white patch or opacity" of the skin, surrounded by a zone of redness, gradually spreading and inducing contraction of 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 un- satisfactory. Extirpation with the knife has been tried, but the disease almost invariably^ recurs. Nussbaum and Andeer advise the local applica- tion of resorcin, and Hardaway reports a cure following the employment of electrolysis. Leviseur recommends deep scarification, followed by the use of caustics or the thermo-cautery. 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 papillary 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's Ulcer, is most often seen in the eyelids, cheeks, upper lip, nose, or scalp, but may also occur in other parts of the body. It is a disease of late adult life, and commonly originates in some tubercle or mole, which may have existed for many years. It is usually single, at first rounded, but becoming irregular as it spreads, with indurated base and edge, and a somewhat abrupt and hut 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 in- volved. Fig. 304, from a photograph kindly given me by Prof. De 566 SURGICAL DISEASES OF THE SKIN. Fig. 304.—Kodent ulcer of sixteen years' standing, causing loss of orbital contents. (From a patient under the care of Dr. De Schweinitz.) Schweinitz, exhibits rodent ulcer in a typical form. The microscopic charac- ters of the rodent ulcer are, according to Paget, Hutchinson, and (Jolding- Bird, simply those observed in ordi- nary 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 excel- lent monographs upon the subject, look upon it as a form of cancer. The treat- ment consists in complete extirpation, which is best accomplished, when pos- sible, with the knife. If, however, ex- cision be contra-indicated by the size or locality of the ulcer, or the age of the patient, caustics may be employed, the Vienna or Canquoin's paste, or nitric acid, or acid nitrate of mercury, being respectively preferred, according to the deep or superficial character of the affec- tion. Fig. 30.3.—Rodent ulcer in an advanced stage. (From a patient in the University Hospital.) Perforating Ulcer of the Foot__This is a curious affection, which appears to be less common in this country than in Europe. I have, how- ever, seen twTo cases of the disease, corresponding in every particular with the descriptions given by Hancock, Duplay, and other writers on the sub- ject. The affection consists in an intractable form of ulceration, usually occupying the anterior part of the sole of the foot, and leading to destruc- LUPUS. 567 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 anaesthetica), but Duplay and Morat, from dissection of numerous specimens and careful study of the literature of the affection, .•onclude that the disease originates in degenerative lesions of the nerves of the part, from traumatic or other causes. Fischer, Savory, and Butlin adopt a similar theory, and the former describes the disease as a malignant form of neuro-paralytic ulceration ; but a more recent autopsy recorded bv 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 bursa? mucosae of the sole, and con- cludes that it is caused by a vascular change analogous to the endoarteritis obliterans or proliferans of Friedlander and Billroth. Perforating ulcer has been not unfrequently confounded with the Mycetoma, or fungus disease of India (tubercular disease of the foot, of Hancock), which is believed by Boyce and Surveyor to be identical with actinomycosis. The treatment consists in removing the diseased bone by gouging, excision, or, if neces- sary, 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 vas- cular 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. Xerve-stretching is recommended by McLeod. 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 SimpAe Lupus, and Lupus Exedens, or Ulcerating Lupus. Lupus Non-exedens appears 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 in- convenience 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, especially of cod-liver oil, with arsenic, and in the local use of a solution of nitrate of silver, gr. x-xx to fgj. Lupus Exedens, Ulcerated Lupus, or Lupous Ulcer, is usually seated on the tip or alae of the nose, but sometimes of the upper lip, or in other situations, and is chiefly seen in young persons. It begins as one or more reddish papules or tubercles, wThich 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 phagedaenic form, which was known to the older writers as noli-me-tangere. The phagedenic lupous ulcer is a very painful affection, attended with great destruction of tissue, and accompanied with a fetid discharge. Under its influence the greater part of the nose may melt away, as it were, in the 568 SURGICAL DISEASES OF THE SKIN. 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 be- come at least temporarily ar- rested. The affection rarely proves fatal by itself, and cica- trization may occur, adding to the deformity caused by the dis- ease, by inducing contraction and distortion of neighboring parts. The microscopic ap- pearances of lupus have been investigated by several pathol- ogists, among whom Essig finds that the corium is infil- trated with round cells which, in some specimens, follow the track of the vessels and arrange themselves in heaps around them ; spindle-shaped and giant cells are also found in some fig. 306.-PhagedaeDic lupous ulcer. (Druitt.) cases. According to Thoma and Thin, the cell infiltration originates in exuded white corpuscles. Lang believes the giant cells to rep- resent the intermediate stage in the process of degeneration of the tissues. Friedlander looks upon 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 con- sists 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 employment, for from half a minute to two minutes, of a solution of caustic potassa (one part to two), followed by appli- cations of finely powdered iodoform. J. G. Marshall employs with success an ointment of salicylic acid (3iss-|j), and Bertarelli one of resorcin (50 per cent.). Advantage appears to have been derived in some cases from the use of Koch's tuberculin, though the expectations of benefit from this remedy have, on the Avhole, not been realized. Kliegl recommends injec- tions of teucrin, and Hebra those of thiosinamine, a preparation made from the oil of mustard, alcohol, and ammonia. The phagedaenic variety of lupus requires the application of caustics, or of the actual or electric cau- tery, together with the constitutional treatment already recommended. Volkmann employs evasion, or scraping away the diseased tissue with a sharp spoon or scoop (see Fig. 239, page 247), and Hutchinson prefers this mode of treatment, which has proved very successful in my own hands, to any other; Piffard, Morris, and 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 iodo- form and oil of eucalyptus. Squire recommends linear scarification, as m eases of " port-wine stain." (See Chap. XXX.) Harrison employs lotions of hyposulphite of sodium and hydrochloric acid alternately, so as to get the effect of nascent sulphurous acid. Excision may be resorted to in DISEASES OF THE LYMPHATIC SYSTEM. 569 certain situations, as the upper lip or nose, the resulting gap being closed by a plastic operation, if necessary. Lupus, complicated with a syphilitic taint, requires the administration of the iodide of potassium. Malignant Diseases of the Skin—Both carcinoma and epithe- lioma may occur primarily in the skin, as was mentioned in speaking of those affections. The treatment consists in excision, or amputation, ac- cording to the size and situation of the malignant growth. Diseases of the Areolar Tissue. Cellulitis, or Inflammation of the Areolar Tissue, may be circum- scribed or diffused: in the former case it gives rise to an abscess, and in the latter to diffused suppuration. When depending upon an erysipela- tous taint, it constitutes cellular erysipelas (see pp. 438, 455). Elephantiasis Arabum, or Arabian Elephantiasis, 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 XXVII. It is chiefly seen in the scrotum, and in the lower extremity, where it constitutes the affection known as Barbados leg. Its appearances are well shown in the annexed cut (Fig. 307). This form of elephan- tiasis is closely analogous to the affection known by mod- ern pathologists as Sclerema or Scleroderma, as well as to that described by Mott and Stokes as Pachyderma- tocele, the Eiloides of War- ren, the Dermatolysis of Wilson, and the Molluscum fibrosum of Pollock and Ford. The treatment con- sists in the use of pressure, ligation of the main artery of the part, excision, or am- putation, according to the circumstances of the particular case (see page 529) hypodermic injections of pilocarpine. Fig. 307.—Elephantiasis Arabum in the lower extremity; Barbados leg. (Smith.) Poulet recommends Diseases of the Lymphatic System. Angeioleucitis or Lymphangeitis (Inflammation of the Lym- phatic ^ Vessels or Absorbents) may occur as an idiopathic affection, as a complication of erysipelas, or as the result of the irritation produced by a wound, ulcer, or local inflammation, as in cases of gonorrhoea. Its occurrence is usually preceded or accompanied by marked constitutional disturbance, ngors, 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 570 DISEASES OF THE MUSCLES AND TENDONS. point at which the disease originates to or beyond the nearest lymphatic glands, which are always themselves inflamed. The line of the absorbents is somewhat doughy, and not very tender, and the limb is usually swollen and often erythematous. If the inflammation affect only the dee]) lymph- atics, the affection of the glands mayr 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 peculiar cord-like and knotty sensation to the touch. The local treatment consists in the application of nitrate of silver along the line of inflamed lymphatics, so as to blacken without blistering the skin ; the limb may then be wrapped in carded cotton. If suppuration threaten, poultices may be employed, 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 495), 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 ad- ministration of anodyne diaphoretics during the acute stage, and tonics, such as cod-liver oil and iron, especially in the form of the iodide, when the affection assumes a chronic form. The lymphatic glands are affected in Tuberculosis, in Scrofula, and in Syphilis, and are frequently the seat of various morbid growths, particu- larly the adenoid, and those of a malignant nature. The treatment appro- priate to these various conditions has already been described in the chap- ters on the several affections referred to. Varicose Lymphatics; Lymphangeiomata.—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 filariae. By spontaneous rupture, or accidental wound, a fistulous opening may be formed, through which the lymphatic fluid escapes, constituting thedisea.-e known as Lymphorrhcea. The treatment consists in the application 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, especially of the bones TUMORS IN MUSCLES. 571 and joints. Its symptoms and treatment have already been sufficiently considered in the chapters on Inflammation in general. Fatty Degeneration of muscle is a not infrequent sequence of in- flammation of the muscular tissue, conjoined with long disuse, and may probably in some cases be dependent on the latter cause alone. In some cases, to which the name of interstitial fatty degeneration has been given, the striated character of the muscular fibre is still preserved, the connecting tissue alone being replaced by oily matter ; in other cases the change is more complete, the whole muscle being converted into a fatty and granular mass (necrobiotic or intrinsic fatty degeneration). The latter condition appears to depend upon more complete disuse of the muscle than the inter- stitial form, and is probably 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 rijrid contraction of the affected muscle, giving rise to deformity, and often attended with much pain. This is most often seen in the sterno-cleido- mastoid and splenius muscles, the rigid contraction of which causes the affection known as stiff or wry-neck. The pelvic muscles also often become contracted as a consequence of hip disease. Rigid muscular contraction may likewise result from mere disuse, from long-continued spasm, and from paralysis of opposing muscles. Examples of the two latter conditions are seen in cases of club-foot. When ri.uid contraction persists for a long time, it is accompanied by atrophy, and usually by fatty degeneration of the muscular tissue. The treatment of the inflammatory- form of the affection consists in the use of stimulating embrocations, and in the administration of anodynes, eolchicum, iodide of potassium, etc. ; while the more permanent cases require the use of elastic extension, or division of the contracted muscle or its tendon. (See Orthopaedic Surgery.) Ricord and others have described a peculiar form of muscular contraction which is dependent upon syphilis; it is chiefly seen in the biceps, and yields readily- to the administration of iodide of potassium. Ossification of Muscle is a rare affection, of which cases have been recorded by Abernethy and Hawkins, and which apparently depends on the coincidence of muscular inflammation with a tendency to excessive bony deposit. Miinchmeyer 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. The treatment consists in the repeated application of blisters, with the internal use of eolchicum, iodide of potas- sium, etc. Tumors in Muscles.—Various 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- surgical principles. Excision usually-presents no particular difficulties, and, except in the cases of malignant tumor, may be expected to effect a permanent cure. Helferich and Lange have filled the gap left after removing muscular tissue affected with a tumor, by transplanting 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 572 DISEASES OF THE MUSCLES AND TENDONS. chance than excision, and should in most instances be preferred. If, how. ever, the case be seen at a very early stage, an attempt should be made to preserve the limb, by extirpating the tumor with a wide margin of healthy tissue. If practicable, the plan suggested by Teevan might be adopted, of dissecting out the entire muscle in which the malignant growth was seated. Tenosynovitis, or Inflammation of Tendons and their Sheaths or Thecee ( 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, Verchere, 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 sheaths 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 principally 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« fig. 308.-Feion. (Liston.) volving, perhaps, the remaining fin- gers, and causing extensive destruc- tion of parts by sloughing. In the worst form of the disease, or felon, the phalangeal periosteum is involved, often leading to necrosis and exfolia- tion of considerable portions of bone, with destruction of neighboring articulations. The disease commonly originates from some slight puncture 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 position, and with considerable constitutional disturbance. Though suppuration may occur pretty early in the disease, fluctuation is not very apparent, on account of the density of the intervening tissues. Gangrene is 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 deep incision should be made on one or both sides of the affected phalanx, so as to relieve tension and evacuate any pus that may be present. The incision should not be made in the centre of the finger, lest the sheath be opened, when the tendon would almost certainly slough; nor too far towards the side, lest the digital artery be wounded. * The incision should be made from above dowTnwards, so that, if the patient withdraw his hand suddenly, he may rather assist than hinder the completion of the operation. If suppuration GANGLION. 573 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 pha- 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 whitlow7 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, or with the capsule of a neighboring joint. Erichsen distinguishes two varieties, the simple ganglion, which is found on the tendinous sheath, and the compound ganglion, wThich consists of a dilatation of the sheath itself, and which often involves several adjacent tendons. According to C. S. Evans, the compound ganglion is really a tuberculosis of the sheath. 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' orginated from floating masses of fibrin, due to previous inflammation, or, as taught by Schuchardt, to have been separated from the lining wall of the sheath, which is itself often fringed and vascular. Ganglia occur chiefly in connection with the extensor tendons on the back of the hand or wrist, or on the dorsum of the foot, though they are also seen in the palm, extending beneath the annu- lar ligament, or on the side or sole of the foot. They occa- sion, in some cases, a good deal of pain by pressing on adjacent nerves, and sometimes inter- fere considerably with the motion of the tendons on which they are seated. The presence of the melon-seed- hke bodies may be recognized by the occurrence of a peculiar grating or creaking sound on manipulation. The treatment of the smaller ganglia Fig. 309.—Compound ganglion. (From a patient in the Episcopal Hospital.) 33 574 DISEASES OF BURSAE. mayT consist in rupture by forcible compression with the thumbs, or bv a sudden blow, as with a book ; or in puncture, and subsequent compres- sion. If these means fail, the interior of the cyst may be scarified, after puncture, with the point of a knife ; or iodine may be injected; or a seton established. Landerer injects a one-per-cent solution of chloride of zinc. Excision is attended with some risk—diffuse inflammation occasionally ensuing—and should therefore be employed with hesitation. For the larger ganglia, and especially those beneath the annular ligament of the wrist, repeated blisters may be employed, in hope of inducing consolida- tion ; or recourse may be had to iodine injection, or to the seton. Division of the annular ligament was recommended by Syme, and has been success- fully resorted to by Dr. Copeland. 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 Burs.e. Synovial bursas exist normally- in certain situations, and may be adven- titiously developed by continued friction or pressure in other localities. The most important bursas, 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. Bursas are also met with beneath the deltoid and gluteus maximus, between the point of the scapula and the edge of the latissimus dorsi, and in the popliteal space. Bursitis, or Acute Inflammation of a Synovial Bursa, is most fre- quently seen in the bursa patellae, constituting a variety of the disease or- dinarily known as "Housemaid's Knee," from the fact that women who constantly kneel in scrubbing are peculiarly exposed to the affection. Similarly, the enlargement of the bursa over the olecranon is knowrn as " Miner's Elbow." Acute inflammation of a bursa is attended with much pain and considerable constitutional disturbance. The swelling is superficial, and in the case of the bursa patellae above the bone—a diagnostic point of some importance, as in inflammation of the joint—the patella is floated up by the articular effusion. The treatment consists in the enforce- ment of rest, with the application of a suitable splint, a few leeches perhaps, evaporating lotions —or poultices and warm fomentations, if more agreeable to the patient—together with the ad- ministration of anodyne and sedative diaphoretics. If suppuration occur, a free and early opening must be made, and the case treated as one of fig. 3io.-Eniarged bursa abscess. If the incision be delayed, the pus may ZZ^r^™tJ. Effuse itself somewhat widely around tb. prt (Liston.) necessitating numerous counter-openings, oanw BUNION. 575 of the patella is an occasional sequence of housemaid's knee, requiring the use of the gouge to remove the diseased bone. Sloughing of the bursa mav likewise sometimes occur, leaving a large ulcer which slowly heals by granulation. Simple Enlargement or Dropsy of a Bursa (Hygroma) may result from subacute inflammation, or simply from long-continued pressure. This condition in the bursa patellas constitutes the true housemaid's knee, and sometimes causes considerable inconvenience by the bulk of the swell- in°\ The fluid in these enlarged bursas 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 separated by the friction and constant motion to which the part is subjected. Virchow and others have observed intra-bursal bands, attached by both ends to the wall of the tumor. The treatment consists Fig. 311.—Formation of seton with trocar and canula. (Erichsen.) in the application of discutients, such as iodine or blisters ; or in tapping followed by the injection of iodine, or by the establishment of a seton— the thread being passed through the canula as in Fig. 311. Favardin recommends the injection, without emptying the bursa, of a few drops 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 maybe 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 lymph in the interior of the sac, previously filled with fluid, until the whole or nearly the whole of the cavity is obliterated. A bursa, when cut open under these circumstances, presents a laminated appearance, such as is seen in a partially consolidated aneurism. In some cases, 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 any neighboring articulation, and, in the case of the bursa patellas, not to open the deep fascia which is attached to that bone, lest the structures of the ham should become involved in suppuration. Annandale has recorded a remarkable case of bony tumor occupying the position of the bursa pa- tellas, 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 by distortion of the foot from wearing narrow-soled and high-heeled shoes, by which the weight of the body is thrown forwards, while the toes 576 DISEASES OF BURSJ3. are crowded together. Hawes believes that the deformity is caused by displacement 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 developed, becoming enlarged and painful. The bunion is liable to repeated attacks of inflammation, and suppuration mav occur, leading perhaps to the formation of a fistulous ulcer, accompanied byr a carious condition of the bone and disorganization of the joint, consti- tuting a form of the "perforating ulcer of the foot" of French writers. (See p. 566) 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 apparatus (the action of which may be seen from Fig. 312); 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. Hawes recommends removal of the displaced external sesamoid bone. In mild cases it may be sufficient to protect the part by the application of tw-o or three thicknesses of soap plaster, cut into a horse-shoe form, as recommended by Brodie, and by the adaptation of a loose and well-fitting shoe. If the bunion contain fluid, and be uninflamed, attempts to promote absorption may be made by applying an ointment of the red oxide of mercury (gr. x-|j), which is highly recommended by T. Smith. If this fail, subcutaneous puncture and discission of the sac, followed by the external use of iodine, may be tried, and is, according to Gross, as satisfactory as, while it is certainly a safer method than, excision or incision with cauterization. If suppuration occur, the bunion must be opened and treated as an abscess. If caries and articular disorganization follow, 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 operation has been performed with good results by Kramer, Pancoast, and others, and the latter by several surgeons, including Hueter, Hamilton, Gay, of Buffalo, and A. Rose, who recommends the operation even in cases of simple contraction without caries {hallux valgus). Fia. 312. — Apparatus for treatment of bunion. the NEURITIS AND NEUROMA. 577 CHAPTER XXIX. 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 pain, 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 phenomena manifested in other portions of the body. The patho- logical appearances 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 depletion, with the application 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 Virchow as really false neuromata, or in other words, as fibrous tumors. Neuromata are almost exclusively confined to the nerves of the cerebro- spinal system,1 are most common in the male sex, and grow slowly, some- times attaining a very large size; they are commonly multiple, not less than 1200 sometimes coexisting, according to R. W. Smith, in the same patient. A neuroma is movable transversely, but not longitudinally, on the nerve upon which it is developed. Neuromata may arise sponta- neously, or as the result of injury ; they may occur in the continuity of a nerve, or at its cut extremity, as is seen in stumps after amputation (see The " plexiform ueuroma," however (a name given by Verneuil), has been found in the solar plexus. 37 578 SURGICAL diseases of the NERVOUS SYSTEM. page 122). They are often, but not alw-ays, 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 bv many- writers to be a " true neuroma" (see page 538). It is advised by Brown- Se"quard that, in examining a neuroma, the nerve should be firmly compressed above the tumor, so as to diminish the pain caused by the necessary manipula- fig. 3i3.-section of a neuroma; three tions. The treatment consists in extir- nervous trunks terminating in it. The pation 0f the tumor which should, if DOS- fibrous arrangement shown, as observed -i 1 1 j- l j r ,1 . , by the naked eye. (Sm.th.) Slble> be dissected from the nerve with- out 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 231). For the treatment of neu- romata in stumps, see page 123. 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. Kosinsky, and Duhring and Maury, have, however, reported remarkable cases of multiple painful neuromata of the skin, in which temporary relief was afforded by excision of the nerves of the affected parts. Neuralgia. Neuralgia is an affection of the nervous system characterized by intense pain of a paroxysmal form, usually- referred to the course of particular nerves. Any discussion as to the nature and pathology of neuralgia in 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 anasmia. 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. Sangree records a case of neuralgia of the fifth nerve from eye-strain. 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 variety of character and intensity ; it is always paroxysmal, and often absolutely intermittent, and is uniformly aggravated by the supervention of any additional source of depression." There are almost always tender spots (points douloureux) in the course of the affected nerve, particularly where it penetrates a fascia, or emerges from a bony canal, and very con- stantly there is tenderness over the spinous processes of those vertebrae NEURALGIA. 579 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 writh spasms 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 paroxysmal character, by the absence of fever, by the superficial nature of the pain (often accompanied with marked cutaneous hyperesthesia), and by its being relieved rather than aggravated by pressure; if, however, as sometimes happens, neuralgia coexist with deep-seated inflammation, it may be extremely difficult to de- cide how much of the pain felt is to be attributed to one, and how much to the other affection. In cases of neuralgia affecting the joints, the diagnosis may be assisted by remembering that organic disease cannot long exist in an articulation without causing deformity or other physical alteration. The prognosis of neuralgia, as regards life, is usually favorable ; the disease, however, is often very intractable, and may cause so much suffer- ing 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 particularly 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 adapted to anasmic cases, and valerianate of zinc and assafcetida to those which are complicated with hysteria. Advantage may often be derived from sea-bathing, or from the systematic employment 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 certain 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 Magendie'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 may be used, great care being exercised lest a poisonous effect be induced. Deep 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, 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 580 SURGICAL DISEASES OF THE NERVOUS SYSTEM. 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 and body 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 four out of five cases, in which I have employed it, has afforded entire relief. Prof. Gross, 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 operation 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 satisfactory than the ordinary mode of procedure. Sonnen- burg 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. 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 in- ferior maxillary nerve has been divided from without by Michel, Letievant, and Vallette, and from within by Ne*laton and Panas. The lingual nerve has been successfully excised by Kusinin, and Chiene has excised both this and the inferior dental nerve, exposing them by trephining the ramus of the jaw above the position of the inferior dental foramen. The Superior Maxillary Nerve may be reached, close to the foramen rotundum, by a Y-shaped or 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 operation, which was introduced by Car- nochan, has been at least temporarily successful in several instances; but that the relief is not permanent, would appear from the researches of Connor, 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 sub- sequent history of the patient traced for more than a year. Dennis, 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. A more radical procedure than Carnochan's is that of Pancoast and Salzer, to approach the nerve from the side, separating the zygoma which is turned downwards with a flap of the soft tissues, pushing the parts away from the external pterygoid plate, and dividing the nerve as it comes from the foramen rotundum with a curved tenotome. The inferior maxillary nerve may be reached in the same way at its exit from the foramen ovale. This operation has been successfully employed by Mixter, Weir, and other surgeons. Rose removed the Gasserian ganglion by trephining over the foramen ovale after preliminary excision of the upper jaw. Destructive inflammation of the eyeball followed, requiring enucleation of the globe, but the patient was freed from pain and remained well six month:- afterwards. The same surgeon has since operated several times success- NEURALGIA. 531 fully by approaching the part from the side, depressing the zygoma and cutting away the coronoid process of the lower jaw, and this operation has also been successful in the hands of Andrews, Tiffany, Park, D'Antona, and Lanphear. Andrews suggests that the ganglion might be attacked with a small curette after enlargement of the foramen ovale without tre- phining. Horsley, after removing the squamous portion of the temporal bone with trephine and forceps, divided the fifth nerve behind the Gas- serian ganglion—tearing it away from its attachment to the pons—the patient promptly dying; but Hartley, by temporarily separating the squamous portion and turning it downwards, was enabled to excise the ganglion completely^, and gave his patient relief, which continued six months subsequently. In order to prevent hemorrhage during these operations, Park ties the carotid as a preliminary step. 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, Vance, Golding-Bird, Sands, and myself, with at least temporary benefit. Gersung has supplemented neurectomy7 by transplantation of a rabbit's nerve to fill the gap caused by the opera- tion. Abbe, in two cases of intractable brachial neuralgia, exposed the lower cervical nerves by- excising the laminae of the corresponding vertebras, and divided the posterior roots of the affected nerves inside of the dura mater. The patients recovered from the operation, but did not appear to have been materially benefited. A similar case, involving the lumbar nerves, in the hands of W. H. Bennett, terminated fatally on the 12th day. 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 uppper section is made through healthyr structure ; to pre- vent reunion, 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. 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 re- moving that part with cutting-forceps; and T. G. Morton and E. Mason have cured neuralgia of the fourth metatarso-phalangeal joint by excision of the articulation. N. F. Graham has relieved a similar condition by re- section of the corresponding digital nerve. The operation of stretching nerves for neuralgia of traumatic origin has already been referred to at page 232, and the same operation has been employed in intractable cases of spontaneous origin by many surgeons, myrself included. Of 14 such cases collected by Gen, 10 were successful. The facial nerve has been successfully stretched in cases of spasm of the facial muscles by several surgeons, including Baum, Schussler, Eulenberg, Putnam, Southam, and Godlee. Walsham has successfully stretched the infra-orbital nerve, and LoDentu the lingual. The operation of nerve-stretching is not entirely free from risk, five cases recorded respectively by Socin, Langenbeck, 582 SURGICAL DISEASES OF THE NERVOUS SYSTEM. Billroth and Weiss, Berger, and Benedikt, having terminated fatally.1 Ligation of the common carotid artery, in cases of facial neuralgia, is ad- vised by Nussbaum, Weinlechner, and Patruban, and has been successfully resorted to by numerous surgeons, including Hutchison and F. II. Gross. Of 54 cases collected by Hueter, only 3 proved fatal. Tetanus. Tetanus is a disease which manifests itself through the nervous system, and is characterized by persistent tonic contraction of some or all of the voluntary muscles. In the large majority of cases tetanus results from a wround, 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 urasmic eclampsia2 than with true tetanus), it is by far most common in males in early adult life, though, probably not disproportionately- so, in viewr 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 dis- ease which particularly 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 severity7. 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 cam- paign 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 dis- ease 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, ac- cording 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 mastica- 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 the median and musculo-cutaneous nerves for congenital epilepsy. McLeod, Lawrie, and Wallace have successfully resorted to nerve-stretching for anozsthetic leprosy, and of 46 cases thus treated, collected by Mitra, more or l^ss im- provement was noted in 22; benefit has been claimed from the operation, by Laiigen- buch, in cases oi pemphigus and senile prurigo. R. M. Simon reports advantage from the same procedure in a case of infantile paralysis and Blum in one of hysterical tremor of the leg, while W. J. Morton reports good results from nerve-stretching in reflex epilepsy, paralysis agitans, athetosis, lateral sclerosis, and chronic transverse myelitis. Elaborate tables of cases of nerve-stretching have been published by Chandler, Artaud an>l Gilson, and Ceccherelli; 252 cases of all kinds, tabulated by the last-named surgeon- gave 189 more or less complete successes, 1(5 failures, 10 doubtful results, and 3i deaths—29 of these, however, in cases of tetanus. 2 According to Sims, Wilhite, and Hartigan, tetanus nascentium is a traumatic affec- tion resulting from displacement of the occipital or of one of the parietal bones. TETANUS. 583 tion; Opisthotonos, to spasm of the muscles of the back, the patient with arched body resting merely on head and heels; Emprostholonos (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 twTenty-two clays, 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 unhealthyr-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 mani- fested in the muscles of the wounded limb. In a short time, great diffi- culty in chewing or swallowing is felt, and trismus soon becomes fully de- veloped, 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 charac- teristic symptom of the disease; the abdominal muscles become tense, hard, and board-like, and all of the voluntary muscles, except those of the hand, ey-eball, and tongue, become more or less involved. The counte- nance assumes a peculiar, old-looking expression, being pale, anxious, and distorted into the so-called risus sardonicus or tetanic grin. This distor- tion of face sometimes persists after recovery, and Poland refers to a case in which it was still apparent after eleven years. During the height of the disease, the body is often arched backwards, so that the patient is sup- ported merely by his occiput and heels ; while the muscular spasm is tonic, and never entirely disappears, it is paroxysmally aggravated, and the cramps are occasionally so violent as almost to hurl the patient from his bed; the pain is greatest during the cramps, which are also accompanied by profuse perspiration, and great heat of skin (105°-110.75° Fahr., accord- ing to Radcliffe). The temperature may continue to rise even after death ; thus, in a case recorded by Wunderlich, the thermometer marked 108° before death, 112.5° at the time of death, and 113.5° a short time subse- quently. Ogle and Keen have recorded cases in which the evening was higher than the morning temperature. As the disease advances, the reflex excitability is much increased, the slightest touch or the least current of air being sometimes enough to bring on a paroxysm of cramp. Dyspncea and want, of sleep combine to render the condition of the patient still more deplorable. There is no delirium, and little or no fever, the heat of the skin being chiefly confined to the paroxysms, and the rapidity of the pulse being due to exhaustion rather than to febrile disturbance. Among the symptoms of less importance are constipation, retention of urine, priapism (probably due to spinal meningitis), aphonia, accumulation in the mouth and fauces of viscid saliva, self-inflicted lacerations of the tongue or cheek, 584 SURGICAL DISEASES OF THE NERVOUS SYSTEM. and permanently dilated or contracted pupils. Death may occur in a par- oxysm, from apncea ; or, at a later period, from simple exhaustion. There may be a certain degree of muscular relaxation previous to death, or tetanic rigidity may be, as it were, directly transformed into rigor mortis. Pathology.—The pathology of tetanus is involved in much obscurity. It is ordinarily^ called a disease of the nervous system, because it is through the medium of the nerves and spinal cord that its phenomena are mani- fested, and because the nervous system alone has as yet been found to present post-mortem changes with sufficient constancy to be considered significant. It is, however, almost certain that, as suggested by Travers, J. A. Wilson, Richardson, Humphry, and others, tetanus is essentially an infectious disease, due to the absorption of some septic material. Probably it would be correct to say that it usually begins as an infectious neuritis. It has been found to be communicable by inoculation, by Giordano, Bonome, Reynier, and others, and, according to Fliigge, is caused by a bacillus which occurs in rnany^ 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 Yerneuil to be transmissible from the horse to the human being. Bacilli have been found in tetanus by Fliigge, Hochsinger, Nicolaier, Reynier, and other observers, while Brieger has succeeded in isolating three ptomaines which he calls tetanine, tetanotoxine, and spasmotoxine, respectively. He has repro- duced tetanus by inoculating the first-named substance, for which he gives the formula, C„H30N204, and the disease has also been artificially produced by Kitasato, a Japanese surgeon, by inoculating cultures of Nicolaier's bacil- lus. A^ailland and Vincent, however, attribute tetanus to the effect of a poi- son—not a ptomaine—secreted by the specific organism found in cases of the affection, and believe that the bacillus of tetanus is inactive except in the presence of other organisms, looking upon the disease, therefore, as one depending upon mixed infection. The nerve or nerves in the immediate neighborhood of the wound are commonly, though not invariably, 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, Dickin- son, Charcot and Michaud, Aufrecht, Stirling, and Coats, of Glasgow. The first-named writer ascertained, from an examination of six specimens, that there were, in several portions of the cord, marked patches of soften- ing and disintegration affecting the gray matter, the cord itself being altered in shape. The structural change varied from mere granular soft- ening to absolute fluidity, and was accompanied by numerous extravasa- tions 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 disintegration. We have reason, therefore, to infer that the lesions of structure had their origin in a morbid condition of the bloodvessels, resulting in exudations with impair- ment 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 present, are so in but a small degree ; (2) these lesions are not the DIAGNOSIS OF TETANUS. 585 effect of excessive functional activity of the cord, but result from a morbid state of the bloodvessels; (3) these lesions are not the sole cause of the tetanic spasms, as similar lesions exist in cases of paralysis unaccompanied by tetanus; and (4) the tetanic spasms depend, first, on an abnormally- excitable state of the gray nerve-tissue of the cord, induced by the hyper- semic and morbid state of its bloodvessels, with the exudations and disin- tegrations resulting therefrom (this state of the cord being either an extension of a similar state along the injured nerves from the periphery, or resulting from reflex action on its bloodvessels excited by those nerves); and secondly, on the persistent irritation of the peripheral nerves, by which the exalted excitability of the cord is aroused—the same cause thus first inducing the morbid susceptibility of the cord to reflex action, and subse- quently furnishing the irritation by which reflex action is excited. Dickinson's observations tend to confirm those of Clarke, and add the interesting fact that the situations of the various lesions correspond ana- tomically with the side on which the injury exists. " The irritation from the left hand, conveyed, as we must suppose, by certain of the left poste- rior roots, occasioned especial congestion of the left posterior horn, and further changes in the white matter in contact with it—that is, in the left posterior and lateral columns. The central and anterior parts of the gray- matter were most extensively affected on the side opposite to that of the injury, as might have been anticipated from the decussation in the cord of the sensory fibres. The irritation having reached any column or segment of the cord, appeared to diffuse itself throughout its whole length with undiminished intensity. Although the 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 Micbaud note the same appearances that are described by Lockhart Clarke, but believe them to be due to exudation from the bloodvessels, and not to degenerative changes. It is in the posterior commissure of the gray matter of the cord, and especially in the lumbar region, that they- have found what they regard as the " essential alteration" of tetanus; this con- sists in the development of a large number of nuclei which are variously disposed, and many of which are flattened from mutual compression ; the changes are in fact the same as, though perhaps more marked than, those described by Fromman as occurring in cases of subacute myrelitis. Coats has observed the morbid changes in the medulla oblongata, as wrell as in other portions of the spinal cord. Ringer and Murrell controvert the ordinary view that tetanus is due to increased excitability of the spinal cord, and believe that it is due to a diminished " resistance" of the cord, which allows impressions conveyed by the afferent nerves to spread through the reflex portion of the central nervous system. According to Ross, very much the same changes are found in tetanus as in hydrophobia, and this writer suggests that the differences in symptoms may be due to the cerebellum being more involved in the former, and the cerebrum in the latter, disease. Motti has observed lesions of the sympathetic nerve, on the side opposite to that of the injury. Amidon 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 spinal meningitis being, in a great degree, voluntarily assumed in order to pre- sent pain of motion. From Hydvophobia, the diagnosis may be made by observing that, in the latter disease, the spasmodic movements are clonic, 586 SURGICAL DISEASES OF THE NERVOUS SYSTEM. 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 poisoninq by strychnia, the diagnosis is sometimes very difficult, particularly 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 intermission between the paroxysms, and that (according to Po- land) 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 coexisted 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 devel- oped at a comparatively late period, and running a less violent course, there is more hope of a successful issue, and by prompt treatment life may 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 mav diminish the morbid excitability of the spinal cord, and at the same time lessen the irritation of the peripheral nerves—it being probably to a com- bination of these two elements that the production of the tetanic spasm is due. At the same time, concentrated nutriment in a fluid form should be given as freely as practicable, for death frequently results, as has been seen, from pure exhaustion. The modes of treatment which have been proposed for tetanus are almost countless, including such diverse remedies as 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,2 bella- donna, cannabis Indica, wroorara,3 bromide of potassium, salicin, antipy- rine, gelsemium,4 hydrate of chloral, and the Calabar bean. Of these the first and last two are those upon which I am disposed to place most reli- ance, and of which I would, therefore, recommend the employment. Eighteen cases collected by Eben Watson, in which the Calabar bean wa> used, gave ten recoveries and eight deaths ; upon the whole, a favorable record. The bean may be given in large doses (Holthouse gave i\ grains of the extract at once, the patient recovering), the only limit to its admin- istration being the effect produced in controlling the spasms. It appears to act as a direct sedative to the spinal cord, and it has the additional ad- vantage 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 Lay ton. Opium in large doses may be properly given at the same time with the Calabar bean, as suggested by 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. 2 Hypodermic injections of conia were used with some success by C. Johnston. 3 Recoveries under the use of woorara have been reported by Maturin and McArdle. The latter suggests that the woorara should be combined with pilocarpine. 4 Recoveries under the use of gelsemium have been reported by Read and Spiatly. TREATMENT OF TETANUS. 587 Holtbouse, on account of its w-ell-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 combina- tion having furnished but 59 deaths—a mortality of less than 38 per cent. Urethan has been successfully employed by W. T. Jackman ; sulphate of zinc in large doses by J. S. Hunt; cocaine, hypodermically injected, by Lopez; and pilocarpine, used in the same way, by Casati and Dell'Acqua. The blood-serum of rabbits, rendered immune to tetanus, has been experi- mentally-employed by Tizzoni, Cattoni, Behring, and Kitasato, and, under the name of " antitoxin," has been successfully employed in the human subject by Gagliardi, Schwartz, Pacini, Nicoladoni, Albertoni, -Berger, and Finotti, who has collected nine cases successfully treated in this way. A cathartic may sometimes be required at the beginning of the treatment, to remove any irritating matters from the bowels, and concentrated food and stimulus must be given, throughout the case, in as large quantities as the patient can be induced to take. The inhalation of ether or chloroform may occasionally be resorted to with temporary benefit, and the application of an ice-bag to the spine might be tried, though its use should be watched, lest it induce too great depression. Tracheotomy has occasionally been resorted to, and, according to Richet, may be expected to be of service when spasm occurs in expiration. The inhalation of nitrite of amyl has been successfully employed by Foster, Curtis, Funkel, and Forbes. 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, amputation may be performed, if a limb be the seat of injury-; under other circumstances the tissues sur- rounding the wound mayr be freely- removed by- excision. Nerve-stretching, as suggested by Nussbaum and Callender, has been successfully resorted to by Yerneuil, Vogt, Wheeler, W. J. Smith, Clark, Ratton, Ransohoff, D'Ollier, and Fenger, but 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 resorted to at an early- period, it should not be neg- lected even at a later stage of the case. If no special nerve-lesion can be detected, a f\ incision down to the bone may be made, as advised by Lis- ton and Erichsen, so as to insulate the part. The wound itself should be dressed with narcotics—particularly opium, in the form of laudanum, or a solution of sulphate of morphia (gr. v-f^j), or, if the wound is sloughing, powdered opium with charcoal (9j-3j)—and in cases of burn or scald, this will often be the only local treatment which can be employed. The application of atropia to the end of the divided nerve, or by hypodermic injection, has occasionally been found useful. If the wound were already healed, it would be proper to dissect out the cicatrix with the tissues around it. 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 Labbe'e, the recoveries have usually been in chronic cases, in 1 Of 45 cases tabulated by Ceccherelli, 14 were successful, 2 doubtful, and 29 fatal. 588 SURGICAL DISEASES OF THE VASCULAR SYSTEM. which equally good results may often be obtained by internal treatment alone. During the whole course of treatment, the patient should be kept in a rather dark, warm, and dry room, and should be carefully guarded from currents of air. Verneuil even recommends that the whole body should be immobilized in a gutter-splint, and covered with cotton-wool. Xegretto 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 XXX. SURGICAL DISEASES OF THE VASCULAR SYSTEM. Diseases of 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 193) 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 coat.s of a vein, according to II. Lee, who has particularly investi- gated the subject, that the changes of phlebitis are chiefly found. The cellular coat becomes preternaturally 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 layer? of the inner coat becoming disintegrated, or flakes of its lining membrane being cast off into the interior of the vessel. Phlebitis destroys the nat- ural pliability of the venous coats, so that, when divided, an inflamed vein remains patulous like an artery. The formation of a clot in an inflamed vein is caused, as pointed out by Schmidt, by the union of two substances always found in the blood, 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 i= local, and unattended with any particular danger. 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 ca.-t^, the clot has reached beyond the point at which veins carrying such impure PHLEBITIS. 589 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 process 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 page 463). 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, dusky-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 cedema 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 cedema may be soft, allowing pitting on pressure, or may be hard and tense. If the vein be deep-seated, the occurrence of tumefaction and pain may be the only evidences of phlebitis. The cedema usually subsides with the restoration of the circulation through the natural or collateral chan- nels, though it may persist 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 erysipelas, which often extend rapidly in the course of the veins, and which are apt to terminate in pyaemia. (See pages 438, 455, 462, and 569.) 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 presents, and its invariable complication with adenitis. Deep-seated phlebitis may be mistaken for neuralgia, but the diagnosis may be made by observing that the pain of the latter affec- tion is rather relieved than aggravated by pressure, and is not accompanied by cedema. 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 pyaemia, or other grave constitutional condition, the question is very different; and even traumatic phlebitis, occurring in a person who is broken down in health, should be looked upon as a grave affection. Treatment.—In the treatment of phlebitis, all depressing measures should be avoided, the chief risk of the affection being from 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 590 SURGICAL DISEASES OF THE VASCULAR SYSTEM. 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 operation proposed by H. Lee, which consists in acupressing a healthy portion of the vein at two points about three-fourths of an inch apart, and then dividing the vessel subcutaneously between them. Tobin reports a case of septic phlebitis successfully treated by excision of the affected veins. The cedema may be relieved by position, by gentle friction, and by the subsequent use of an elastic bandage. Varix, Varicose Vein, or Phlebectasis, consists iu a morbid dilatation of a vein, usually accompanied by thickening of its walls. Any veins may become varicose, but those most commonly affected are the veins of the lower extremity, scrotum, and rectum. The varicose condition may be limited to the principal venous trunks of the part, or may affect the subcutaneous venous plexus, giving the appearance of a network of a purple hue. The branches of the internal saphena are most frequently affected among the superficial veins, but it is probable that in the majority of cases the deep vessels are likewise more or less involved. The anatomical 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, wTalking, 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 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. Deep varix is more difficult of recognition, the subjective symptoms 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 Gay, quite significant of a vari- cose condition of the deeper veins, and Quenu believes that varix is some- times the cause of sciatica. Varicose veins are liable to be attacked by phlebitis and thrombosis, while inflammation of the surrounding tissues may lead to various troublesome conditions, such as the occurrence of eczema, or of ulceration (giving rise to the varicose ulcer), or to a sclere- matous condition of the part analogous to the Arabian elephantiasis. 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 bj either palliative or radical, the VARICOSE VEINS. 591 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. Musser has found advantage from the internal administration of the Hamamelis Virginica or witch-hazel. Hemorrhage from a varicose vern may be checked by elevating the limb and applying a firm compress. The Radical Treatment may be employed if the varicose vein be evidently so altered in structure as to be useless for carrying on the circulation (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 Fig. 314.—Application of pins to varicose veins. (Miller.) instances must be looked upon as incurable. Various means have been pro- posed for the obliteration of varicose veins, such as (1) the application of blisters or of caustic, so as to form eschars over the line of the vessel, or, as suggested by Linon, the application of a strong solution of the sulphate of iron; (2) the injection of coagulating agents (chloral is particularly recommended by Porta and other Italian surgeons) ; (3) the hypodermic in- jection of ergotin or alcohol; (4) the passage of an electric current through the vessel; (5) the subcutaneous section of the vein ; (6) its compression at various points by means of a pin passed beneath the vessel, 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. 314) ;x (1) the application of a metallic ligature ; (8) simply denuding and isolating the vein, as recom- mended by Rigaud, Cazin, and Bergeron ; and (9) excision of a part of the vein, a Celsian mode of treatment revived by Marshall, Steel, Howse, Davies-Colley, and Dunn, and which I have myself practised with advan- tage. Probably the safest plan is that recommended by H. Lee, which consists in (10) securing the vein at two points, about an inch apart, by passing acupressure-needles beneath, but not through, the vessel; apply- ing, over the ends of the needles, elastic bands or figure-of-8 ligatures ; and then subcutaneously dividing the vein at an intermediate point. The needles, which are removed in three or four days, serve to approximate, without injuring, the sides of the vein, while obliteration of the vessel takes place at the point of subcutaneous section, the parts healing in about a week. A special instrument for compressing veins in this manner is employed, under the name of "vein-brooch," by Mr. Douglas. 592 surgical diseases of the vascular system. Vascular Tumors or Angeiomata.1 (Arterial Varix, Aneurism by Anastomosis, Nsevus.) 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 respect, the same. The vessels become tortuous, and in parts sac- culated, their coats (especially the middle) being thin, and causing the artery to resemble the 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- cating to the touch a spongy or doughy sensation, accompanied 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 them- selves usually dilated and tortuous) are compressed, and returns with an expansive pulsation when the pressure is removed. Auscultation 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 wideot the disease, in order to avoid profuse or possibly fatal hemorrhage. Fig. 315.—Aneurism by anastomosis. (Fergusson.) 1 See page 537. N^IVUS. 593 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 preferred 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 injection 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 studv 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 atone or more sittings, are to be preferred. Ligation of the main artery is the plan which has been most frequently employed, particularly when the affection has involved the orbit. In such a case the primitive carotid is the vessel to be tied; but if the disease were limited to the scalp, it might be better to adopt Bruns's suggestion, and tie one or both external 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 Naevi, which are commonly, if not always, congenital, occur as flattened elevations, of a red or purple hue, usually upon the face or upper part of the trunk, but occasionally in other situations. They may involve a considerable extent of surface, but rarely give anyr annoy- ance except from the attendant deformity. Sometimes, however, they ulcerate and bleed. They consist of a congeries of capillary vessels, and may accompany the aneurism by anastomosis on the one hand, or the venous naevus on the other. (2) Venous Naevi occur as prominent tumors or outgrowths, of a reddish- purple hue, smooth or lobated in outline, and somewhat compressible, doughy, and inelastic to the touch: they are less exclusively confined to the upper part of the body than the capillary naevi, and, in their structure, consist of thin, tortuous, and sacculated veins, often interspersed with cysts. Venous naevi may occur subcutaneously, when they form tumors which may be partially emptied by pressure, slowly filling again when the pressure is removed, and becoming distended by violent exertion or strug- gling on the part of the patient. Treatment.—Cutaneous naevi which are small and not disposed to spread, may often be left without treatment—when they may disappear spontaneously; and, on the other hand, a naevus may involve such a large •'xtent 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, or a paste containing tartarized antimony, one part to [our. Bradley recommends tattooing with carbolic acid, and an ingenious instrument for the purpose has been devised by Sherwell, who supple- 594 SURGICAL diseases OF THE VASCULAR SYSTEM. ments the operation by compressing the part by the application of collo- dion. For the treatment of the diffused form of naevus known as "port- wine stain," B. W. Richardson advises the application of the ethvlate 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 ingenii»u> instrument for the purpose, consisting of a number of thin knife blades placed closely together; the incisions are best made in an oblique direction to the surface. Moderately large, or subcutaneous, or even small cutane- ous 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 compression. Owen recommends punc- tures 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 injections, 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 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. 316). The needles may be passed unarmed, the ligatures—which may be of strong silk or whipcord—beim' introduced as they are withdrawn. The nooses are then cut, and an assistant holds six ends firmly, while the surgeon knots the other two, tbb 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. 317, taken from Holmes. When the naevus is elongated, a better plan is that described by Erichsen, which consists in passing a double ligature, 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 NiEVUS. 595 each side of the tumor (Fig. 318). The black loops being then cut on one side, and the white on the other, the ends are secul-ed as in Fig. 319, so as Fig. 316.—Noevus; application of the quadruple liga- ture. (Liston.) Fig. 317.—Subcutaneous ligature of nae- vus. The upper figure shows a single liga- ture carried around the tumor. The lower (in which no tumor is depicted) shows a double string carried below the centre of the base, then divided into two, a a' and b b/ and each of the two carried subcu- taneously around half of the nsevus, and then tied. (Holmes.) to strangulate the growth in numerous sections. After the operation the tumor sloughs, and comes aw-ay in a few days, leaving an ulcer which heals Fig. 318.-Diagram of ligature of flat and elongated naevus. (Erichsen.) Fig. 319.—Diagram of tied flat and elon" gated naevus. (Erichsen.) 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 used, of puncturing the m>b i GS °f the brain ' and nence in this situation> ai"ter incising the skin witli a lancet, the ligature should be carried beneath the growth by means 596 SURGICAL DISEASES OF THE VASCULAR SYSTEM. of an eyed probe. The scalp is so adherent to a naevus in the cranial region that no attempt should usually be made to preserve the skin in this locality. For naevus of the tongue, the use of the ecraseur may be advan- tageously substituted for that of the ligature. H. Lee has recommended, in cases of vascular tumor of the face and neck, the use of India-rubber thread instead of the common ligature, the elastic contracton of this agent servin" to divide the tissues without hemorrhage, and thus effecting rapid and painless removal of the morbid growth. Barwell suggests subcutaneous strangulation with a wire tightened 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 employed by Bontflower. 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 pulmo- nary 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. Diseases of Arteries. Arteritis and Arterial Occlusion__Arteritis, or Inflammation of the Arterial Tunics, may occur as a primary affection, the result of injury or exposure to cold, but in the immense majority of cases is secondary to ArterialOcclusion, 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. 199), 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 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 young and healthv 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 CHRONIC STRUCTURAL CHANGES IN ARTERIES. 597 occlusion almost invariably producing gangrene); or the clot may become completely disintegrated, and capillary embolism (arterial pyaemia) result The treatment consists in the administration of opium to relieve pain and of tonics, stimulants, and concentrated food, to maintain the patient's strength, with application of external warmth to the affected part in order- to avert mortification. The subject of gangrene as the result of arterial occlusion, and the question of amputation under such circumstances, have been sufficiently considered in previous chapters (pages 105, 218) Chronic Structural Changes in Arteries—The most important of these are Fatty Degeneration, Atheroma, Ossification, and Calcifica- tion. 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 Virchow calls fatty usvre. 2. Atheroma, which is usually- accompanied by the fatty change of the internal coat above described, appears to occur primarily in the ex- ternal layer of the inner coat, at the junction of the latter with the middle Fig. 320.- -Fatty degeneration in inner coat of aorta. (Green.) ig 321.-Atheroma of the aorta, showing the new growth in the deeper layers of the inner coat, ana the consequent internal bulging of the vessel. The new tissue has undergone*more or less fatty egeneration. There is also some cellular infiltration of the middle coat. i. internal, m. middle, e. external coat of vessel. (Green.) coat, and forms a pultaceous (or atheromatous) mass, consisting of granu- lar matter, fat-globules, plates and crystals of cholestearine, and half-soft- nea fragments of tissue which have not yet undergone degeneration. whv'h early Staffe °f atlieroraa> the appearance presented is that of a \Qitish, somewhat elevated spot, projecting into the vessel, but still cov- 598 SURGICAL DISEASES OF THE VASCULAR SVSTEM. Fig. 322.—Atheromatous ulcer of aorta. (Liston.) ered by a portion of the inner coat of the latter1 CFig. 321). As the pro- cess continues, the inner coat becomes perforated, the atheromatous mass is evacuated into the vessel, and the so-called atheromatous ulcer results (Fig. 322), just as in the affection known as ulcerative endocarditis. While this change is occurring between the inner and middle coats of the artery, its outer coat becomes thickened and indurated, thus tending to maintain the strength of the vessel, which at the same time becomes comparatively rigid and inelas- tic. Atheroma is usually- spoken of as a degenera- tive change, but, according to Virchow, Billroth, Niemeyer, W. Moxon, and others, should be consid- ered a result of inflammation. Atheroma is often supposed to occur as a sequel of syphilis, but, ac- cording to Heubner and Evvald, the syphilitic de- generation met with in arteries is a distinct affec- tion (see page 508). 3. Ossification is a rare, but, according to Virchow, an occasional change met with in the inner arterial coat. It may coexist with or may take the place of the atheromatous change (athero- masia), and, like that, results, according to Vir- chow, 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 vessel, and has no necessary connection with the atheromatous change. It con- sists in the deposit of earthy matters, principally phosphate, with a little carbonate, of lime, and occurs in the form of plates, rings, or tubes, consti- tuting the several varieties of the affection known as laminar, annular, and tubular calcification. When in the superficial arteries, it is readily recognized by the touch. These various structural changes may exist independently, or, as is more common, may coexist in the same person. They may occur at any aire, but are by far most frequently seen in those who have passed the period of middle life. They are more frequent in men than in women, and are said to be predisposed to by intemperate habits and by syphilis; when occurring in the limbs, they are usually symmetrical. The effect of these structural changes is, in the first place, to diminish the calibre of the affected artery, and secondly, by lessening its natural resiliency, to lead to its irregular dilatation and elongation; hence an atheromatous or calci- cified artery may become tortuous, and is peculiarly apt to become the seat of aneurism. Rupture may take place through an atheromatous ulcer, and lead to fatal hemorrhage, as has been occasionally seen in the aorta;' while both atheroma and calcification render an artery more apt to be ruptured by external violence, and interfere with the success of haemostatic measures—a ligature, perhaps, cutting through at once, or becoming pre- maturely detached and thus leading to secondary hemorrhage. Finally, the loss of smoothness in the lining surface of an atheromatous or calcified artery, hinders the circulation, and offers a nidus for the occurrence of 1 Mr. Moore, in his essay in Holmes's System of Surgery, 2d edit., vol. Hi., the view formerly held by Rokitansky, that atheroma was a deposit on the lining membrane of the artery, derived from the blood. 2 Similarly, fatty degeneration of the cerebral arteries is a very common antecedent to the occurrence of apoplexy. (See Paget, Lectures on Surgical Pathology, 3d. edit., p. 106.) ANEURISM. 599 arterial thrombosis, thus leading indirectly to occlusion and perhaps gan- grene, as in several cases collected by H. Lee; or, on the other hand, particles detached from an atheromatous ulcer may produce capillary em- bolism, and give rise to one form of arterial pyaemia. Little can be done in the way of treatment for these structural changes, beyond attention to the general health of the patient; if wide-spread, they would, of course, render the surgeon cautious in recommending any cutting operation that was not imperatively- required. Should occlusion and gangrene occur, the case should be treated on the principles laid down in previous portions of the work. Aneurism. Aneurism, as the term is used in this work, is a disease of the arteries, consisting in a circumscribed dilatation of one or more of the arterial coats. Varieties.—We have already considered those forms of aneurism which result from wounds (see page 219), 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- ing portions of the artery remaining healthy. Tubular aneurisms aortic arch may attain a very large size, running a chronic course, >ing harm chiefly by pressure on important parts. They may cause 600 SURGICAL DISEASES OF THE VASCULAR SYSTEM. death by impeding the circulation, and thus causing syncope; or bv com- pressing other parts, as the oesophagus or bronchi; or, when occurring in the intra-pericardial portion of the aorta, by bursting into the pericardia] sac (Fig. 323). More commonly, however, a sacculated ancuri>m (Fig. 324) 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 ves.-el 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 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 perhap- 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 ti>sue. 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 disseciion, 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. Causes of Aneurism__The chief Predisposing Cause is unque>- tionably the existence of structural changes (particularly/a//t/ degeneration and atheroma) in the arterial walls. Calcification does not directly tend to cause aneurism, but rather lessens the dilatability of the artery which it affects; it has, however, an indirect influence, the want of elasticity which it produces tending to increase the strain upon other portions of the vessel, and thus predisposing them to aneurismal disease. Age has been looked upon as a predisposing cause, aneurism usually- occurring during the middle period of life; the explanation is, that at this age, while athero- matous changes have begun, the laborious occupations of youth are com- monly still continued. Similarly, though aneurism is unquestionably much more frequent in the male sex than in the female (about seven to NUMBER, SIZE, AND STRUCTURE OF ANEURISMS. 601 one1), it is probably not more so than might be expected from the greater liability of men to structural arterial changes, and from their being more commonly engaged in occupations which themselves predispose to aneu- rismal disease. Any occupation which requires intermittent violent muscular exertion predisposes to aneurism, by inducing occasional violent action of the heart, and consequent over-distention of the arteries ; thus hotel-porters, soldiers, and sailors, or those 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 predisposing influence, aneurism being probably more common iu 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 calcification produces its effect, and it is thus that aneurism may be developed above the seat of occlusion of an artery by embolism,2 or above the point of application of a ligature. The position of an artery may itself predispose the vessel to aneurism ; thus the exposed situation of the popliteal artery- renders it peculiarly liable to the develop- ment of aneurismal disease. The Exciting Causes of aneurism are wounds, blows, and sudden strains. The effect of wounds has already been considered (see pp. 219, 220) ; 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. Popliteal aneurism is frequently symmetrical. When a large number of aneurisms coexist, as in cases recorded by Pelletan and Cloquet, the patient is sometimes said to suffer from the aneurismal diathesis. Aneurismal tumors vary in size, from that of a pea,3 to that of a child's head; the size varies in different situations, according to the degree of resistance offered by surrounding parts, and the force of the distending blood current. The largest aneurisms are hence commonly those which occur in the aorta, or, externally, in the axilla, neck, groin, and ham. If a sacculated aneurism is laid open, its structure, going from without inwards, is found to be as follows : (1) An investment of condensed areolar tissue, forming an adventitious sac; (2) the true aneurismal sac, consist- ing either of the thickened external, with, perhaps, part of the middle, 1 In the internal aneurisms, according to Crisp, the proportion is four to one, and in the external' (excluding carotid aneurism, which affects both sexes equally) it is thirteen to one: dissecting aneurism is twice as frequent in women as in men. According to Church, embolism is the most frequent cause of intra-cranial aneu- rism in young persons. 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 ^ of an inch. 602 SURGICAL DISEASES OF THE VASCULAR SYSTEM. coat (false aneurism), or of all the coats (true aneurism), in which case the inner and middle coats may sometimes be recognized by the athero- matous and calcareous patches which they contain ; (3) concentric layers or lamina? of decolorized fibrinous clot, which appear to have been success- ively separated from the blood, as if by whipping,1 and of which the inner layers are softer and redder2 than the outer; and (4) an ordinary loose "currant-jelly" coagulum, which may be either of ante-mortem or of post- mortem formation. The laminated fibrinous coagulum serves an important purpose in strengthening the sac-wall, lessening the containing capacity of the sac itself, and, by its tough and inelastic character, diminishing the force of the arterial current in the sac, thus, in every way, tending to limit the spread of the disease, and even to lead to its spontaneous cure, The mouth of the sac, which is round or oval in shape, is of variable size, but always of much less area than a section of the sac itself; in a false aneurism the inner and usually the middle coat cease abruptly at the mouth of the sac, and even in a true aneurism they can rarely be traced for more than a short distance beyond the same point. The structure of the tubular, and that of the dissecting, form of aneurism have already been referred to (pp. 599, 600); 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 whip—or (as in the case of intra-orbital aneurism) hearing a sudden sound, as of the explosion of a percussion-cap—a small, pulsating tumor being, perhaps immediately, or soon after, discovered upon examining the part. In other cases, the 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 upon the flow of blood through the aneu- rismal 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. 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 compressible; but if, on the other hand, the sac contain a large amount of fibrinous clot, it will be comparatively hard and inelastic ; the skin over an aneurism is usually healthy, though stretched ; as the tumor grows it may, however, become discolored, thinned, or even ulcerated, and sup- puration may occur in the subcutaneous areolar tissue. Muscular weak- 1 This is denied by W. Colles, who believes that the laminated coagulum is formed by the walls of the sac itself. 2 In a case observed by H. D. Schmidt, however, the older and harder layers of fibrinous coagulum presented the darker color—the difference probably depending, as suggested by this writer, rather upon the amount of haemoglobin contained in the respective layers than upon their relative ages. SYMPTOMS OF ANEURISM. 603 ness 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 pul- sation 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 pulsation in the latter ceases, and it becomes flaccid; if now the hands be placed on either side of the tumor, and the compression be suddenly removed, the entering blood redistends the sac, with a forcible, expanding beat which is almost pathognomonic. The pulsation of the artery below the tumor is sometimes greatly dimin- ished ; this is a sign of considerable value in certain cases of intra-thoracic aneurism, in which the radial pulse of the affected side may be much weaker than on the sound side, or altogether absent. This, in particular instances, may be due to arterial occlusion from arteritis, to the rigidity produced by calcification, or to external pressure, but, in the majority of cases, is prob- ably owing to the mechanical action of the sac-walls in equalizing the blood current, and thus lessening pulsation, just as the air-chamber does in the ordinary " hydraulic ram." Bruit.—This is the name given to the intermittent sound which is heard by applying the ear to an aneurismal tumor, and which is 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 synchro- nous with the aneurismal pulsation, and ceases with the latter if the artery be compressed above the tumor—returning immediately when the pressure is removed. According to Savory, the thrill is most marked when the aneurism 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 cedema, from compression of the deep- seated veins. In some cases a varicose condition of the superficial veins may result from the same cause, and gangrene may even follow from the obstruction to the returning circulation. The risk of gangrene may be further increased by pressure of the aneurismal sac upon its own or neigh- boring arteries, thus leading to an insufficient vascular supply to more distant parts. Pressure upon nerves gives rise to intense pain, usually of a lancinating character, and, in certain situations, may lead to serious con- sequences by interfering with the functions of important parts; thus, hoarseness and spasmodic dyspncea may result from compression of the recurrent laryngeal nerve (Fig. 326), dyspncea, or (as in a case recorded ".v W. F. Atlee) uncontrollable eructation, from pressure on the pneumo- 604 SURGICAL DISEASES OF THE VASCULAR SYSTEM. gastric, and, in cases of intra-cranial aneurism, facial paralysis, deafness ptosis, strabismus, or blindness, from compression of various cerebral nerves' Pressure upon secreting glands, or their ducts, may cause trouble by inter- fering with the functions of the part. Pressure upon bones aud joints often leads to serious consequences, the flat bones (as the sternum or ribs) be- coming eroded and perforated (Fig. 325), or caries and disorganization of articulations ensuing, and seriously- complicating the treatment of the case. The erosion of bone by the pressure of an aneurismal tumor is often attended by a distressing sensation of burning or boring pain, as in the vertebral column in cases of aneurism of the aorta. Finally, serious consequences Fig. 325.—Ribs perforated by an aortic an- Fig. 326.—Aneurism of the innominate artery, com- eurism. (Pirrie.) pressing and stretching the recurrent laryngeal nerve, and pushing the trachea to the left side. (Erichskn.i may result from pressure on important viscera: thus, dyspncea may be due to compression of the trachea (Fig. 326), 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 exercised by an intra-cranial aneurism on the brain. Symptoms of Diffused Aneurism.—When the aneurism becomes diffused b\T rupture of its sac, the symptoms undergo a certain change. The tumor loses its definition of outline, while it becomes rapidly very much larger; the pulsation, bruit, and thrill become faint, or entirely disappear; the part becomes ©edematous, and often cold and livid, from venous congestion; the pain is suddenly increased, and syncope may occur; the swelling be- comes hard from coagulation—and, in some rare cases, a boundary of clot and condensed areolar tissue serves to limit the further spread of the dis- ease, which may possibly, in these circumstances, undergo a spontaneous cure. Usually, however, the sw-elling continues to increase, with or with- out pulsation, or evidence of inflammation, and the case ends in gangrene, from conjoined arterial and venous obstruction ; or, the clot becoming dis- integrated, with suppuration and ultimate giving way of the skin, death follows from external hemorrhage. In some cases rupture of the aneu- rismal sac leads to wide extravasation of blood among the tissues of the part, the accident being accompanied with much shock and pain, faintnes- perhaps resulting from loss of blood from the general circulation, and gan- grene ensuing at no distant period. TERMINATIONS OF ANEURISM. 605 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 forcible 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 jnilsation 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- time 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, Dease, and Pirogoff. It is probable 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, Paget and West have described localized pulsations of arteries which simulate aneurisms, but are not persistent. Terminations of Aneurism.—An untreated aneurism may termi- nate in a spontaneous cure, or may cause death by pressure on important parts, by inducing syncope, by rupture and consequent hemorrhage, or by causing gangrene. 1. Spontaneous Cure__This, which is unfortunately a rare 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 |S the most frequent mode of spontaneous cure, and is seen almost exclu- 606 SURGICAL DISEASES OF THE VASCULAR SYSTEM. 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 arterv 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 compression on the car- diac side of the sac, by flexion, by the Hunterian mode of ligation, and to a certain extent by Wardrop's operation. A modification of this mode of spontaneous cure is that which is said to occur from the compression of the artery by the aneurism itself, or by another aneurism or solid tumor. (2) Occlusion of the Artery below or above the Sac by means of a 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 laminated clot; or, possibly, the artery above the sac, by a similar fragment derived from the heart or a higher aneurism. The former occur- rence is imitated in the treatment by manipulation and in Brasdor's operation, and the latter in Anel's method. (3) Inflammation of the Sac may possibly cause coagulation, and con- sequent cure of the aneurism, though the soft clot formed in this way is more apt to become subsequently disintegrated, leading to suppuration and rupture of the sac. This mode of cure is imitated by the use of direct pressure, galvano-puncture, the injection of coagulating fluids, etc. (4) Finally, a spontaneous cure may, perhaps, occasionally result from Suppuration and Gangrene, leading to the extrusion 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 Antyllus, which is practically equivalent to an excision of the sac. The evidence of the occurrence of a spontaneous cure consists in the more or less gradual disappearance of the aneurismal pulsation and bruit, the sac at the same time becoming firm and contracted, and the circulation being carried on by means of collateral branches. 2. Modes of Death__An aneurism may prove fatal by (1) pressure on im- portant parts, as the phrenic or pneumo- gastric nerve, the trachea, heart, or lungs; (2) syncope, which may occur from a large aneurism becoming suddenly diffused, and is sometimes the immediate cause of death in cases of aortic aneurism ; (3) rupture of the sac and hemorrhage—which may be internal, into the brain or spinal canal, pleura, pericardium (Fig. 327), trachea, oesophagus, or abdominal cavity—or ex- fig. 327.-steiiate rupture of aa aor- ternal, as when an aortic aneurism perfo- tic aneurism into the pericardium, rates the sternum and bursts upon tne (Erichsen.) surface of the body ; and (4) gangrene, which is apt to occur when an external aneurism becomes diffused, and which is usually complicated with hemor- rhage. TREATMENT OF ANEURISM. 607 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 sei-ous surface, by the formation of a fissured or star-like opening. (Fig. 327.) 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 certaiu 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 a deposit in the sac of laminated, fibrinous coagulum. To effect this, the patient should, in the first place, be kept at perfect rest—in bed, if possible—and should limit his diet, particularly avoiding irritating or indigestible food, stimulants, and large quantities of liquid. The treatment by position and restricted diet has been very successful in the hands of the Irish surgeons, particu- larly Bellingham and 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 dyspncea, 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 reputa- tion 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 Hutchinson, and the latter by Balfour. Speir recommends the employ- ment of gallic acid and the sulphate of iron, and F. Flint the adminis- tration of chloride of barium. Digitalis, veratrum 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 danger- ous 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. 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 the Cardiac Side, as in Hunter's and Anel's methods ; and on the Distal Side, as iu the plans of Brasdor and Wardrop. 1. The "Old Operation."—This, which until the early part of the last century was, with the exception of amputation, the only operation employed in the treatment of aneurism, is also spoken of as the Antyllian method, from Antyllus, who was one of the first, if not the first, to employ it. It consists in opening the sac and applying ligatures above and below, as was directed in speaking of traumatic aneurism (see page 219), though 608 SURGICAL DISEASES OF THE VASCULAR SYSTEM. it would appear that by the older surgeons the ligatures were sometimes applied first, and the sac subsequently laid open, or even totally excised. The operation is often a very- severe one, and is more liable to be followed by hemorrhage than the Hunterian operation, on account of the arterv being tied in immediate proximity to the sac, and where, therefore, it mav probably be diseased. In certain situations, however, as in the axilla, root of the neck, or gluteal region, this operation may sometimes be properly 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 B. A. Watson, consists in plugging the sac, and, if pos- sible, the opening of the arterv 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 employed in preference to any other, is that known as the Hunterian Method (Fig. 329), 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 arterv for the application of the ligature, and still allowing a certain amount of blood to pa>> through the sac by 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. Anel's Method (Fig. 328), which is spoken of by most French writers as identical with Hun- ter's, consists in the application of a proximal fig. 328. Fig. 329. ligature immediately above the sac; it was em- Anei's Hunter's ployed by Anel in 1710, in a case of traumatic operation. operation. aneurism of the brachial artery, and apparently as a mere experimental variation upon the old method.1 It does not seem to have been repeated, except once by Desault, and fell into oblivion until after the promulgation of Hunter's plan of operation. Anel's method is defective in not allowing any current through the sac, except from the distal end—imperfect coagulation and suppuration being therefore apt to follow—and in requiring the ligature to be applied to a part of the vessel which is very liable to be diseased, thus exposing the patient to a considerable risk of hemorrhage ; the operation is, more- over, difficult, on account of the displacement of the artery by the tumor, and not free from danger. In performing the Hunterian operation, those precautions are to be observed which were mentioned when speaking of ligation in the continuity of arteries (page 209); 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,2 and often 1 Keyslere subsequently (in 1774) modified the old operation by substituting com- pression for the distal ligature, retaining, however, the incision of the sac. 2 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- LIGATION ON CARDIAC SIDE OF ANEURISM. 609 becoming painful and hypersesthetic ; 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. When two sets of collateral branches are enlarged, the lower arch of anastomosis is commonly first developed, owing to the aneurismal swelling itself having led to previous dilatation of the neighboring vessels. If the lower anastomosis be defective, 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 the greater freedom of arterial anastomosis in the former situation, but is apt to occur in any locality in which large branches are given off in close proximity to the point of ligation—the clots, upon which arterial occlusion after the use of the ligature depends, being, under such circumstances, insufficient to resist the force of the circulation. With regard to the material to be employed as a ligature, strong, well-prepared, chromicized 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 properly prepared, and applied with sufficient force to divide the inner and middle coats of the vessel and thus secure permanent obliteration, is not likely to permit failure, which may otherwise occur from the artery remaining pervious 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 218. hire at first falls, and subsequently rises when the collateral circulation is established. But, according to Broca, this rise of temperature does not take place in animals, although in these the collateral circulation is most rapidly established. The increased temperature is apparently due to capillary 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. _ This is doubted by Ballance and Edmunds, although they do not deny that an intermediate portion of the artery is usually found pervious. o9 610 SURGICAL DISEASES OF THE VASCULAR SYSTEM. (2) Recurrent Pulsation is met with when the upper anastomotic arch allows an unusually free flow of blood into the arterv, between the sac and point of ligation, and is proportionally most frequent in cases of carotid aneurism, for in these the circle of Willis allows the collateral circulation to be very quickly established. In many cases the recurrent pulsation consists of a mere thrill, without any bruit; but it is occasionally as distinct as before the operation. It usually- occurs within twenty-four hours after the tightening of the ligature, though sometimes not for four or six weeks, and more rarely at an intermediate period. The prognosis of these cases is usually favorable, the pulsation again disappearing as consolidation is completed—though occasionally a fatal result ensues from suppuration and sloughing of the sac. Pulsation sometimes recurs several months after the consolidation and contraction of the aneurismal tumor, and the case is then properly called one of secondary aneurism, though it is probable that in most instances the new tumor is developed at a slightly higher point of the artery than the seat of original disease. Enlargement of the sac after ligation, without 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 thu.s converted into a solid, fibrinous tumor. Treatment—Before tighteuing 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—a plan which I myself successfully adopted in a case of recurrent pulsation after ligation of the femoral artery for popliteal aneurism—but if sloughing of the sac be imminent, the surgeon's only resources will be amputation and the "old operation," the former being indicated incases 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 coagu- lation 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- five per cent, of the cases in which this accident happens) death resulting from hemorrhage. Bleeding is particularly apt to occur in those case? 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 LIGATION ON CARDIAC SIDE OF ANEURISM. 611 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 ap- plication of the actual cautery—and, if these fail, amputation should be practised, provided that the situation of the aneurism admits of such a course. (4) Gangrene of the Limb usually results, as has been mentioned, from the combined effects of arterial occlusion and venous congestion ; it is par- ticularly apt to occur in cases of very large or of diffused aneurism, and is predisposed to by loss of blood, by erysipelas, or by the exposure of the limb to undue pressure, cold, or excessive heat. It is most frequent in the lower extremity, and occurs usually from the third to the tenth day, being 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 218) ; in some cases it may be proper (in order to relieve the venous trunks from pressure) to lay open the sac and evacuate its contents —and, indeed, it is one of the recommendations of the old operation, over that of Hunter, that it is less apt to be followed by mortification. If gan- grene have actually occurred, amputation must be performed, usuallyr 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, according to Pilz), and Intra-thoracic Inflammation about two-fifths of the deaths after ligation of the 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 at- tended with unusual risk; (2) in any case in which less dangerous modes of treatment have been tried and failed ; (3) in case an aneurism has burst into an articulation; (4) in case an aneurism has become diffused, and yet not so widely diffused as to require amputation ; and (5) in case an aneu- rism has burst or is about to burst externally, and, in case, therefore, the operation is imperatively required to prevent death from hemorrhage. The use of the ligature is, on the other hand, contra-indicated (1) by the presence of any complication—such as extensive arterial or cardiac disease, the existence of internal aneurism, old age, or the prevalence of erysipelas —which would probably 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 popliteal arteries; and (3) by the locality of the aneurism being such, that, from the proximity of anastomosing branches, or from any other cause, the operation would almost certainly terminate unsuccess- fully—the imminence of rupture being in such a case the only circumstance that could justify operative interference. Multiple aneurism is usually, though not always, a contra-indication ; thus, if two aneurisms exist on the same limb, they may both be cured by the same operation ;x or double popliteal aneurism by ligation of both femoral arteries ; in most cases, Pemberton has recorded a case in which three aneurisms on the same limb were cured by ligation of the external iliac artery. 612 SURGICAL DISEASES OF THE VASCULAR SYSTEM. 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°wouId 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 reputation°and the interests of his patients, rather by adapting his remedies to the ex- igencies of each particular case, than by advocating and invariably em- ploying: any exclusive mode of treatment. 3. Ligation on the Distal Side of the Tumor__This operation is attributed to Brasdor, whose name it bears. It was recommended by Desault, but first practised by Deschamps, and subsequently by Wardrop—being in- deed often spoken of as Wardrop's method. Though this surgeon, however, success- fully employed Brasdor's operation, the plan which he himself suggested, and which properly bears his name, is somewhat dif- ferent. In Brasdor's operation the whole circulation on the distal side of the sac is arrested—in Wardrop's only a part of the distal circulation, by the application of a ligature to a branch of the main trunk, or to one of several arteries proceeding from the aneurism. Thus distal ligature of the carotid for carotid aneurism would be an example of Brasdor's method, but the same operation for innominate aneurism would be properly called Wardrop's. The former aims to produce entire, and the latter par- tial, 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 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 termination. 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 Fig. 331. Wardrop's operation. COMPRESSION IN ANEURISM. 613 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 213.) III. Compression.—Compression may be made directly upon the aneurism, or indirectly upon the arteryT, 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 employed 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 val- uable adjuvants to pressure on the proximal side of the sac, as in the plan adopted by Reid, Wagstaffe, Weir, and others, who have cured popliteal aneurisms by pressure with Esmarch's bandage. Stimson has collected 62 cases of aneurism treated in this manner, a successful result having been obtained in 35, 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 position which it now occupies in the estimation of the profession until it was, about fifty years ago, revived and systematized by the Irish school of surgeons, par- ticularly by Bellingham, Hutton, Tuffnell, and Carte. It is not necessary, as was formerly supposed, to make such firm pressure upon an artery which is the seat of aneurism as to entirely interrupt the flow of blood—and still less to excite such a degree of inflammation as might lead to the oblitera- tion of the vessel; on the contrary, the object being to imitate nature in her mode of effecting a spontaneous cure, by inducing the gradual deposi- tion of laminae of fibrinous clot, it is sufficient to exercise enough compres- sion to simply arrest the pulsation of the sac, without preventing the flow of blood through it. This mode of treatment is particularly applicable to sacculated aneurisms, though it may also succeed in cases of the tubular va- riety, in which, however, the cure is effected rather by the gradual contrac- tion of the aneurismal dilatation, than by the deposit of fibrin. The chances of success by compression are greatest when the sac contains only fluid blood, coagulation in an already partially consolidated aneurism being apt to occur suddenly and in an imperfect manner. After recovery, the sac is commonly entirely filled up, but in some cases a channel remains, through which the normal circulation is carried on. During the treatment by compression, the patient should, of course, be confined to bed,2 and the hygienic and other means spoken of under the head of Medical Treatment put in force. Nervous irritability and pain should be controlled by the free use of opium, and in certain cases, in which the needful pressure cannot be otherwise borne, ether or chloroform may be administered by inhalation. 1 Laplace reports several cures effected by direct pressure applied through a hol- lowed-out ball of cork by a figure-of-8 bandage. Dr. Buckuiinster Brown has, however, reported a case in which direct compres- sion effected a cure while the patient continued to walk about. 614 SURGICAL DISEASES OF THE VASCULAR SYSTEM. 1. Instrumental Compression may be effected by the use of various forms of apparatus, such as a Signoroni's or a Skey's tourniquet (Figs. Fio. 333.—Gibbons's modification of Charriere's compressor. 30, 31), Lister's compressor (Fig. 32), Reade's or Carte's apparatus (in the latter of which (Fig. 332) elastic force is ap- plied by means of vulcanized India-rubber bands), or a simple conical weight, held in position by means of a leather socket, or, as successfuly employed in Fig. 332—Carte's compressor for the groin. Bellevue Hospital, New 1 Ork, a bag of shot suspended from the ceiling.1 In situations in which a considerable extent of artery can be dealt with (as in the thigh), alternate pressure upon several points may be practised, by means of an instrument such as that represented in Fig. 333, 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 applica- tion of instrumental compression, to see that the artery is fairly pressed against the bone, while the pressure is not so widely diffused as to cause great venous congestion from implication of the deep-seated veins, and to guard against excoriation of the skin by carefully shaving and powdering the part, and by frequently changing the point of pressure. In situations in which very deep pressure is necessary to control the circulation, and in which, therefore, the treatment becomes very painful (as in compressing the aorta, common iliac, or subclavian), anaesthesia may be previously in- duced, as proposed by Murray, and may be steadily kept up for as many hours as mav be thought safe. Rapid Pressure Treatment of Aneurism.—Murray, Heath, Mapother, Levis, Agnew, and other surgeons have succeeded in curing aneurisms of 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'- aud Brasdor's operations. While " the rapid pressure treatment" is un- 1 Sawyer employs a shot-bag terminating in a distended India-rubber ball, which gives a certain degree of elasticity to the apparatus, and Beach employs an India- rubber " water-pad" for the same purpose. Palmer 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. COMPRESSION IN ANEURISM. 615 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 compression—which aims to effect a cure by inducing a o-radual 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, and which has been successfully resorted to by Knight, Parker, Wood, S. W. Gross, Agnew, and many others, myself included, may be employed as an exclusive measure of treatment, or as an adjuvant to compression by means of 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 statistical results are very favorable (the aver- age duration of treatment in successful cases being, according to Glross 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 super- imposing 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 particularly studied by Fischer, 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 subse- quent ligation, three times after amputation, and twice after opening the sac. Digital compression is estimated by Fischer to be five percent, more successful than instrumental compression, and is considered by him superior to any other mode of treatment except flexion, which he thinks should be preferred in any case in which it is applicable. When it is resolved to attempt the cure of an aneurism by pressure, the patient being prepared as has been directed, and the circulation through the aneurism controlled by the application of a suitable instrument, 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 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'splan of interposing 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 many instances, a cure has been effected in from a few hours to three or 616 SURGICAL DISEASES OF THE VASCULAR SYSTEM. four days, and the average duration of treatment, in successful cases, ia 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 ope- 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 compression tends rather to increase than to diminish venous congestion, will probably not be doubted. Nor is it fair to assert that the long list of failures after compression is entirely due to want of care in its application ; for the advocates of the ligature might as justly respond, with the late Mr. Syme, that most of the untoward results of that operation were due to the operator's want of skill —Syme himself, as is well known, having tied the femoral artery thirty- five times with but a single death. In what cases, then, should compression be used ? The answer should, I think, be somewhat as follows: Compression should be employed, by 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 the use of com- pression, and in which the pressure treatment, if even it failed, would not seriously lessen the prospect of benefit from subsequent ligation; and (3) in all cases, on the other hand, in which the aneurism, from its locality or size, would not 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 employed in almost every case —even in popliteal aneurisms of moderate size, which are those specially adapted to the use of the ligature. If, however, decided benefit be not obtained in a short time—three or four days,1 or after a still shorter trial, if venous congestion, cedema, 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 Ernest Hart, in 1858,2 and has since been successfully employed by Shaw, Pem- 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 ol a double collar or figure-of-8 bandage. If flexion is to be employed by itself, 1 Holmes gives a week as the proper limit. 2 It is said to have been previously employed by both Fergusson and Maunoir. ACUPUNCTURE, ETC., IN ANEURISM. 617 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 bv 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 oave 28 successes (20 by flexion alone) and 29 failures. It is probable that a combination of flexion with alternate instrumental and digital compression, would often be found 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, having been combined by the last-mentioned surgeons with proximal compression. According to Van Buren, this is the true explanation of the cures reported from the use of Esmarch's bandage, as of many other recoveries attributed to compression alone. The dangers of this mode of treatment are that rupture of the sac and consequent diffusion of the aneurism, or inflammation and gangrene, may be caused by the application of too much force; and that (in cases of subclavian or carotid aneurism, for the former of which Fergusson employed it) a fragment of clot may occlude the carotid or vertebral artery, and thus lead to grave, if not fatal, cerebral disturbance. Cases are mentioned by Esmarch and Teale in which death followed the occurrence of this accident during the mere preliminary examination of patients suffering from carotid aneurism, and Tillaux has recorded a case of paralysis and aphasia resulting from embolism similarly occurring during the examination of an aortic aneurism. YI. Galvano-puneture was first employed by B. Phillips, in 1838, and has since been resorted to in a number of cases of aneurism by Pe'tre- quin, Ciniselli, Duncan, Althaus, and others. Needles from both poles of the battery, should, as a rule, be introduced into the sac. The great risks of the operation are that coagulation en masse will probably occur, and that sloughing of the aneurismal wall may take place 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 Wheelhouse. The statistics of this mode of treatment are not very- favorable ; 89 cases collected by Duncan gave 12 deaths and only 31 recoveries, while Petit's collection of 114 cases gives 38 deaths and only 69 recoveries, many of these, too, not having been permanent. The only cases, therefore, to which galvano-puneture seems appropriate are such as forbid either compression or ligation, and yet require active treatment. Guimaraez has reported a case of carotid aneurism cured by the external application of electricity. YII. Injections of Coagulating Liquids, and especially of the per- chloride 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 compression or ligation would be equally applicable, and certainly preferable. VIII. Acupuncture, and the Introduction of Foreign Bodies, such as ^ne wire (Moore, Domville, Murray, Buck, Loreta, Gerster, Ran- 618 SURGICAL DISEASES OF THE VASCULAR SYSTEM. sohoff, Lupine (three cases), Lange, Morse, Pringle, Hulke (two cases) Rubio, Bourget, Morris, and Gould); watch spring (Montenovesi, Bacelli (three cases), Pritchard and Saboja) ; pins (Richardson); horsehair (Levis. Maury, Stimson, 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. Acupunc- ture, the pins being inserted to such a depth as slightly to scarify the oppo-ite wall of the sac, and being allowed to remain for a limited period, has proved successful in several cases of aneurism reported by Macewen, J. P. Bryant, and Wyeth, but has also failed in the hands of Weir and Page, J. I). Bryant, and Curtis; while the introduction of foreign bodies has proved useless in everyr case but three (Morse, Rosenstirn, Pritchard), in which it has thus far been employed.1 Barwell introduced a steel wire and then passed a galvanic current through it, but his patient died within a week, and three cases similarly treated by Roosevelt, Abbe, and Stewart, were likewise unsuccessful. Rosenstirn's patient, on the other hand, recovered, and continued well at the end of two years; Corradi's case (which ante- dated Barwell's in time) was temporarily successful, but the patient died in three months. Kerr is said to have operated in this way on three pati- ents, of whom two died, and one passed from observation. IX. Strangulation has been successfully employed for very small aneurisms, two needles or harelip pins being passed beneath the tumor and a liirature thrown around their extremities, as in cases of naevus. X. Caustic has likewise been used with success as an application to very small aneurisms. XL Amputation__Finally, amputation would be required, if an aneurism in a limb should become diffused and threaten gangrene, if the pre?-sure 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 already been described (see page 220). Treatment op 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 innominate be also involved, the left carotid is, as pointed out by Dr. Cockle, the one to be chosen), or to tying this and the subclavian artery as well. The former plan has been adopted in eighteen cases,2 and the 1 Dr. Dobell recommends the injection of melted spermaceti. 2 In the fifth edition of this work 17 cases were tabulated, with seven deaths, and another, fatal after two months, has since been recorded by Mr. Heath. ANEURISM OF INNOMINATE ARTERY. 619 latter in twenty-seven,1 relief having been afforded in seven of the first group and in seventeen of the second ; the most successful operations have been those of Heath, one of whose patients lived four and a half years after ligation of the carotid only, and another four years after the simulta- neous ligation of the carotid and third part of the subclavian.2 In a case of supposed aortic aneurism in which Mr. Holmes tied the left carotid, the patient survived twelve years, dying eventually of phthisis. An autopsy 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. Villar is said to have treated an aneurism of the aortic arch by " temporary ligation" of the descending thoracic aorta; the case termi- nated fatally. Even less successful than ligation has been the treatment by coagulating injections, and that by the introduction of a coil of wire or watch-spring, which was first tried by Moore, and has been more recently employed by Domville, Murray, Hulke, Gould, Sabojo, Barwell, Bourget, and in three cases each by Kerr and Bacelli; no benefit resulted in Domville's case; Bourget's was only traced one month after the operation ; one of Kerr's patients was lost sight of, and the other cases all terminated fatally, as did those in which the introduction of silk threads was tried by Schrotter, and that of horsehair by Maury. Rosenstirn, however, by introducing silver wire, and then passing a galvanic current, as in Barwell's method, suc- ceeded in effecting a cure, which persisted after two years. Distal pressure proved of benefit in cases recorded by Lyon and Edwards, as did galvano- puneture in 13 out of 36 cases referred to by Bowditch, and in 69 out of 114 cases collected by Petit. The only treatment, however, to be ordi- narily recommended, in a case recognized as aneurism of the thoracic aorta, is the medical and hygienic treatment described at page 607. 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 32 times, with 10 more or less permanent recoveries, and 22 deaths. The subclavian or axillary alone has been tied 0 times, with at least tempo- rary benefit in 3 instances. The double ligature has been employed in 65 cases,3 the arteries having been tied consecutively- in 10, and simulta- neously in 5f>, only 4 of the former category and 19 of the latter proving fatal. In 4 cases which have been already referred to (Hobarth's, Heath's, Maunder'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 innominate aneurism) the affected artery was found after death to have been the subclavian. Hodges, of Boston, employed the double simulta- neous ligature in a case of supposed innominate or aortic aneurism, but 1 To the 18 cases with 6 deaths tabulated in the fifth edition of this work, may be added 9 more, one occurring in my own hands, and others attributed to Wolf, Schede (two cases), Jameson, Busch, Wyeth, Mackellar, and J. D. Bryant. Of the additional cases, one of Schede's, Busch's, Wyeth's, aud Bryant's proved fatal. 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. 3 To the cases tabulated in the fifth edition may be added carotid ligations by Butcher, nevner, Bryant (2 cases), Kuester, Golding-Bird, and Ferguson ; a subclavian ligation by Lane; consecutive double ligations by Beany (2 cases) and Hodenpyl; and simul- taneous double ligations by Lane, Gerster, Heath, Pettus, Paul, Rosenstirn, Le Dentu U cases), Marriott, Winslow, and Markoe. For several of these cases I am indebted t" Dr. Winslow's tables, published in the Annals of Surgery for May, 1891. 620 SURGICAL DISEASES OF THE VASCULAR SYSTEM. after the death of the patient, which occurred on the eleventh day, n0 aneurism at all was found, though both vessels were dilated; and in a similar case referred to by Stimson as having been operated upon In- 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 Land, Cheever, of Boston, in a case of innominate aneurism, made an unsuccessful attempt to apply the double ligature ; the position of the carotid artery could not be detected, and in endeavoring to secure the subclavian artery, the accompanying vein was ruptured, death following in two hours. Prom the above figures it may be seen that, as far as sta- tistics 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 w-ould 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, with antiseptic methods, the risk of hemorrhage is so much lessened that the question of tying the first portion of the artery may Fig. 334.—Result of simultaneous ligation of carotid and subclavian arteries for innominate aneurism. (From a patient in the University Hospital.) properly be entertained. But as the operative treatment by any plan 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 cai-e of Luke's, repeated bleedings and the use of digitalis effected a cure; while Coote obtained an equally happy result by the enforcemeat of rest and the application of ice. Fig. 334 shows the result of a case in which I tied both > Wyeth, however, believes that there was an aneurism of the innominate in this case, and that it was cured by the operation. ANEURISM OF CAROTID ARTERY AND BRANCHES. 621 arteries for innominate aneurism at the University Hospital. The symp- toms of aneurism gradually disappeared after the operation, and the patient is known to have remained well for at least five years afterwards. 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 per cent.1 Of 82 cases in which the common carotid was tied during our late war, no less than 63 (76.8 per cent.) terminated fatally, and 101 cases collected by Mr. Maunder, of ligation for wound of traumatic aneurism, gave but 34 recoveries. I have myself tied the common carotid in nine 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 occurred 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 pressure proves unavailing, ligation of the primitive carotid must be resorted to. Ligation by the Hunterian method has, according to Pilz, been done in eighty-seven cases, with fifty-five known recoveries and thirty-one deaths, the result of one case not having been ascertained. For traumatic aneurism at the root of the carotid, the surgeon may choose between Brasdor's and the " old operation," which has been successfully employed by Syme and Frothing. Fig. 335.—Carotid aneurism. (From a patient in the University Hospital.) 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 been performed, six recovered (Wardrop, Bush, Colson, Wood, Delens, De Mello Ferrari) and three died (Lambert, Demme', Lane)—a sufficiently 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. 622 SURGICAL DISEASES OF THE VASCULAR SYSTEM. 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 Noyes, having given twenty-five recoveries and but one death, and sixty-four cases quoted by Wolfe, from Saltier, having given forty recoveries, ten failures, and fourteen deaths. The internal carotid artery has been successfully tied in cases of hemor- rhage by Keith, Buck, Briggs, Sands, S. Smith, A. T. Lee, and Barba, but does not appear to have been tied in cases of aneurism. Bramlette's and Byrd's cases, in which the common carotid was tied with both its branches, have already been referred to (page 222). Vertebral Artery.—Including Fenger's case, this vessel seems to have been tied on six occasions, and five times successfully ; but it does not appear 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 yertebral, recorded by Kocher, and compression alone in cases reported by Weir and Simes. Mobres cured his patient by the application of cold. Ligation of one or more 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 cases, but in no instance with any permanent benefit to the patient. Three successful cases are, however, recorded by- J. L. Gray-, and in a patient under the care of Telford Smith the convulsions were arrested for four years. 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-puneture are also worthy of further trial. The Hunterian operation is justifiable in cases in which the aneu- rism is situated in the third portion of the vessel, so that a ligature can be applied outside of the scaleni muscles, or even between them—the ca-« under such circumstances approximating to one of axillary aneurism When, however, the disease involves the second portion of the artery, the surgeon can only choose between ligation of the innominate (first prac- tised by Mott), ligation of the first part of the subclavian, extirpation of the sac (a form of the "old operation"), and some form of the di>tal method. 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. 623 Table Showing Results of Various Modes of Treatment in Subclavian Aneurism. Mode of treatment. Cases. Recovered, or in process of recovery. Died. Uncer-tain. 1. None, or medical treatment only 49 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 (j. Acupressure of axillary and innominate 1 1 7. Manipulation ....... 4 *2 2 8. Galvano-puneture5...... 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 case7 ..... 11 11 13. Ligature of innominate ..... 12 12 14. Ligature of innominate, carotid, and vertebral8 1 i 15. Ligature of subclavian and carotid9 1 i 12. Ligature of subclavian, carotid, and vertebral 1 1 16. Ligature of axillaryj ral0 17. Ligature of carotid j v ' {* 4 1 ... IS. Amputation at shoulder-joint11 1 i 122 33 84 5 The innominate artery has, in all, been tied in 30 cases,12 of which at least 27 have proved fatal. The only instances of recovery are that recently recorded by Mr. Coppinger, and that in which Dr. Smyth, of New Orleans, tied also the carotid and vertebral, the patient surviving ten years, and 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. * Levis tried the introduction of horsehair, and Hulke that of wire, both with fatal results. 5 A second success by galvano-puneture has been recorded by Saboja. 6 Another (fatal) case occurred in the practice of the late Sir W. Fergusson. 7 Halsted has successfully tied the first part of the subclavian on the left side, pre- vious to extirpation of the entire aneurismal sac. 6 A case of simultaneous ligation of the innominate and carotid has been recorded by Mr. Banks. 9 A successful case has been since recorded by Little. Gerster has successfully tied the carotid and axillary. 10 Successful cases have since been reported by Toland and Forbes Moir. 11 Unsuccessful cases have been since recorded by Holden, H. Smith, and 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 Rose, the carotid was also tied, and the aneurism was practically cured four weeks after the operation, though hemiplegia had followed the interference with the cerebral circulation. 12 In the fifth edition of this work 27 cases were tabulated, and others have since been recorded by Coppinger, Bull, and Twynam. 024 SURGICAL DISEASES OP THE VASCULAR SYSTEM. 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, and Halsted's case in which the vessel was secured a> a preliminary to extirpation, been tied twentyT-one times,1 and in every in- stance but one (Halsted's) with a fatal result. Eighteen of these opera- tions were upon the right side, and three (Rodgers, McGill's, and Hal- sted's) upon the left. We have thus 51 cases of ligation of either the innominate or the first part of the subclavian, or, considering cases of subclavian aneurism only, 40 instances of the proximal operation, with only four ascertained survivals, and only three of these recoveries—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 main artery. 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 ? Halsted has recorded a remarkable case in which after ligating the first portion of the subclavian and the second of the axillary, he dissected out the whole aneurismal sac, the patient recovering, but amputation at the shoulder-joint (which would act as a modified distal operation) would under such circumstances probably be, in most instances, the best procedure. It would, as pointed out by Fergusson, who suggested the plan, have the advantage over the ordinary distal method of diverting the force of the circulation by removing the part which had previously demanded an arterial supply. This method has been put in practice by Spence, Holden, H. Smith, Heath, and Rose, 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 patient being anaesthetized), should be tried, and may some- times prove successful, as in two cases referred to by May; advantage might also be obtained from the flexion method, the arm being bandaged across the chest. If it be determined to resort to severer measures, the sur- geon must choose between ligation of the axillary below the clavicle, ligation of the third portion of the subclavian, the old operation, and amputation at the shoulder-joint. Ligation of the axillary below the clavicle has been done for aneurism (as a Hunterian operation) in 22 cases,' 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 1 To the 20 cases tabulated in the fifth edition is to be added the successful oper- ation of Halsted. e 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 aoupressed the axillary artery, ar.d subsequently the innominate. Another case has been added by May. ABDOMINAL AND INGUINAL ANEURISMS. 625 should, I think, be preferred, particularly as on theoretical grounds it would seem to be safer—ligation below the clavicle being of the nature of Anel's, rather than of Hunter's method. Ligation of the third portion of the subclavian is, however, in itself a very serious operation,1 and it is, therefore, worth while to inquire, with Syme, whether the old operation might not in some cases be preferable. Statistics are as yet wanting to decide this question, but the operation, which was twice successfully re- sorted 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, 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 pro- ceeding, but would of course have the disadvantage of necessarily sac- rificing the upper extremity. Hemorrhage during either operation 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 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 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. 220, 221). Abdominal and Inguinal Aneurisms.—Murray cured an aneu- rism of the abdominal aorta by instrumental compression above the sac, in five hours (the patient being under the effect of chloroform) ; and 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 success- ful case has been reported by Moxon and Durham, a fourth by Greenhow, and a fifth by Phillipson. This mode of treatment is, however, not en- tirely 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 aneurism of the cceliac axis), an autopsy reveal- ing 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 haviug proved fatal in the practice of 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 Simon; a fifth, also from intestinal gangrene, in a case of distal compression recorded by Lunn and Benham ; and a sixth, from rupture of the sac, in a patient treated by distal compression by Skerritt. Still, the successful result in The mortality for all causes is, according to Norris's statistics, 43^ per cent., 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. 40 626 SURGICAL DISEASES OF THE VASCULAR SYSTEM. the first-mentioned cases undoubtedly brings within the range of sur"-ical treatment an affection otherwise almost hopeless. The instrument to be employed may be either Skey's or Lister's (Figs. 31, 32), 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 report-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. Pringle and Morris's case, in which a similar operation was performed, terminated fatally on the fifth day, and Lange's case was also unsuccessful. In Morse's case the patient recovered from the opera- tion, and was reported as doing well seven weeks subsequently. Dr. Stewart's fatal case, in which after introduction of the wire a galvanic current was passed through it, as in Barwell's method, has already been referred to. 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 amesthesia. Cases are recorded by Mapotber, 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. Yarick's case of succe.-sful distal compression has already been mentioned. Ligation of the abdominal aorta for inguinal aneurism, was first per- formed by Sir Astley Cooper,1 in 1817, and has since been repeated by James, Murray, Monteiro, South, McGuire,2 Stoke? (by Porter's method of modified acupressure), and Watson.3 Czerny, of Vienna, has also tied the aorta for hemorrhage following a gunshot wound, after previous Mira- tion of the external and common iliacs, and Czerny, 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, Wat- son, and Czerny, ligation of the aorta would seem to be not only justifi- able, but absolutely necessary. Ligation of the common iliac artery (which was first practised, in 1812, by Gibson, of this city, in a case of gunshot injury) may be required in cases of aneurism involving the common iliac artery, or either of its branches. To the 32 cases collected by Dr. Stephen Smith, of New York, I have been able to add 51 others ; of the whole 83 but 24 terminated suc- 1 Sir Astley Cooper's operation, perhaps the boldest in the history of surgery, bas 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. 2 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. 3 For secondary hemorrhage, after previous ligation of the common iliac. ANEURISMS OF INTERNAL ILIAC AND BRANCHES. 627 cessfully, showing a mortality for the operation, as employed for all causes, of over 71 per cent.1 It is probable that the old operation would, in some cases of aneurism of the common iliac, be preferable to ligation of that vessel, as it certainly would be to ligation of the aorta. This procedure has, however, not yet been employed; it was attempted by Cooper in the case in which that surgeon tied the aorta, and was believed to have been 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, ac- cording to Erichsen, but one case of each known. Aneurisms of the gluteal and ischiatic arteries are more common, and may be treated in a variety of ways. A. G. Miller records a case of gluteal aneurism cured by Macewen's method of " needling." Fischer has particularly investigated the statistics of these affections, and from an analysis of 35 cases (14 of traumatic and 21 of spontaneous aneurism) concludes that the injection of the perchloride of iron is the best mode of treatment. If this method fail, or if it be not thought proper to employ it, it would further appear that for traumatic aneurisms the "old operation," 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 following table is compiled from Fischer's paper:— Traumatic. Spontaneous. Aggregate. Mode of Treatment. Cured. Died. A = o ■~!~2~' Cured. Died. "Not" stated. Total. i P 1 a; s 5 Not stated. Total. None, or medical only . ... ; 2 1 3 1 5 1 7 Compression .... 1 1 1 ... ... 1 1 1 2 Galvano-puneture . . ... : i ... 1 1 ... 1 Old operation2 .31 ... 4 3* 1 ... 4 Ligature of gluteal8 .11 ... 2 ... ... 1 1 2 " " internal iliac 1 2 ... 2 5 *3 ... 8 5 5 ;;; iio " " common iliac . ... 1 ... 1 ... 2 ... 2 3 ... 3 Injection of perchloride of iron . 1 ... ... 1 3 2 ... ; 5 *4 2 , ... 6 Summary .58 1 14 10 10 1 21 ;«" 18 2 35 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-puneture or the use of coagulating injections; if these means fail, the internal iliac should be tied, unless the surgeon thinks that he can find the artery outside of the pelvis, in which case the old operation, or ligation on the proximal side of the sac by Anel's method, would be preferable. Dennis and Chew recommend that In the fifth edition of this work 82 cases were tabulated, and an additional (suc- cessful) case has since been reported by Lucas. 3 Another (fatal) case of the old operation has been since recorded by Turner. Other cases of ligation of the gluteal artery have been recorded by McGrraw, Thorndike, Trepper, and Lindner. 628 SURGICAL DISEASES OF THE VASCULAR SYSTEM. ligation of the internal iliac should be preceded by a preliminary laparot- omy with temporary extrusion of the bowels, so as to afford free access to the artery through the peritoneum, and this plan was adopted in Dr. Williams's successful case. Dr. Sands reports a case of gluteal aneurism treated (without benefit) by digital compression through the rectum. The old operation is particularly adapted to cases of traumatic aneurism, as in these the communication with the artery will be certainly within reach ; to prevent hemorrhage during the operation, Bickersteth's plan might be adopted, and the circulation controlled by means of the aortic tourniquet; or Davy's rectal lever might be used, as was done by Mr. Turner. In a case, however, of spontaneous gluteal or ischiatic aneurism, the surgeon could seldom be sure that the sac did not extend within the pelvis, and hence, in such a case, ligation of the internal iliac would com- monly be a safer procedure This artery has been tied on at least 36 oc- casions, 13 times successfully and 21 times with a fatal result (two unde- termined), showing a death rate of nearly 62 per cent.1 Iliac and Femoral Aneurisms—Aneurisms involving the exter- nal iliac cr common femoral arteries should be treated, if possible, bv compression on the cardiac side of the tumor; but if this fail, ligation of the external iliac, or possibly of the common trunk, will be required. The rapid pressure, treatment has, according to Holmes, succeeded in seven out of ten cases in which it has been reported to. Other successful ease- have since been recorded by Staples and by Agnew. Compression, how- ever, should not be persisted in, unless some benefit be seen from its use within a reasonable period, since when it does no good it is apt to do harm. Thus, of 36 cases of aneurism in this position collected by Walsham, in which compression was attempted, only 9 were cured, while 2 proved fatal, and 25 ended in failure, 15 of these seeming to have been made worse by the treatment which was adopted. R. P. White has success- fully employed Porter's method of modified acupressure, while acupunc- ture (in conjunction with proximal compression) has been successfully re- sorted to by Macewen. Levis introduced horsehair into an iliac aneurism, the sac sloughing, and the patient, after ligation of the external iliac artery, dying from peritonitis. Norris collected, in 1847, 118 cases of ligation of the external iliac (first performed by Abernethy, in 1796), to which may be added 35 collected by Cutter, and 26 tabulated in the third volume of the Surgical History of the War. This gives 179 operations for all causes the mortality being 70, or a little over 39 per cent. If cases of aneurism alone are considered, the results are still more favorable, 126 cases then giving 35 deaths, a mortality of less than 28 per cent. The " old opera- tion" has been successfully employed in a case of iliac aneurism by Buchanan. Aneurism of the Deep Femoral Artery (Profunda) is very rare. Holmes referring to but five cases, two observed by Erichsen. two by Cock, and one by P. H. Watson. The treatment would consist in compression at the groin, or, if this should fail, in ligation of the common femoral, or, which many consider safer, of the external iliac. Ligation of the common femoral artery is recommended by Holmes for these cases, and for those of aneurism of the superficial femoral, which are situated at too high a point to admit of ligation below the place of bifurcation; and ten cases of the former operation are referred to, of which only three proved fatal. Other writers, however, give a different estimate of the results of this procedure. The operation is probably attended with more 1 To the 33 cases tabulated in the fifth edition of this work may be added a success- ful case recorded by Williams and two (results unknown) attributed toFeuger. ANEURISMS OP ARTERIES OF LEG AND FOOT. 629 risk than ligation of the external iliac, but has, on the other hand, the ad- vantage of being much more easly performed. Rabe has collected nearly 400 cases of ligation of the external iliac and common femoral arteries, and finds that the risk of gangrene after the former operation is but 11 per cent, as compared with 18 per cent, after the latter, and the risk of hemorrhage but 15 per cent, as compared with 39 per cent. Many years ago, in a case of hemorrhage, I secured the common femoral artery by acupressure. Lister, Pemberton, Turner, and Spofforth have successfully tied the same vessel with carbolized or chromicized catgut, as have Keetley, with kangaroo tendon, and H. M. Johnson with ordinary silk. Aneurisms of the Superficial Femoral and Popliteal Arte- ries are the most frequent of all external aneurisms, the former vessel giving 66, and the latter 137, out of 551 cases of aneurism of all parts, collected by Crisp. The treatment consists in compression, or in ligation by the Hunterian method. The considerations which should guide the surgeon in choosing between these modes of treatment have already been set forth, and need not again be referred to (pages 611, 616). Popliteal aneurisms are particularly adapted to the treatment by flexion, and by "the use of Esmarch's bandage. The latter mode of treatment is, according to Bellamy, most apt to succeed when the sac already contains a certain amount of fibrinous clot. Ligation of the superficial femoral artery would appear to be a more successful operation when performed for femoral, than when for popliteal, aneurism, the reason being that the risk of gangrene from venous conges- tion is much greater in the latter case than in the former. This is seen very clearly from Xorris's statistics, which embrace 22 cases of ligation for femoral aneurism, with only one death (from hemorrhage), and 154 cases of the same operation for popliteal aneurism, with 39 deaths—of which no less than 19 were from gangrene. Norris's table embraces in all 204 cases, with 50 deaths and 154 recoveries; or, if femoral and popliteal aneurisms alone are considered, 176 cases, with 40 deaths and 136 recoveries—con- secutive amputation having been performed in 5 of the successful and in 6 of the unsuccessful cases. The mortality- of ligature of the femoral artery for femoral and popliteal aneurism is, according to these statistics, 22.7 per cent., or about one in four and a half. Crisp's statistics are more favor- able, giving 122 cases, with 107 recoveries (7 after amputation) and only 15 deaths, a mortality of but a little over 12 per cent., and this is, accord- ing to Holmes, about the death-rate of the operation in London hospital practice of the present day. I have myself tied the femoral artery ten times: in seven cases for aneurism, with six recoveries and one death; twice for hemorrhage, with one recovery and one death ; and once (unsuc- cessfully) for rupture of the vessel in Scarpa's triangle by an injury received in blasting rock. Syme's remarkable record of 35 operations, with only one death, has already been mentioned. Diffused aneurism of the popliteal artery usually requires amputation ; while if the femoral he the vessel affected, the " old operation" may be advantageously substituted, as has been done, with the most gratifying results, by Birkett and by Forster. Aneurisms of the Arteries of the Leg and Foot are extremely rare—Kinloch succeeded in collecting only 22 cases of aneurism of the posterior tibial artery, including one of his own—but, if met with, should be treated by compression, etc., or, if necessary, by ligation on the cardiac side of the tumor. The injection of perchloride of iron proved successful in a case of tibial aneurism reported by Denuce*. The lines for the ligation of the various arteries have already been given (pages 221-229). 630 DISEASES OF BONE. CHAPTER XXXI. DISEASES OF BONE. The diseases of bone may be divided into those which depend upon the inflammatory process, and those which involve structural, non-inflam- matory changes. The affections which are to be considered under the first head are Periostitis, Osteitis, Osteo-myelitis, Epiphysitis, Abscess, Caries, and Necrosis. Inflammatory Diseases of Bone. Periostitis, or Inflammation of the Periosteum, is a frequent conse- quence of wounds or other injuries, or of certain diseases, as Syphilis. It may be primary, or may be secondary to inflammation of the bone itself, or of its medulla. The Pathological Changes in periostitis consist in swelling (temporary hypertrophy) of the periosteum, followed by rapid cell-proliferation of its deep or osteo-genetic layer, or a rapid accumulation of wandering cells (see pages 37 and 249), and resulting in the production of inflammatory lymph ; these changes may- be quickly arrested, the part returning to its former condition, and the newly formed material being gradually utilized in the normal maintenance of the bone—or the part may remain permanently thickened, or in a state of sclerosis or induration. These changes are usually accompanied by a softening or medullization of the superficial layer of the bone. If the irritation be more intense (as is seen in diffuse jieriostitis), there may be a rapid formation of pus, when necrosis of the subjacent bone is apt to follow. T. Smith has described, under the name of hemorrhagic periostitis, a condition in which bleeding occurs between the periosteum and the bone. Symptoms.—The symptoms of ordinary- periostitis are those of deep- seated inflammation in general, viz., swelling, corresponding to the extent of inflamed periosteum, heat, pain, tenderness on pressure, etc. The pain is apt to be worse at night. The attachment of the periosteum to the sub- jacent bone is loosened, giving sometimes a puffy or evem boggy feel to the part. In diffuse periostitis (which is much the most serious form of the affection, and which chiefly involves the long bones, especially the femur, tibia, or humerus, and is usually the result of injury in young persons of a strumous diathesis), the inflammation rapidly spreads, fre- quently involving the periosteal covering of the entire shaft, and if (as is sometimes the case) complicated with osteo-myelitis, perhaps attacking the epiphyses and neighboring joints as well. In this form of the disea.-c the production of lymph, and subsequently of pus, is rapidly effected, giving rise to the condition known as Subperiosteal Abscess. There is usually a good deal of constitutional disturbance, and fatal pyaemia not unfrequently occurs in the course of the affection. Diagnosis.—The ordinary circumscribed form of periostitis is easily recognized; the diffused variety may be mistaken for diffuse inflammation of the ai^eolar tissue, or for rheumatism. From the former it may be distinguished by its not spreading beyond the neighboring joints, and from the latter by the history of the case," and by the early occurrence of sup- OSTEITIS. 631 puration. Periostitis is said to be sometimes accompanied by a diffused rash, which has caused the disease to be mistaken for measles or scarlet fever. Treatment.—The treatment of circumscribed periostitis consists in the application of poultices, preceded perhaps by a few leeches, with opium to relieve pain, and, in the more chronic stages, in the use of blisters and the administration of the iodide of potassium. Advantage may often be derived from a free or subcutaneous incision, so as to relieve the tense state of the periosteum, and encourage resolution. In the treatment of the dif- fuse form of the disease, no time should be lost in making free incisions through the inflamed periosteum, so as to relax the parts, and allow the escape of pus, if there be any ; these incisions should be so arranged as to allow of free drainage, and should be repeated as often as necessary. At the same time, the strength of the patient must be maintained by the use of concentrated food and stimulus, and by the administration of tonics (especially quinia) with anodynes to relieve pain. In favorable cases, the patient may recover with the loss of more or less bone by necrosis, but pyaemia will often lead to a fatal termination. If the destruction of bone be evidently too great for the recuperative powers of nature to cope with, and particularly if the neighboring joints become implicated (pyarthrosis), showing that the affection is probably complicated with suppurative osteo- myelitis, amputation should be performed—if the patient be in a condition to bear it—and I have under such circumstances removed the arm at the shoulder-joint, with the happiest result. The statistics of amputation for subperiosteal abscess, particularly in the femur, are, however, so gloomy, that the operation can only- be looked upon as a last resort. Osteitis, or Inflammation of the Osseous Tissue itself, is seldom if ever met with as a primary affection, though it is a very frequent second- ary complication of either periostitis or osteo-myelitis. In fact, in the large majority of cases, whichever constituent of bone is first affected, all are sooner or later involved. The first Pathological Change due to osteitis is a softening or medullization of the bone tissue. Absorption of the earthy constituents occurs while the Haversian canals, lacunae, and cana- liculi become widened, many disappearing by the coalescence of numerous spaces and canals. " The enlarged Haversian canals," says Paget, "pre- sent the appearance of medullary spaces, and are filled with a soft, rapidly growing tissue not unlike that of granulation. This process is rapidly accomplished, Oilier having seen complete medullization of the phalanges, without necrosis, in the short space of twenty days. As the result of this medullization, the bone becomes enlarged (though it loses in weight), the layers of its walls becoming separated, and thus giving a porous appear- ance—whence this condition is called rarefaction or osteo-porosis. The bone often at the same time becomes elongated from transference of irri- tation to the epiphyseal cartilage. Paget has described, under the name of osteitis deformans, a condition in which the bones yield to pressure and become much distorted. Five out of eight cases, watched by him until their termination, ended in the development of cancer or sarcoma. Other examples of this affection have been since reported by various surgeons— Thibierge and J. L. Taylor have collected nearly fifty—and I have myself wen one case, sent to me by Dr. Grimshaw, of Wilmington, Del. The deformity in this case is well shown in Figs. 338, 339, taken from pho- tographs. If the irritation be intense or continued, the process of medullization, or decalcification, as it is also called, may run on to the occurrence of sup- puration, with perhaps caries and necrosis ; in other cases, the deposit of 632 DISEASES OF BONE. bony matter is renewed, the parts, perhaps, eventually becoming abnor- mally solid and heavy, the walls being thickened and the marrow-cavity encroached upon—when the condition known as sclerosis or eburnation results. These various conditions are frequently seen in different parts of the same bone, one specimen thus often exhibiting at once osteo-porosis eburnation, and necrosis. Fig. 336.—Osteo-porosis tion of femur. patient in the Hospital of the University of Pennsyl- of femur. (Druitt.) (Liston.) vania.) Symptoms.—The symptoms of osteitis are those of periostitis, with which the disease is almost invariably complicated. The osteocopic pains are per- haps more marked, and the tenderness greater, while the limb feels heavier and more helpless. Treatment.—The treatment is essentially that recommended for perios- titis; if a deep incision do not afford relief, a longitudinal section should be made through the bone, down to the medullary canal, with a Hey's saw; or (if it be suspected that the disease may have run on to suppuration) a small disc of bone should be removed by means of a trephine. If there be no pus, the simple opening of the medullary cavity will be sufficient, reliev- ing pain by the removal of tension, and placing the part in the most favor- able position for recovery. If, on the other hand, pus be found, the open- ing should be enlarged with gouge and mallet until the whole suppurating cavity is thoroughly exposed, when it may be curetted and packed with lint or »'auze as after an operation for necrosis. Osteo-myelitis, as the term is used in these pages, signiBes Inflam- mation of the Medulla or Marrow of Bone. This disease was made a subject of special study by the late Dr. John A. Lidell, whose writings give by far the best account of the affection to be found in our own, if not in any, language. Osteo-myelitis may occur as a primary affection, or may be secondary to inflammation of the periosteum, or of the bone itself— being, indeed, almost invariably accompanied by osteitis or periostitis, or both. It may occasionally occur idiopathically, but is usually a traumatic affection, resulting particularly from contusions or contused wounds of OSTEOMYELITIS. 633 bone, and hence is of special interest in military practice (see page 191). Several varieties of osteo-myelitis have been described by surgical writers, as the acute and chronic, or the diffused and circumscribed. A better classification would appear to be one founded upon the pathological condi- tion in different cases, according as the inflammatory change is limited to cell-proliferation and the production of lymph, or runs on to suppuration, or to sloughing. We may thus speak of—1, simple; 2, suppurative; and 3, gangrenous osteo-myelitis. 1. Simple osteo-myelitis is constantly- met with in connection with osteitis and periostitis. It is present in a circumscribed form in many cases of simple fracture, in which, by- causing a retrograde metamorphosis into bone, it gives rise to the so-called pin callus. The pathological change which characterizes simple osteo-myelitis is called by Lidell carnification or hepatization of the marrow. "The first anatomical alteration in osteo- myelitis, beyond mere hyperaernia of the involved bloodvessels, appears to be," according to Woodward, "'cell multiplication affecting the connec- tive-tissue corpuscles of the marrow, and of the connective tissue sur- rounding the bloodvessels in the canals of Havers. As a consequence, the true osseous tissue is encroached upon, and the portions of it which imme- diately adjoin the multiplying connective tissue disappear. ... It appears probable . . . that the bone cells which occupy the lacunae next to the multiplying connective tissue themselves enlarge and multiply, the matrix between them being absorbed, and that thus the bone-cells themselves contribute to the resulting granulation tissue. The fat in the adipose-tissue cells of the marrow is also absorbed, and these cells appear to contribute by their multiplication to the granulation tissue formed, as is the case in inflammation of the subcutaneous adipose tissue." This granulation tissue of simple osteo-myelitis can be well seen in the florid button of granulations which covers the sawn end of a bone, in the stump of an amputation. Carnified marrow is of a tough, almost fibrous, consist- ence, and usually of a more or less vivid red color, sometimes yellowish from the admixture of fat or of imperfectly organized lymph, or deep red, or almost black from hemorrhagic extravasation, which Lidell calls apoplexy of the marrow. Carnified marrow may- gradually return to its normal state, or may run on to suppuration, or, on the other hand, may undergo a retrograde meta- morphosis, giving rise to the formation of a cylinder of bone, and perhaps to complete obliteration of the marrow-cavity. This is a not infrequent termination of simple osteo-myelitis. 2 Suppurative Osteo-myelitis1 may be regarded as a later stage of the preceding. In the large majority of cases, suppurative is preceded by simple osteo-myelitis, the lymph-corpuscles of the granulation tissue of the latter being converted into pus-corpuscles, and suppuration beginning in several distinct foci, which afterwards coalesce. In some instances, how- ever, under the depressing effect of bad hygienic or constitutional influ- ences, the production of pus is so rapid as to render the suppurative form of the disease to all intents and purposes a primary- affection. If the pyogenic change be limited to a small area, the condition known as Cir- cumscribed Suppuration or Abscess of Bone is produced—an affection which is quite amenable to treatment (see page 636). If, on the other ' Suppurative osteo-myelitis is usually supposed to be due to the contact of infec- tious materials, and its occurrence to be preventable by the adoption of antiseptic measures ; but Colin maintains, from experiments on the lower animals, that it is not excited by a prolonged exposure of any part of the bone to the atmosphere, nor even by the application of putrid substances ; its development seems to be rather due to the action of constitutional causes. 634 DISEASES OF BONE. hand, the medullary suppuration be diffused,1 involving, perhaps, the whole marrow cavity, the affection becomes one of the gravest character__wide- spread necrosis resulting as an almost necessary consequence, even if the occurrence of pyaemia do not lead to a fatal result. 3. Gangrenous Osteo-myelitis is a comparatively rare affection. It occurs, just as inflammatory- gangrene in other parts, from a higher grade of irritation than is concerned in the production of the simple or suppura- tive varieties. When attacked by gangrenous osteo-myelitis, the marrow assumes a very dark, almost black, hue, and has a gangrenous odor. When examined with the microscope, the cell formations are, according to Lidell, found to have been destroyed, amorphous matter (the debris of pre-exist- ing histological structures) alone remaining, with perhaps some connective tissue—all stained of a dark color by decomposing haematoidin. The same bone may be, at the same time, affected in a different part by each of these varieties of osteo-myelitis Osteo-myelitis, in whatever form it appears, has a marked tendency to spread towards the trunk—the upper portions of the long bones (at least in the case of the femur and humerus, which are the bones most often affected) being almost always more seriously involved than the lower. In a case, however, of osteo-myelitis affecting the tibia, observed by H. Allen, the lower portion of the medulla was most inflamed. Beside the immediate risks of osteo-myelitis, of which the chief is un- questionably the occurrence of pyaemia, serious consequences may ensue from the implication of the other constituents of the affected bone; thus, as the result of secondaryr osteitis, there may be caries or necrosis, which may involve the internal laminae only (central necrosis), or, if accom- panied with diffuse periostitis and subperiosteal abscess, may involve the external laminae only (peripheral necrosis), or may cause the destruction of the whole thickness of the shaft (total necrosis). Again, from exten- sion in a longitudinal direction, separation of the epiphyses may follow, or, the epiphyses themselves being involved, ulceration of the articulating cartilages and secondary7 pyarthrosis of the neighboring joints may ensue. Symptoms and Diagnosis of Osteo-myelitis.—Simple osteo-myelitis is ordinarily attended by no recognizable symptoms, being indeed usually a conservative process which can scarcely be called morbid. When it does pass the border-line between health and disease, its symptoms are indis- tinguishable from those of the osteitis and periostitis by which it is accom- panied. Even suppurative and gangrenous osteo-myelitis can rarely be recognized during life, unless the bone affected be iu an unhealed stump, when the protrusion from the marrow-cavity of a suppurating or sloughing fungous mass, or an exploration with the finger or probe, would, of course, indicate the nature of the affection. Under other circumstances, the symp- toms will be usually completely masked by those of the accompanying diffuse periostitis ; if, however, as remarked by Lidell, the free incisions which were recommended for the latter affection should fail in any case to give relief, the surgeon would properly infer that the medullary cavity was involved. A similar inference would be justifiable from the occurrence of pyarthrosis, or epiphyseal separation, or even from the pain and constitu- tional disturbance being more intense than could be accounted for by the existence of osteitis and periostitis alone. Treatment.—The treatment of simple osteo-myelitis is essentially that recommended for osteitis, the longitudinal section with Hey's saw being equally applicable in these cases. If the existence of suppurative osteo- 1 This is the only form of the disease which is recognized under the name of osteo myelitis by many systematic writers. CIRCUMSCRIBED SUPPURATION OR ABSCESS OF BONE. 635 myelitis he ascertained, an attempt may be made to preserve the limb by making one or more openings with the crown of a small trephine, so as to expose the marrow-cavity and allow the exit of pus. The subsequent treatment is that already described in speaking of trephining for osteitis. This plan was employed in the year 1198, by the late Dr. Nathan Smith, with the happiest results, and has been more recently adopted by his son, Morven Smith, and by several other surgeons, including Frank, Boeckel, Pean, and myself. If the affection involve the whole extent of the medulla—particularly if pyarthrosis have occurred—amputation or ex- cision, according to the nature of the bone, may be required. If a short bone, such as the astragalus, be involved (which is seldom the case), excision may suffice; but in the case of the long bones, the choice will lie between amputation and disarticulation. Amputation in the continuity of the affected bone should be rejected, as the disease would almost certainly- recur in the part that would be left; hence, disarticulation, in the case of humerus or femur, and the same, or amputation of the thigh or arm, in the case of bones of the leg or forearm, are the operations to be recommended. Dis- articulation, under these circumstances, proved very successful in the hands of J. Roux and Arlaud, 20 cases, of which 2 were at the hip-joint, having all terminated in recovery.1 The operation should be performed, if possible, before the development of pyaemic symptoms, but has been resorted to with success even at a later period by Sir Joseph Fayrer. Gangrenous osteo- myelitis, if recognized during life, would require amputation even more imperatively than the suppurative form of the disease. It is, perhaps, scarcely necessary- to say- that amputation should not in any case be employed, unless not only the surgeon be well convinced that diffuse suppurative or gangrenous osteo-myelitis is actually present, but unless also the affection is running so acute a course as to endanger life— and unless conservative treatment, especially the use of the trephine, or, which Koplik and Van Arsdale prefer, sub-periosteal excision, has failed to give relief. A large number of cases of osteo-myelitis run a compara- tively chronic course, producing more or less extensive necrosis, but at no time placing life in imminent danger; as a rule, no amputation would be justifiable under such circumstances, but the dead bone should be dealt with as in cases of necrosis from any other cause. Epiphysitis—Under this name, Macnamara describes a state of inflammation often running on to suppuration, occurring in children at the juncture of the epiphysis and diaphysis of a long bone. The affection is apt to be mistaken for arthritis of the neighboring joint, but can be dis- tinguished by careful examination. The general symptoms correspond pretty closely with those of diffuse periostitis, which indeed often follows the original affection. The treatment consists in making an early and free incision, with attention to drainage, etc., and in supporting the patient by the use of quinia and alcohol. If the symptoms persist, the medullary cavity should be opened as in suppurative osteo-myelitis ; amputation may sometimes be required. Circumscribed Suppuration or Abscess of Bone.—This painful affection may occur in any part of a bone, but is most common in the articular extremities, as in the head of the tibia. The course of the disease is usually very chronic, and is marked by symptoms of localized osteitis, especially tenderness and pain, which is most severe at night, and is aggra- vated by walking or other exertion. There is often some swelling and redness of the skin, with concomitant periostitis. Abscess of bone has 1 Roux reports in all 22 cases, of which 4 were at the hip-joint (all successful) ; 2 of the hip-joint cases were, however, for affections other than osteo-myelitis. 636 DISEASES OF BONE. been met with under several conditions, which have been described as dis- tinct affections, though the pathology of all is the same. Thus (1) there may be caries of the superficial portion of the bone, a narrow channel leading down to the focus of suppuration (as in the celebrated case recorded by Hey, of Leeds); or (2) there may be what Markoe has well described as "chronic sinuous abscess of bone," in which an abscess originating in the interior of a bone makes its way towards the surface, and obtains an imperfect vent by perforating the external compact layer; or (3) there may be an abscess entirely- surrounded by bone-structure, as in cases Fig. 340.—Abscess in tibia ; Brodie's case. (Holmes.) recorded by Sir Benjamin Brodie. The only affections with which abscess of bone is likely to be confounded are osteitis, circumscribed osteo- myelitis, stopping short of the production of pus, central necrosis, aud cystic growths originating within the bone. A mistake under these cir- cumstances would, however, be of no practical importance, as the same treatment would answer in either contingency. Treatment.—The treatment consists in perforating the compact sub- stance with a trephine at the most tender point, so as to give free vent to the contained pus, as was done byr Nathan Smith, in 1798, in a case of diffused medullary suppuration (see page 635). A small trephine should be used, the bone being first exposed by means of a suitable'incision. and the opening subsequently enlarged as much as may be necessary; if the abscess be not reached by the aperture thus made, perforations in various directions may be made through the opening with a drill or other suitable instrument. The cavity of the abscess is sometimes found lined with granu- lations, forming what is called a pyogenic membrane, or the surrounding bone may be rough and carious. In the former case the curette, and in the latter the gouge, should be freely used; while if a sequestrum be found it must of course be removed, and the case treated as one of necrosis. The use of the trephine for abscess in bone is usually said to have originated with Brodie, and to that distinguished surgeon is undoubtedly due the credit of having popularized the operation in modern times. It is, how- ever, an old mode of treatment, having been well described by David, in an essay which received the prize of the Royal Academy of Surgery in 1764, and by Bromfeild in 1773. Still earlier the operation had been per- formed by Petit (who died in 1750), and by Walker, of Virginia (in 17o"); and at a later period by Hey, of Leeds (1787), and by Simons, of South Carolina (1825)—Brodie's first case not occurring until 182S. CARIES. 637 The operation should be performed as soon as the deep-seated pain and other symptoms render the existence of an abscess probable ; and if no pus be found, relief will probably be afforded by the diminution of tension and pressure. If the operation should be delayed, there would be reason to fear that the abscess might perforate the articular cartilage, and involve the neighboring joint—an accident which might make it necessary to resort to excision, or possibly amputation. Special trephines have been devised bv McArdle, for use in cases of deep-seated bone disease, the length of the cutting portion of the instrument being from four to six times that of the ordinary trephine. Caries__Caries is the name applied to Ulceration of the Osseous Tissue,1 and it bears precisely the same relation to inflammation of bone that ordinary ulceration does to inflammation of the soft parts. Several varieties of caries are described by systematic writers—such as the cir- cumscribed, diffuse, or phagedaenic—the simple, scrofulous, syphilitic, etc. In caries, as in common ulceration, the dead tissue is thrown off in a state of solution, or in very minute particles; whereas in necrosis (as in ordi- nary gangrene) considerable masses are ejected at once. The term caries neurotica is used by some writers to signify an intermediate condition, analogous to what might be called gangrenous ulceration of the soft tissues. The term caries is strictly applicable only to the degenerative process in which the effete material is cast off or ejected—that in which the products of degeneration are absorbed being more properly designated as interstitial absorption.2 Carious bone is porous and fragile, usually of a dark gray or brown hue, and presenting numerous hollows and cavities, which are filled with the products of disintegration, often intermingled with necrosed frag- ments. The surrounding bone is usually indurated, though, especially in the scrofulous variety, it is often in a state of medullization—fungous granulations over- lapping and masking the carious portion. Carious bone is sometimes, though not usually, sensitive ; bleeds when touched with a probe; and may be felt to be softer than in the normal condition. The disintegrated material de- rived from carious bone consists of oil globules, blood, and various debris, with granular inorganic substances corresponding in chemical composition to the salts of bone. Superficial caries is accompanied with localized periostitis, the periosteum being loosened and thickened, and present- ing a pink, villous appearance; these villous-looking granu- lations occupy the depressions of the subjacent bone. The symptoms of caries are those of osteitis compli- cated by an abscess leading to the softened bone; there cannot be true caries without suppuration. When the bone can be felt (as it usually can by using Sayre's jointed probe. Steel's flexible wire instrument, or the still simpler apparatus of Sarazin, which consists merely in a flexible bougie, tipped with the end of a female catheter), the diagnosis is easy—but under other circumstances can only be made by observing the persistence of the suppuration and other symptoms without obvious cause, and by chemical examination of the pus, which, when proceeding from _ Some writers limit the term caries to scrofulous ulceration of bone ; while others (as Erichsen) consider it a distinct disease, analogous to, but not identical with, ulcera- Eeraarkable cases of this kind have been recorded by Barbieri, Billroth, and other Fig. 341.—Caries. (Druitt.) 638 DISEASES OF BONE, diseased bone, contains an excess of phosphate of lime. Caries may be secondary to disease of the soft parts (as in certain inveterate ulcers, par- ticularly of the lower extremities), or may be a primary aflection. In the latter case it particularly involves the cancellated tissue, and is thus rao>t common in the short or spongy bones, and in the articulating extremities of the long bones—in which situation it not unfrequently leads to destruc- tive disorganization of the neighboring joints. Recovery from caries a9 from ulceration of the soft parts, is effected by granulation and cicatriza- tion—a dense fibrous structure, or an imperfect form of bone, taking the place of the tissue which has been destroyed. Treatment.—The treatment of caries must be both constitutional and local. If the patient be syphilitic, iodide of potassium may be adminis- tered, or if of a scrofulous diathesis, cod-liver oil with the iodide of iron. The hy-gienic condition should receive careful attention, and in many cases a change of air, especially residence at the seashore, will prove of great benefit. The local treatment during the earlyT stages of the disease, while the ulcerative process is advancing, should usually consist merely in keeping the parts clean and free from external sources of irritation. When the acute symptoms have subsided, an attempt may be made to remove the diseased bone by means of applications of iodine or of the mineral acids. Chassaignac has highly recommended the use of dilute muriatic acid, which is injected through the fistulae which lead to the carious bone, and Morris employs the same acid in conjunction with pepsin. Pollock used dilute sulphuric acid, applied with a camel's-hair brush, after turning back the soft parts. The use of caustics, or even of the actual cautery, has likewise been advised by various surgeons, and may occasionally prove useful. The " Liqueur de Villate," which was introduced by Notta, may be used as an injection, and has often been of service in my hands. It may be made according to the following formula: B. Zinci sulphatis, cupri sulphatis, ail gr. xv; liq. plumbi subacetatis, 13-ss; acid. acet. dilut. f5iijss. M. Great advantage may sometimes be derived from the use of an oakum seton drawn through the carious bone, as recommended by Sayre. When the carious bone can be reached from the surface, it may be scraped or cutaway with a gouge or 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 Sean- lot 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, however, 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, e ven tually, in spontaneous recover}; Fig. 342.—Gouge- forceps. Fig. 343.—Burr- head drill. NECROSIS. 639 hence in many cases, particularly with patients who, from their social con- dition 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 jransrene of the soft parts, it may be acute or chronic, dry or moist, in- flammatory, 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 va- riety ; this form of necrosis corresponds to the mephitic gangrene of bone of Lidell. In the large majority of cases, however, necrosis is slowly- developed by the affected bone being deprived of its normal supply of blood; the compact structure is then chiefly involved, and the phenomena of dry or ordinary necrosis are presented. Thus in osteitis, the capillaries of the Haversian canals become strangulated, as it were, against the sur- rounding bony walls, and death of the part results as a consequence of arrested circulation. Among the more remote causes of necrosis may be particularly mentioned scrofula and syphilis, exposure to heat or cold, the application of caustics, exposure to the fumes of phosphorus, etc. The bones most often affected are the tibia, femur, humerus, phalanges, skull, lower jaw, clavicle, and ulna ; unlike caries, necrosis attacks the shafts, in preference to the articulating ex- tremities, of the long bones. Necrosis is not very com- mon in young children (though it may occur among the sequelae of the eruptive fevers), being most frequent in early adult life; it is sometimes seen, like ordinary- senile gangrene, as a consequence simply of the diminished vitality of old age. Bone deprived of its periosteum usually, though not necessarily, becomes necrosed; if both periosteum and medulla perish, 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. 634). The dead bone is at first connected with the surround- ing parts, but becomes gradually loosened, and is finally separated and thrown off as an exfoliation. While the process of loosening is going on, the periosteum, if not destroyed, furnishes new bone, which often forms a sheath around the dead portion, which is then said to be invaginated, and when separated constitutes a seques- trum. The separation is effected, not, as was formerly supposed, at the expense of the dead part, by absorp- tion, but at the expense of the surrounding living bone, which undergoes medullization, and is converted into a layer of granulations. The free surface of an ex- foliation, or of a sequestrum, is pretty smooth, but the pdges and deeper surfaces present a ragged or worm-eaten appearance, Fig. 344. —Central necrosis ; new bone with cloacae. (Erich- sen.) 640 DISEASES OF BONE. with depressions corresponding to the granulations by which they have been surrounded. The sheath of bone which envelops a sequestrum is called the involucrum; 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 perios- teum furnishing a new osseous sheath, the medulla likewise, by a process of retrograde metamorphosis, becomes partially ossified,1 and the seques- trum is thus surrounded on both sides by living bone. Moist Necrosis.—This, which is a comparatively rare form of necrosis, is well described by Lidell under the name of Mephitic Gangrene of Bone. This form of the disease manifests its peculiarities chiefly in the cancellated structure of bone, which, when thus attacked, is moist, more or less softened, and of a dirty gray or greenish-brown hue, with an extremely offensive odor. This form of necrosis may occasionally be seen in compound fractures, in what Dupuytren called primary splinters (see pp. 187, 274), if these be not promptly removed ; it may also result from violent contusion of bone, being thus more frequent, probably, in military than in civil practice. Moist necrosis is always total—involving, that is, the whole thickness of the affected bone; there is little or no effort at repair on the part of nature in these cases, the periosteum either itself sloughing, or at best furnishing but a few imperfect nodules of bone. Symptoms of Necrosis.—The symptoms of necrosis may be described as belonging to two periods, that in which the bone is dying, and that in which its separation as an exfoliation or sequestrum is effected; in moist necrosis, as the bone is at once deprived of vitality, the first stage is absent. The symptoms of the first stage of necrosis are those of osteitis, it being impossible to decide, before the occurrence of suppuration, whether necrosis is or is not about to occur. The death of any portion of the osseous skeleton is usually, though not invaria- bly, attended by extensive suppuration of the soft parts,2 the abscesses thus formed gradually contracting to sinuses through which, if a probe be passed, the necrosed bone can be readily recognized by the hard and rough sensation which it communicates. In cases of central necrosis, the diagnosis can only be cer- tainly made if cloacae exist, through which the dead bone can be felt: if there be no cloacae, the affection may be indis- tinguishable 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 meas- urably subsides upon the occurrence of suppuration, though occasional exacerba- fig. 345.-Necrosis oi the skull. tions may be observed during thewhole (From a patient in the University process of exfoliation. During the sCC- Hospital.) ond stage, the dead bone acts as a for- 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 (see pp. 249 et seq.). 2 Necrosis without suppuration has been observed by Stanley, Paget, and Morrant Baker. NECROSIS. 641 ei«-n body, keeping up the discharge and furnishing the necessary irrita- tion to effect its own separation and to excite the osteogenetic function of the periosteum, by which the process of repair is chiefly accomplished. The time required for the separation of a necrosed portion of bone varies from a few weeks to many years ; it is usually less for the upper than for the lower extremity, and, other things being equal, is proportionally- shorter as the necrosis is more circumscribed and superficial. 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 parts 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 exhaus- tion 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 pos- terior 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 operative 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— 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 forceps. If the necrosed bone be in the form of a sequestrum, the operation is more complicated: an incision should, in this case, be made down to the bone, in the line of the principal cloacae, joining two or more of them, if there be several, in such a manner as to avoid the chief vessels and nerves. In some cases, if a cloaca be large, it may be possible to 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, 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 openings, when a see-saw motion may often be detected. It sometimes happens, however, that at the operation the sequestrum is found to be only partially detached, bringing with it, when wrenched away, a portion of living and vascular bony tissue. The cavity left by the removal of a sequestrum is commonly lined by- a layer of granulations—though in scrofulous cases a sequestrum may be surrounded with carious bone, which must then be re- 642 DISEASES OF BONE. 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 fiom the neighborhood of the wound, and that this may heal firmly from below. Neuber, Lange, and Gerster assist Fig. 346.—Sequestrum forceps. Fig. 347.—Necrosis of femur, following gunshol fracture. (From a specimen in the museum of the Episcopal Hospital.) the closure of the cavity by depressing the soft parts and fixing them to its base with strong, straight needles, and grafts of decalcified bone have been successfully7 employed by Senn, Poncet, Kiimmel, Halsey, Deaver, Curtis, and other surgeons. The after-treatment consists in applying a light dressing, and in placing the limb, if the involucrum be thin, on a suitable splint, so as to prevent deformity from bending. In acute necrosis resulting from subperiosteal abscess, when the whole diaphysis of a long bone has perished, Holmes and Giraldes 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 success- fully resorted to by Holmes, Letenneur, McDougall, Spence, Heath, Duplay, Weinlechner, Bockenheimer, Pye, Shrady, and myself, requires a very free incision, dividing the periosteum which will be found entirely separated, the bone being then bisected with a chain-saw, and wrenched from its epiphyseal lines by means of the lion-jawed forceps (Fig. 377). The bone most commonly affected is the tibia, but Bockenheimer's operation was on the femur, and Shrady's on the humerus. Even if the limb be left per- fectly flail-like at the time, it probably will become consolidated, and ulti- NON-INFLAMMATORY STRUCTURAL DISEASES OF BONE. 643 matelv useful. My own experience in this procedure is limited to three cases, in one of which I removed the whole humerus (at two operations), in one the whole clavicle, and in the third the upper half of the tibia. In the two latter cases, 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 inserting 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 mayr 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. 347), 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 yariety known as Osteoma (see page 536): when resulting from inflammation, it receives the name of Periostosis. In neither case does the affection admit of treatment. Atrophy of bone often occurs simply as a senile change, but may also result from injuries, as contusions or fractures, or from mere disuse. It is not unfrequently met with as the result of a fall, in the neck of the thigh-bone in old persons, where it gives rise to shortening, and may be mistaken for fracture of the part (Fig. 348). 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 475). 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 degen- eration, and the other to which the name osteo- malacia should be strictly confined, consists in an absorption of the earthy constituents of bone, the part affected being more or less reduced to a cartila- ginous state. The latter form of the disease attacks particularly the bones of the trunk, especially the pelvis twhere in the female it may impede parturition), while the former is more common in the bones of the extremities. Several bones are usually affected. Fig. 348.—Senile atrophy of neek of femur. (Liston.) 644 DISEASES OF BONE. The softening process begins at the centre and spreads outwards; the cancellous structure is dilated, its cells being filled with 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 frac- ture, as in remarkable cases reported by Tyrrell, Arnott, R. W. Smith Joseph Jones, and Blanchard. If the whole thickness of the bone, on the other hand, be involved, it becomes pliable and easily bent, the most curious distortions resulting, as in the oft-quoted case of Madame Supiot. The disease seldom occurs in childhood, but usually in early adult or middle life ; it is more common in women than in men, and often appears to have been induced by pregnancy or parturition. It is sometimes hereditary, and, according to Heitzmann, may like rickets be artificially produced bv long administration of lactic acid. It is not uncommon among the insane. Symptoms.—The early symptoms are generally obscure, consisting chiefly in vague pains, which are probably considered rheumatic. Some- times the giving away of the limbs, the bones being either fractured or bent, is the first circumstance which attracts attention. The urine, and sometimes the other secretions, contain an abnormal quantity of phos- phates ; and in a case recorded by Maelntyre, the urine contained also a large amount of animal matter of an albuminous nature. As the disease progresses, the patient becomes bed-ridden, and may remain in this state for many years, eventually dying from simple exhaustion, or from some independent affection ; in other cases, the viscera may become fatally de- ranged 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, 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 bedsores, 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 Maelntyre, and Busch records two cases in which marked improvement followed the use of phosphorus. Fehling and Truzzi report cures following the operation of oophorectomy. 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 page 471). The tendency of modern opinion is, however, in the opposite direction, and pathologists now believe that true tubercle often occurs in bone, where it may be either circumscribed (encysted) or diffused (infiltrated). The circumscribed variety is the rarer, and occurs chiefly in the skull and the articular extremities of the long bones, especially the tibia ; it produces no disturbance until softening occurs, when it leads to an intractable form of caries, and, if in the neighborhood of a joint, often in- 1 Osteomalacia is sometimes called Rachitis Adultorum. TUMORS IN BONE. 645 volves the latter in a destructive form of inflammation. The diffused tubercle affects particularly the shafts of the bones, and is, according to Holmes, less apt to run into softening than the circumscribed variety. In the treatment of tubercle occurring in bone, injections of iodoform in sterilized glycerin or oil (1-10) have proved useful, as have similar injec- tions of a ten-per-cent. solution of chloride of zinc. 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 dis- organizing changes, and in the absence or feebleness of the natural efforts at repair. The affected bone is soft, light, and oily, the proportion of fat and of soluble salts being increased, and that of calcareous matter and of the organic matrix mark- edly diminished. The symp- toms of scrofulous osteitis are those of scrofula in general, superadded to a chronic and indolent form of bone inflam- mation. The treatment consists in the administration of remedies adapted to the scrofulous dia- thesis, 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, applied by strapping the part with compound gal- banum plaster or soap plaster. Should suppuration occur, the resulting caries must be treated as directed in the preceding pages, it being re- membered, however, that the prognosis of operations, both in scrofulous and tuberculous cases, is less favorable than when there is no constitutional taint (see pajres 472, 474). Syphilitic Affections of Bone have already been referred to (p. 509). Changes of Bone due to Affections of the Nervous System. —Blanchard has noted boue-changes in cases of locomotor ataxia; these consist 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 in- dependent formations, or may be secondarily developed in solid tumors. Serous and Mucous Cysts are met with in the jaws, and rarely 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 the front wall of the cyst with trephine and gouge, the cavity being then stuffed with gauze, so as to induce contraction and healing by granulation. I have thus twice successfully dealt with large cysts of the tibia. Percussion is recommended by Liicke as a means of recognizing the presence of a tumor in bone, the morbid growth causing a lower resonance than in the normal condition. Fig. 349.—Scrofulous osteitis ; magnified 250 diameters. (Erichsen.) 646 DISEASES OF BONE. 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 appear 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. Pierson has reported a case of sanguineous 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. XXVII. 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 Fig. 350.- -Osteo-sarc'oma of bones of forearm. (From a patient in the University Hospital.) with chamois leather), without making any ex- ternal wound ; such a plan was twice success- fully adopted by 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, enu- cleation may (as pointed out by Paget) be occasionally preferable to excision or amputa- tion. 3. Malignant Tumors.—Any form of malignant tumor may occur in bone, by far the most frequent, however, being one or other variety of sarcoma, an affection which in this situation runs a course fully justifying the name of malignant. Sarcoma may origin- ate in the interior of a bone, when it is said to be central or interstitial, or may be primarily developed in and beneath the periosteum, when it is called periosteal or peripheral. In other instances it is said to be infiltrated, when the whole bone is softened and filled with sarcomatous Fig. 351.—Enchondroiua of fe- mur. (From a patient in the Uni- versity Hospital.) PULSATING TUMORS OF BONE. 647 material__a condition which, as already remarked, has been confounded with osteomalacia. 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 fracture. 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 cover- ino- of the shafts of the long bones, the bony tissue itself remaining com- paratively free from disease, though it occasionally becomes softened, when fracture may occur. In this form of tumor, partial ossification not unfre- quently 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 exploring-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. 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, and 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 primary carcinoma of the femur seems to have been well established. Treatment.—This consists in excision or amputation: excision is to be employed in the case of the flat bones (as the scapula), or those of the face (as the upper jaw), but is rarely justifiable if the disease have passed the limits of the bone itself, involving the soft structures or 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 possible. It is usually advised to remove the limb at or above the nearest joint, but it would appear from cases recorded by Collis, Pemberton, and others, that amputation in the continuity, or through the epiphyseal line, is sufficient; probaby 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- s'bly, true aneurisms of the osseous arteries. The latter alone should receive the name of Osteoid Aneurism. The disease originates in the can- 648 DISEASES OF JOINTS. cellated structure (usually the head of the tibia'), 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 compres.-in.r the main trunk, the pulsation stops, and the tumor may then be emptied by pressure, a cavity surrounded by a bony wall being perceptible. The pulsation may disappear when the resistance of the periosteum is overcome. The bruit* which is commonly distinct in pulsating 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 springs should be likewise removed. Ligation of the main artery has been occasionally employed, but usually with only temporary, if any, benefit. If the disease be far advanced, or if other measures have failed, amputa- tion, as in malignant disease, is the only resource. Pulsating Tumors of the Cranial or Trunk Bones are almost inva- riably of a malignant character, and rarely admit of successful treatment. CHAPTER XXXII. DISEASES OF JOINTS. The older surgeons confounded together all diseases of the joints under the common names of arthritis and white swelling, and it is within a com- paratively recent period only, and in a great measure through the labors of Sir Benjamin C. Brodie, that a more accurate classification has become possible. The tendency at the present day, as justly 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 amor- 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 syphilis. Simple or uncomplicated synovitis may be acute 1 Peugnet 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 aneui ism. SYNOVITIS. 649 or chronic, the difference being comparative, and referring to the intensity of the affection, rather than to any specific diversity. Pathology.—The first effect of inflammation on a synovial membrane is to produce increased vascularity, with a diminution of the natural shin- ino- 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 part 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 sinuous tracks; the ligamentous structures become elongated, thickened, and softened, and partial or complete dislocation may occur. Symptoms.—The symptoms are usually well marked. There is pain, often accompanied by a feeling of distention, and usually referred to the affected joint, but occasionally- to others: thus pain ia the knee attends inflammation of the hip. The pain is increased by motion or pressure, is often worse at night, and in some cases (as in the synovitis of pyaemia) is attended by marked cutaneous hyperaesthesia. Swelling, varying with the amount of intra-articular effusion, is a characteristic symptom—the shape of the joint being altered by the 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 superincumbent 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. 650 DISEASES OF JOINTS. The occurrence of suppuration in a joint (pyarthrosis) is marked bv 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 granula- tion 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 become much aggravated, assuming a peculiar "jumping" or " starting" character (usually worse 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 tne Local Treatment of synovitis (during the acute stage), great benefit will often be derived from the application 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 hops ; that application should be preferred which is most agreeable to the patient. In every case, the joint should be placed at complete rest, and in such a position as will secure the greatest 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. 654), 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 use of mercurial and bella- donna ointment, or by the repeated application of blisters or tincture of iodine, together with douches, frictions with stimulating embrocation-, moderate pressure by means of a soap plaster and bandage, and the caution- employment of passive motion, if anyr 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 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 ARTHRITIS. 651 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 Gue'rin advises punctate cauterization with a hot iron. Billroth's iodo-glycerin injection C1—10) is sometimes of service. 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 pyiemia. 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 suction trocar. The treatment consists in evacuating the pus by means of a free incision, drainage being secured by position or by the use of Chassaignac's tubes or Ellis's wire coil (see p. 436). In some cases, ad- vantage may be derived from washing out the joint by injecting diluted tincture of iodine, or a weak solution or 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 lijraments 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 defeneration, called by the former pulpy, and by the latter gelatiniform, degener- ation; Barwell, on the other hand, regards it as essentially the same as the panulation change referred to in speak- Iug Of the pathology of Synovitis in Fio. 352.-Gelatinous arthritis of elbow. 652 DISEASES OF JOINTS. general, the difference being that, in ordinary synovitis, this granulation- tissue undergoes further development, while in the cases now under con- sideration it remains in a rudimentary state. Godlee has studied the granu- lation-tissue from these cases of "white swelling," and finds it to consist of cells and nuclei embedded in a trabecular meshwork with which "giant- cells" are connected by processes. In fact, the appearances closely resemble those of miliary tubercle, and tend to confirm the view that the disease is of tuberculous origin ; similar observations have been made by Friedlander. As the disease progresses, the articular cartilages undergo a somewhat analo- gous change, the disease finally reaching the bones, which become softened and carious. The symptoms of this peculiar 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 elasticity, 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 character, differing both from the acute pain of ordinary synovitis, and from the "jumping" pain which attends exposure of the bone by ulcerating car- tilage. There is little or no heat, and if the part be at first red, the 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 a low form of osteitis of the articulating extremities, which is often described as stru- mous, but which has no necessary connection with the scrofulous diathesis (see page 471). Yolkmann 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 237), sprains, contusions, exposure to cold and moisture, pyaemia, the puerperal state, scarlet fever, the scrofulous diathesis, etc. Symptoms—The symptoms 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 i- 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 already been referred to. These spasms occur particularly at night, coming on when the muscular SYMPTOMS OF ARTHRITIS. 653 system is relaxed by sleep, and often causing the patient to wake with a scream. These "jumping" pains have long been associated with ulcera- tion of the articular cartilages, and were formerly supposed to be due to the condition of those structures ; it is now, however, generally acknowl- edged that inflammation and ulceration of cartilage are not, in themselves, attended with pain (cartilage containing no nerves), and that the peculiar starting pains of arthritis are really due to the condition of the plate of bone immediately beneath the seat of 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 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 rest- ing on the bed, the leg flexed on the thigh, and the thigh on the pelvis—the opposite knee drawn up so as to serve as a guard, and to keep off the weight of the bedclothes—and the whole attention apparently concentrated and directed to shield the diseased part from injury. The inflammatory fever is severe, assuming a typhoid type if suppuration occurs, and perhaps yielding to hectic in the advanced stages of the disease. The symptoms which accompany the occurrence of suppuration in cases of arthritis are very much the same as were described iu speaking of pyar- throsis from synovitis. Pointing sometimes takes place at a comparatively early period, but in other cases the pus, after escaping from the cavity of the joint, dissects up the muscular interspaces of the limb for some distance before making its appearance on the surface. Occasionally many of the symp- toms of suppuration may have been present, 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 ab- sorbed, the pus corpuscles undergoing fatty or calcareous degeneration. It is in such cases as these that residual abscesses are sometimes observed after considerable intervals of time (see page 437). When arthritis of a large joint, as the hip or knee, has advanced to the stage of abscess, the prospects of spontaneous 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 ob- tained, the opposing joint surfaces becoming united by granulations which are subsequently organized into a fibrous or imperfect bony tissue; but in most instances, and as a rule with hospital patients, unless rescued by 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 prog- Elongation of the affected limb is occasionally observed in arthritis Fig. 3.i3.—Arthritis of knee-joint in an advanced stage. (From a patient in the Children's Hospital.) HOsis 654 DISEASES OF JOINTS, |\ 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, is a very fatal one, 32 out 73 cases recorded by Townsend, who re- gards it as a pyaemic affection, having ended in death. When recovery occurs there is little risk of anchylosis, but the joint may be weakened bv the loss of portions of bone. 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, duping the acute stage—followed by tonics, especially iron and cod-liver oil, at a later period. Mercurials, which may be proper in traumatic arthritis, should be used, if at all, with great caution in these cases—medicines of any form being, indeed, of less importance than nutriment, which should be given abundantly and in an easily assim- ilable form. The most important part of the Local Treatment is to place the joint in a state of complete and long-continued rest, and in a favorable position. If the shoulder be affected, the arm should be kept to the side, and di- rected somewhat forwards, while the elbow, if diseased, 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 pesequi- 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. 150). 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 affecting the knee or hip, the greatest advantage may be derived from the use of continuous extension, which may be applied with Barwell's splint, in which the ex- tension is effected by an India-rubber accumulator; with a spiral wire spring surrounding the limb, as suggested by Holthouse; or (which I prefer) with the ordinary weight-extension apparatus—a mode of treat- ment 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 inge- nious splint for making extension incases of arthritis of the wrist has been Fig. 354. — Barwell's splint for making con- tinuous extension. ARTHRECTOMY. 655 devised by Fagan. The relief from pain afforded by continuous extension in cases oi'joint-disease is very marked. It appears to act by counteracting the tendency to muscular spasm, and thus preventing the inflamed ends of bone from being pressed together. With regard to topical medication in cases of 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 occurrence of suppuration (the patient being anaesthetized), by drawing the iron, heated to a black heat only, rapidly across the joint, in lines at least an inch apart; it is not 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 touches. Nelaton suggests the use of a metal rule as a guide to the lines in which the cautery is to be applied. The hot iron, though doubtless an efficient remedy, is one to which all patients have a feeling of repulsion, and should therefore, I think, be reserved for very urgent cases. Blistering I have usually found quite satisfactory ; the blister should be placed over the seat of greatest pain, and it is better to use a small than a large blister, repeating it if necessary-. The tincture of iodine may also be employed, painting it around but not over the joint, in the way recommended by Furueaux 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 Knorr, Hueter, Petersen, Schmidt, and other surgeons. Le Fort injects a ten- per-cent. solution of sulphate of zinc, with one-fourth part of alcohol. If suppuration occur, the case must be treated by free incisions, etc., as directed in speaking of pyarthrosis ; if the bones be but slightly involved, recovery may still be sometimes obtained by perseverance in 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 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 Haward and other surgeons, and that of phosphate of copper in cases recorded by Lu- ton. Iodo-glycerin injections may be of benefit, as may those of iodoform in sterilized glycerin (one part to ten) or olive oil (one to ten, or one to five), or of chloride of zinc (one to ten of water). Erasion of Joints; Arthreciomy.—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 's now generally known by the name of arlhrectomy, is especially applica- ble to the knee-joint; I have adopted it in nine cases, seven patients making good recoveries, one requiring subsequent excision, and the ninth, 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 fol- lowed by shortening, but, on the other hand, is very apt to be followed by 656 DISEASES OF JOINTS. secondary contraction, to guard against which the patient should wear some mechanical support for a long time. Mandry, from an analysis of 60 cases operated on by Yolkmann, Konig, 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 ft5 per cent., and only eight patients recovered with a mov- able joint. In cases of qelatinous 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- 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 in 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 many cases 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 some cases are simply of an inflammatory- nature, and that, in a majority of instances, the dis- ease is to be looked upon as having a local origin, and (which is of the highest importance, in a practical point of view) as specially demanding local treatment. Causes.—The exciting causes of hip-disease are usually of an 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, Avorse in the evening; but the " starting" pains caused by mus- cular spasm do not come on until a comparatively late period. In the 1 Of 100 consecutive admissions for hip-disease into the Children's Hospital of tliH city, 61 were boys and 39 of girls. Again, of 419 cases of excision for hip-disease collected by Culbertson, in which the sex of tlie patient was ascertained, 297 were in males, and 122 in females. HIP-DISEASE. 657 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 ad- vances, 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 deep situation of the joint. (3) Deformity.—In the first stage of hip-disease, the knee is slightly flexed, and the limb usually but not always abducted—this position being involuntarily assumed, as most easy to the patient. Slight limping 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 elongation of the limb, the latter in the large majority of cases being ap- parent merely, and due to a twist of the pelvis, caused, as pointed out by Barwell, 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 Fio. 355. — Hip-dis- ease in second stage; showing flattening of Imttock, with appar- ent elongation. (From a patient in the Chil- dren's Hospital.) Fig. 356. — Hip-disease in third stage; showing shorten- ing and adduction, with ob- liquity of pelvis. (From a pa- tient in the Children's Hospital.) >e placed in the recumbent posture, the limbs jevel the deformity apparently disappearing; it will be found that the relative position of ■wme as in the standing posture, the lumbar 42 Fig. 357.—Excised head and neck of femur; showing change in shape of bone in third stage of hip-disease (see Fig. 356). (The specimen is in the Mfitter Museum of the College of Physicians of Philadelphia.) may be brought to the same but by careful examination the thigh and pelvis is the spine being unduly arched, 658 DISEASES OF JOINTS, and the pelvis distorted into an abnormally vertical position. In this sta^e there is marked lameness, and it is to this stage also that the pain in the knee particularly belongs. In the acetabular variety7 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. 356), 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 sta»e inclined towards the affected side (Fig. 355), 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. 357), and in some cases, though in fewer than was formerly supposed, from positive dislocation taking place. The deformity of the first and second stages 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 stai:e 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 mayT become perforated, the head of the femur perhaps slipping through into the cavity of the pelvis. (5) Suppuration may or may not occur in the arthritic form of hip-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 point- ing occurs is often significant; thus an abscess opening on the outer part of the thigh, below the trochanter, indicates dis- ease of the caput femoris, while abscesse? opening in the pubic region denote disease of the acetabulum—the abscess being in- tra-pelvic or extra-pelvic according a- it opens above or below Poupart's ligament. Ab.-cess 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 anchvlosed, provided that the limb have fig. 358. - Deformity resulting from i^ei/kept in a straight position, the result double hip-disease. (From a patient ... . l . .. . .• „w,l«litv of under the care of Dr. Hodge in the Chil- Will be quite satisfactory, the mobility 0 drm s Hospital.) the pelvis compensating in a great ae.rc HIP-DISEASE. 659 for the stiffness of the joint; but unless precautions have been taken in reo-ard to position, anchylosis with great deformity will ensue, such dis- tortion as is exhibited in the accompanying cut (Fig. 358) being by no means unfrequently met with. If suppuration have occurred, and there- fore we may say as a rule in cases of acetabular or femoral coxalgia (par- ticularly if followed by consecutive dislocation), the utmost that can usually be attained by conservative measures is recovery with a shortened, de- formed, atrophied, and often useless limb. Death may occur from simple exhaustion, diarrhoea, tuberculosis, amyloid, degeneration, or pyaemia, or from some intercurrent affection which would have been successfully re- sisted but for the constantly depressing influence of the joint-affection. Diagnosis.—Hip-disease may be distinguished from rheumatism by observing the limitation of the affection to one joint, and by noting the characteristic deformity. This may be readily made apparent, as pointed out by 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 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 Fig. 359.—Sayre's short splint applied. Fig. 360.—Sayre's long splint applied. (Sayre.) (Sayke.) 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 Gibney, »s not unfrequently mistaken for hip-disease. From sacro-iliac disease, 660 DISEASES OF JOINTS. the diagnosis may be made by observing that in that affection the seat of greatest tenderness is different, that there is no shortening, and no pain on moving the hip if the pelvis be fixed, and that the pelvic distortion is 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- rence : this impression is confirmed by the results of 9 terminated cases observed by Gibert, which gave 8 deaths and but 1 recovery. It is true that hip-disease does not appear very frequently in our mortuary records, but this is owing to the fact that the patients are carried off by secondary complications or intercurrent affections, to which death is attributed—no reference being made to the chronic condition, without which those affec- 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, however, 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 the first 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 the adaptation of a suitable splint. I commonly employ a moulded pasteboard splint, well padded, with extension and sand-bags, as in the treatment of fractured thigh ; but the surgeon may use with equally good results the carved splint of Dr. Physick, one moulded from gutta- percha or leather, or splints made from wire gauze, as recommended by Bar- well and Bauer, or finally any of the forms of immovable apparatus which were described at page 94 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, con- tinuous 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 extension, 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 contracted muscles, an operation which has, however, been successfully employed by Bonnet, Bauer, Sayre, and other surgeons. If the affection have run ou to the second stage, the same treatment is to be employed, together with counter- irritation by blisters or the cautery, applied to the seat of the greatest pain, usually a little above and behind the great trochanter; the general condi- tion 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 car- HIP-DISEASE. 661 ried out, a marked improvement will soon be manifested, the pain and tenderness gradually disappearing, till at length motion of the joint is no longer productive of suffering, and the patient feels and considers himself well. The time required for this favorable evolution of events is of course variable, six or eight weeks being probably a minimum period. If now all further treatment be neglected, the disease will in a short time almost inevitably recur, and prob- ably in an aggravated form ; and yet it is very impor- tant 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 apparatus devised by Davis, Sayre, Andrews, Taylor, Thomas, Lovett, Agnew, and other surgeons, are particularly serviceable; they act by keeping up extension and counter-extension, while the patient is enabled to walk about and lead a compara- tively 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, distending 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 Bauer. Under other circumstances, the abscess should, I think, be treated on the general principles laid down at page 43Y. 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.2 Iodoform-glycerin injections, both interstitial and intra-articular, may be of service in this stage of hip-disease; Krause enters the joint from the outer side, above the trochanter, but Kiister and Biiugner make the punc- ture anteriorly. After abscesses have opened in cases of hip-disease, leaving sinuses which lead down to carious bone, it is still possible in some instances to obtain a cure by anchylosis, and, in cases not admitting of operation, this is the best termination that can be hoped for. Little can be done, under these circumstances, beyond keeping the limb straight, moderately ex- tended, and with the foot well supported, while the strength of the patient is maintained by appropriate constitutional and hygienic treatment. In 1 Hutchison 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 lnomas and Agnew, but, by their instruments, they secure immobility of the joint at tne 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. ., Jy J^kson advises that the joint should be freely opened at an early period, and a head of the femur turned out for a few days, to be afterwards replaced when the inflammation has somewhat subsided. Fig. 361.—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. 662 DISEASES OF JOINTS. many of the cases, however, which reach this condition (at least amon^ the class of children that come into our city hospitals), excision, or pos- sibly amputation, 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 hip-disease of the femoral variety. The two first-named surgeons supple- ment the operation by applying potassa-cum-calce to the track of the wound Arthritis of the Sacro-iliac Joint (Sacro-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 Ne'laton 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- 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 wasted from atrophy of its muscles. It is sometimes markedly cede- matous, from obstruction of the iliac vein The hip is deformed, from the side of the pelvis being tilted forwards and rotated downwards. Suppu- ration occurs at a rather late period of the disease, abscesses pointing, according to Erichsen, over the joint, in the gluteal or lumbar region, 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 po>terior curvature, by the presence of tenderness in the region of the affected ver- tebrae, 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 pain, and by the absence of any real displacement of the as 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- oped, 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 anil other surgeons. The Treatment consists in endeavoring to prevent suppuration, by plac- ing the joint at rest by means of the weight-extension apparatus, as ad- RHEUMATOID ARTHRITIS. 663 vised by Prof. McGuire,1 and at a later period by supporting the part with a leather or pasteboard splint, moulded to embrace the pelvis, hip, and thigh, or, which Kidlon and Jones prefer, an apparatus like that employed by Thomas in cases of double hip-disease ; 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, admissible in this grave affection, though, if caries had occurred, it might be proper to make an incision aud endeavor to remove the diseased bone with gouge and curette. Ridlon and Jones, indeed, advise operative interference with trephine, cutting forceps, and hot iron, as soon as suppuration is detected. Rheumatoid Arthritis. Rheumatoid Arthritis is the name proposed by 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 probablv begins with hyperaemia of the synovial membrane and increased synovial secretion, followed by thickening, and sometimes 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 disap- pears, and the head of the bone becomes irregularly enlarged, flattened, sometimes elongated, and placed at a right angle with the shaft. The cervix femoris becomes shortened, apparently by interstitial ab- sorption, aud 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. Exten- sive stalactitic bony outgrowths often ap- pear about the base of the great trochanter, and especially along the inter-trochanteric line, while similar osteitic formation^ are developed in the ligamentous and other soft tissues. On section, the bone is found to be rarefied, with an excess of oily matter—in a state, indeed, of 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 Fig. 362.—Appearance of the head of the femur in rheumatoid arthritis. (Druitt.) 1 J. Wood employs double extension, as in cases of hip-disease. 664 DISEASES OF JOINTS. 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 a^e, the patients are generally females; 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 often 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 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. (arthropathia tabidorum), 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 employment of ordinary hygienic means and the administration of tonics, especially cod-liver oil, iron, and quinia, the affected joint being, during the acute stage, kept at rest, and occasionally blistered. Iodide of potassium may be sometimes used with advantage, as may be arsenic and guaiacum. R. W. Smith speaks highly of the latter drug, in combination with sulphur, rhubarb, alkalies, and aromatics. Change of air, and a 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 in- ducing an aggravation of pain. Erichsen recommends, in the case of the hip, external support by means of lateral irons, jointed opposite the articu- lations, with a pelvic band and leather socket for the thigh and leg. Ex- cision 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 AND ANCHYLOSIS. 665 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 periarticular 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 mayr 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 equiv- alent 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 bauds of fibro-cellular material which cross from one articular surface to the other, and which result from the organization of inflammatory lymph, or of the granu- lation structure which in joint-diseases replaces the synovial membrane and articular cartilages. The stiffness of the part is further promoted by con- traction and adhesion of the neighbor- ing 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. 363) the joint may be entirely obliter- 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 which may be new formations, of the nature of exostoses, or may result from the deposit of ossific matter in ligaments or other pre-existing soft struc- tures. Bony anchylosis is rarely- met with except as the result of traumatic arthritis, fibrous anchylosis being more common in the ordinary forms of the disease, particularly in patients of a strumous diathesis. It not un- frequently happens, indeed, under the latter circumstances, that, while more or less perfect anchylosis is taking place in one part of a joint, caries or necrosis is in existence at another. In bony anchylosis there is abso- Fig. 363.—Synostosis of hip-joint. (Pireie.) 666 DISEASES OF JOINTS. lutely no motion of the joint, while in the fibrous variety slight motion may always be elicited by careful examination, particularly if the patient be in a state of anaesthesia. Sometimes the surgeon endeavors to obtain anchylosis as the best termination of arthritis, or as a means of increasin" 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 employed, being aided by frictions, the salt douche, etc. In fibrous anchylosis of the elbow, the patient may himself practise passive motion by swinging a flat-iron or other weight, as advised at page 25b Advantage is occasionally derived from the use of well-padded splints, the angle of which may be varied by means of 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 at- tempt subcutaneous division of the restraining intra-articular bands, but the operation is not very promising, and is necessarily attended with some risk. Fibrous anchylosis of the shoulder is often followed by the devel- opment of a bursa beneath the scapula, the motions of which bone give rise to a crackling sound, described by Terrillou under the name of sub- scapular friction. 2. Fibrous Anchylosis in a Bad Position.—If the elbow be anchylosed in an extended position, or the shoulder, knee, or hip at a right angle, it becomes important to adopt more active treatment, though no operation should be performed until acute symptoms have passed away. In many cases, 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 flex- ing and extending the joint, and thus rupturing the intra-articular adhe- sions, while the patient is in a state of anaesthesia. If this be done, the force should invariably be first applied in the direction of flexion, aud the adhesions 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. 367), or a weight, will be safer and equally efficient; the humerus has been fractured in attempting forcibly- to break up adhe- sions 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 al- lowed to elapse before the employment of extension. Any inflammation which follows 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. 364). Fn these cases, simple extension, even with division of the hamstring tendons, is not sufficient, the back- ward displacement persisting, and rendering the limb weak and compara- tively useless ; under such circumstances, the ingenious apparatus of Mr. Bigg (Fig. 368) may be employed, which acts by means of springs, draw- ing the head of the tibia downwards and forwards, while the condyles ol TREATMENT OF ANCHYLOSIS. 667 the femur are at the same time pressed upwards and backwards. Subcu- taneous division of the adhesions uniting the femur and patella is sug- o-ested by Willett, and has been advantageously resorted to by Maunder, as has subcutaneous section of the crucial ligaments by Tiffany. Anchy- Fig. 364.—Deformity (consecutive dislocation) following arthritis of knee-joint; the tibia displaced backwards and upwards. losis of the knee in a position of over-extension is extremely rare ; it is well seen in the accompanying illustration (Fig. 365), 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. 366), excision or amputation will not un- frequently be required. ^ Fig. 365.—Anchylosis of the knee-joint in position of over-extension. (From a patient in the Episcopal Hospital.) Fig. 366—Chronic arthritis of knee-joint, with partial anchylosis in bad position. (From a patient in the Episcopal Hospital.) 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 '•nib, prudent surgery would dictate that no operation should be resorted m DISEASES OF JOINTS. 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 Bad Position.—Various operations have been employed to remedy bony anchyiosis under these circumstances. Hip.—J. Rhea Barton, in the year 1826, treated a case of osseous anchylosis of the hip by sawing through the femur between the trochan- ters, thus allowing the limb to be brought into a straight position; the patient recovered, as was anticipated, with an artificial joint, which re- mained 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, J. Kearney Rodgers improved upon Barton's operation by removing a disk of bone from between 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 1862, Sayre still further improved upon Rodgers's procedure, by re- moving a segment of bone from between the trochanters, the upper section being semicircular, with its concavity downwards, and the upper end Fig. 367.—Barwell's splint for making continuous extension in cases of anchylosis of the knee. 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 operation has been employed by Volk- mann. H. Leisrink has tabulated ten cases, in which one or other of these operations was resorted to, which, with Barton's orignal case, one referred to by Holmes, and others in the hands of Textor, Post, Peters, Volkmann, and Walter, who has operated on both hips of the same patient, give 23 operations (on 22 per- sons), 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 termi- Fig. 368.—Bigg's apparatus fur con- traction of the knee. TREATMENT OF ANCHYLOSIS. 669 nated in death. 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 Oblique is preferred to transverse osteotomy by Ter- rier, Broca, Schwartz, and other surgeons. W. Adams has 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.1 This procedure, therefore, though inferior to those of Sayre and Volkmann as regards the ultimate result,2 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 Fig. 369.—Adams's saw for subcutaneous division of the neck of the femur. 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, Figs. 370 and 371.—Subcutaneous osteotomy of both thigh-bones for anchylosis following hip-disease. (From a patient in the Children's Hospital.) and other surgeons have successfully divided the thigh-bone below the lesser trochanter—Gant with a saw, and Maunder and his followers with ^ Bellamy lost a case by secondary hemorrhage from the deep femoral artery. In Sands's, Jessop's, and Lund's cases, however, movable joints were obtained. 670 DISEASES OF JOINTS. chisels. Of 64 operations in this situation analyzed by Dr. Poore, 54 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. I have myself employed either Adams's or Gant's operation in twenty-six cases (in four cases upon both sides, Figs. 370-373) and in every instance but one with a favor- able result, the disease recurring in that case and requiring subsequent excision. The choice between the operations should depend upon the con- dition 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 trochanter is better, and may- be safely employed even in cases of fibrous anchylosis 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-posterior direction. Figs. 374 and 375, from electrotypes kindly given me by Dr. Wharton, show the occurrence of firm bony union after such an operation. Barton's operation has been, according to Chelins. 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 re- sorted to if it should be necessary to interfere in a like condition of the shoulder. Knee.—Barwell recommends (in case of bony anchylosis of the knee) that, in persons under fourteen years of age, advantage should be taken of the fact that the upper epiphysis of the tibia is, at this time of life, not yet united to the shaft, to straighten the limb by producing an epiphyseal frac- Figs. 372 and 373.—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 case of bony anchylosis of the knee, in a bent position, 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, TREATMENT OF ANCHYLOSIS. 671 subsequently, gradually brought into an almost straight line. The result was entirely satisfactory, the thigh becoming firmly united in its new position. In 1844, Gurdon Buck, modified this procedure by exsecting a wedge-shaped mass embracing the entire thickness of the bone, and con- Figs. 374 and 375.—Bony union after subcutaneous osteotomy of the femur. taining the condyles of the femur, head of the tibia, and patella, perform- ing, in fact, what has since been called " excision in a block." In 1853, the same surgeon, in a case of fibrous anchylosis, substituted for the re- moval 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, J. E. Adams, and Kilgarriff, 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 em- ployed thirty-nine times with five deaths—the mortality of the former operation being 11.8, and that of the latter about 12.8 percent.1 A safer method consists in subcutaneously perforating the anchylosed joint in various directions by means of a suitable drill (Fig. 130), 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 extend- ing apparatus. This operation appears to have been first suggested by Malgaigne, who proposed to use a chisel and mallet (as has since been done by L. S. Little and Maunder), though Dieffenbach had previously suggested separation of the united joints by means of a chisel and saw— not, however, used subcutaneously. Brainard, 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, in 1859. Brainard subsequently applied the drill to the knee-joint itself, and the operation has since been repeated upon several occasions by Prof. Gross and others. Nine cases, collected by S. W. Gross, in 1868, had -proved uniformly successful. Sec- tion 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 to Other successful cases, operated on by Buck's first method, have since been re- corded by Morton and by Vance. 672 DISEASES OF JOINTS. life, but having the great advantage of not shortening the limb by the re- moval 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 bursa?. 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 fig. 376,-Trocbiea of humerus: showing narrow pedicles to the parietes of the formation and connection of loose cartnag- joint, but subsequently often becoming inous bodies. (Miller.) isolated. They are, according to R. 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 and 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, however, denied by 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, Yolkmann, 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 rapid synovial effusion commonly supervenes. These symptoms, it will be seen, closely resemble those of dislocation of the semilunar cartilages (see page 327). 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 adhesive strips applied externally, when absorption of the foreign body may often be obtained. Richet employs a ring with sharp points which transfix the cartilage and hold it in position until it adheres. Hadden uses a small truss for the same purpose. The radical treatment, which ARTICULAR NEURALGIA. 673 consists in removing the foreign body, either by direct or by subcutaneous incision, is attended with considerable risk to life, the mortality of the direct operation being, according to H. Larrey's and Barwell's statistics, 18, and of the subcutaneous procedure 7.6 per cent. Hence neither should be employed, unless the disease be attended with so much suffering as to make interference absolutely necessary. The direct operation consists in making a sufficiently free incision over the loose cartilage, which is firmly fixed between the surgeon's finger and thumb, the skin being drawn to one side so as to make a valvular opening, as recommended by B. Bell. The loose cartilage is then squeezed out through the cut, which is immedi- ately closed, while the limb is kept at rest upon a splint. Any inflam- mation 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 may 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, is to squeeze the loose car- tilage into, but not through, the subcutaneous opening in the synovial membrane, fixing the foreign body in that position by means of a com- press 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 cannot 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. Bellamy recommends that the joint should be opened and the finger swept around it so as to rupture any adhesions which may be present. Articular Xeuralgta. (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 vet 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 'ftses, as instances of neuromimesis or nervous mimicry of disease. The 1 When performed with the precautions of the antiseptic method, the risks of this H ejLation are reduced to a minimum. Eighteen cases treated in this way, collected by J. n. 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. 674 EXCISIONS. 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 aud superficial character of the pain and tenderness, which are not increased by pressing together the joint surfaces (as would be theea.M in arthritis), and are not attended with the other signs of inflammation and with the constitutional disturbances, 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 mav 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 mean* employed to promote recovery. In the belief that the disease is mental, it U 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 ca>es under consideration. Meyer recommend.* the application of an induced current of electricity to the affected joint. CHAPTER XXXIII. EXCISIONS. Excision in General. The operation of resection, in cases of compound fracture and disloca- tion, appears to have been known to the ancients, aud, in the case of frac- ture, was occasionally practised in later times, as is shown by references: to the operation in the writings of Salmon and Wiseman, but as regard.- 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 appears to have been that performed by Filkin, in 17^ 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 0. Heyfelder and Hodges, and to my article in the Inter- national 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 previou- chapters f-ee pp. 187, 237, 667) ; and I shall, therefore, in the following pages, confine my-e.f to a description of the operative procedure in the different regions of tL< INDICATIONS FOR EXCISION IN GENERAL. 675 body, and to a consideration of the applicability of excision to diseases of bones and joints, especially- to caries and arthritis. Indications for, and Contra-indications to, 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 incumbrance, and less useful than a well-formed stump; this is par- ticularly 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 642). (3) If the soft tissues around a diseased bone or joint be extensively diseased, infiltrated with lowly organized lymph, and riddled with sinuses, the result of an excision is less apt to be satisfactory than under 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 operation, and, in the case of early childhood, on account of the risk of interfering with the growth of the limb, which is chiefly dependent upon the integrity- of the epiphyseal cartilages. Bceckel, however, from an examination 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 performed. This is confirmed by my own ob- servation 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 con- tracted, though a considerable portion of bone was of course removed, 1 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 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. 676 EXCISIONS. advanced phthisis, or from Bright's disease, amputation will usually be the preferable procedure. From the above remarks, it will be seen that, while excision is, in suit- able cases, an admirable and truly- conservative operation, aud 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 por- 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 preserved —and this can rarely be done in excisions of the short bones, as of the calcaneum—repair is effected by the wound filling with granulations, which are subsequently transformed into a dense, fibrous, cicatricial mass. In excisions of the joints (particularly among patients who have not attained their full height), it is important not to remove the entire epiphysis, nor even to encroach upon the epiphyseal line; for, if this be done, the sub>e- 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 631, 653). 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. 377). Gouges and gouge-forceps will also be found useful for dealing with carious bone. The saw which I prefer, in most cases, is that designed Fig. 377.—Fergusscm's lion-jawed forceps. OPERATION OF EXCISION IN GENERAL. 677 by Butcher (Fig. 378), and 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. 379) is more Fig. 378.—Butcher's saw. 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 Buck. If an ordinary saw be employed, a spatula or retractor must be slipped beneath the bone in order to guard the soft parts ; a good instrument for the purpose is the "resection sound" of Blandin, or the probe-pointed grooved retractor described by Prince; or, which in some cases will prove satisfactory, an ordinary^ broad lithotomy staff, grooved on the back, which may be readily slipped around the bone, and then turned with its convexity upwards. Another instrument which I have found of value, is the knife-bladed forceps of Mr. Butcher (Fig. 380). This cuts like a pair of scissors, and is very efficient in removing the thickened and degenerated synovial tis- sues, which, if allowed to remain, 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 interspaces, so as to avoid unnecessary destruction of tissue. The incisions should, if practicable, include any sinus 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 or carious spots with the gouge or trephine. The epiphyseal line should never he 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 hone which is merely inflamed and softened (medullized), for that which is carious, nor bone thickened and roughened by inflammation, for that which Fig. 379.—Chain-saw. 678 EXCISIONS. 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, mayr, however, be advanta- Fig. 380.—Butcher's knife-bladed forceps for excisions. geously cut away with the knife-bladed forceps; and, indeed, Volkmann goes so far as to advise complete " extirpation" of the joint capsule. Felizet applies for a few seconds an intense heat by means of a blowpipe flame, with the view of removing any tuberculous foci which may- be present. 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. Gluck recommends that the excised joint should be replaced by an artificial one of ivory. The ordinary antiseptic dressings should be employed, and precautions must be adopted to secure free drainage, by the arrangement of the incis- ions and by the use of Chassaignac's tubes. Concentrated food, with tonics and stimulants, may be required during convalescence. Finally, although the case should not progress as favorably as may he wished, the surgeon must not hastily conclude that the operation has failed, and that amputation is necessary ; even if caries or necrosis should recur in the sawn bony extremities, a re-excision may often be attended with a satisfactory result. Special Excisions. Scapula.—Excision of the scapula, complete or partial, may be 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 135). The operation maybe done with a crucial incision, or, which is probably better in most cases, a T-shaped incision, as recommended by Syme, the transverse branch of the cut running from the acromion to the posterior edge of the bone, and the other passing downwards, at a right anirle from the centre of the former. If the opera- tion 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. The history and statistics of this operation have been particularly inves- CLAVICLE, RIBS, STERNUM, AND PELVIS. 679 titrated by Stephen Rogers and by Adelmann, who has, however, made no distinction between excisions of the scapula with or without amputation of the arm. Removal of the scapula with the, arm has been considered under the head of amputation above the shoulder (page 135). The first case in which the entire scapula was removed, the arm being preserved, was that of Langenbeck, who, in 1855, excised the whole scapula with three inches of the clavicle. Including this case, complete excision of the scapula, with or without interference with the clavicle and head of the humerus (the arm being preserved), appears to have been done in 59 cases,1 of which 43 have terminated successfully^ and 12 in death, the result of 4 being unknown. Extirpation of the scapula, subsequent to amputation at the shoulder, appears to have been practised in 20 cases, with 13 recoveries and 5 deaths, the termination of 2 being unknown 2 Total is thus but little less successful than partial excision, 207 cases of which operation, to which I have references, having given 50 deaths, or nearly one in four. Clavicle, Ribs, Sternum, and Pelvis.—The clavicle may require partial, or, in rare instances, complete excision, on account of caries, ne- crosis, 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 opera- tion may be made subperiosteal, and presents no particular difficulties, a simple incision following the course of the bone being sufficient for the purpose. In a lad from whom I removed, at the University Hospital, the whole left clavicle for acute necrosis, reproduction was rapidly effected by the periosteal sheath, and the boy regained the use of his arm in not much longer time than would have been required had the bone been simply frac- tured. 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 extirpation of the clavicle was first practised by McCrearry, in 1811,3 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 Mott's famous case, or of excisions & deux temps, such as those of Ndlaton and y Southam, Maclean, Phelps, Weir, Bull, and Putti (two cases). ^ One case (Jesset's) is added to the 19 tabulated in the fifth edition. 4 jMttamer's operation, in 1732, was only a partial excision. Cases additional to the 33 tabulated in the fifth edition, are one in my own hands Uor necrosis) and those recorded by Jessett and Tansini. 680 EXCISIONS. unknown ; the mortality of determined cases, theref >re, was but little over 14 per cent. Truehart reports a case of partial excision of the clavicle successfully supplemented 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 men- tioned by Hevfelder gave eight deaths. Resections of the ribs for tumor have been performed by Langenbeck, Warren, McClellan, Kolaczek, Fischer, Park, and other surgeons. Ten cases referred to by Zarubin gave 6 recoveries and 4 deaths. Alsberg records a remarkable case in which, beside portions of several ribs, a segment of the diaphragm wa.- 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 likewise be employed in cases of empy-ema. (See p. 409.) Konig has reported 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 and bv Mening, for caries, and by Kii-ter to facilitate removal of a tumor from the mediastinum. Graves has successfully excised the gladiolus for sar- coma. Resection of the ensiform cartilage has been successfully employed by Linoli, Rinonapoli, and myself. C. Nelaton has successfully excised the whole ilium, the patient retaining the power of walking fairly well. Shoulder-joint.—Excision of the scapulo-humeral articulation, or of the head of the humerus, may be required in cases of arthritis, caries, or necrosis, compound fracture or dislocation, or non-malignant tumor. 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—passing be- tween the fibres of the deltoid muscle, in the line of the bicipital groove for about tive 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 fig. 38i.—Excision of shoulder- cutting-forceps. If the glenoid cavity be dis- joint by longitudinal incision, eased, it may then be attacked with the gouge- (Ekicusen.) 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 axil- lary pad, or a Stromeyer's cushion. In some cases, as of tumor, the longi- tudinal incision may not suffice to give access to the part, and the surgeon EXCISION OF THE ELBOW-JOINT. 681 mav then raise a flap by means of a V shaped cut, or one in the form of a t"» T> or U> as may be thought most convenient. These all have the common disadvantage of involving a transverse division of the fibres of the deltoi'd, and of therefore protracting 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, in 1771, while the first complete excision of the shoulder joint was performed by the elder Moreau, in 1786. Shaef- fenberg's and Thomas's operations (1726, 1740) are, according to Gurlt, not to be regarded as true ex- cisions. The operation is quite a successful one, considering its magnitude, 169 cases of excision for all causes having given, according to Hey^felder, but 30 deaths, a mortality of less than eighteen per cent. If excisions for disease alone be considered, the statistics show an almost equally favorable result, 115 cases tabulated by Culbertson giving 94 recov- eries and but 21 deaths. The preserved arm is known to have been useful in more than three-fourths of the success- ful cases. Seven cases of this operation in my own hands have given excellent results (Fig. 382), as did an eighth in which, at a second operation, 1 removed all of the remaining portion of the humerus. The risk which attends this procedure is indeed so moder- ate 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 190), 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 recom- mended by Oilier and Bigelow, is quite a successful procedure (see page 264). The operation consists in making a single longitudinal incision on the outer side of the arm, in one of the muscular interspaces, and, after carefully dividing and stripping off the periosteum (which should always be preserved), removing as great an extent of bone as may be thought necessary with a chain-saw ; the resected bony extremities 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 has reported a case in which reproduction of a humerus was effected by transplanting grafts of bone taken from other patients, and Banks one in which the same operation was successfully employed upon the tibia Trueheart has successfully grafted periosteum 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 Fig. 382.- -Result of excision of shoulder-joint. patient in the University Hospital.) (From a 682 excisions. Fig. 383.—Excision of elbow-joint by longitudinal incision. (Bryant.) (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 orioj. nally suggested by Park) by means of a single longitudinal incision (Fig. 383), beginning two inches above the olecranon and carried about three inches below it, the line of the incision being parallel to the course of the ulnar nerve, and a few lines to its radial side. The only point requiring special attention in this procedure is to avoid injuring the ulnar nerve, which must be care- fully dissected from its position behind the inner condyle (the edge of the knife being kept close to the bone), and then held out of the way with a blunt hook or spatula. The back of the articulation being thus exposed, the olecranon should be cleared, and may then be cut off with strong cutting-pliers, this, though not essential, serving greatly to facilitate the subsequent steps of the operation.1 In order to preserve the function of the triceps muscle, Spence divides its tendon by an inverted /\-shaped incision, while Hodges and Maunder take care not to cut the tendinous fibres which are inserted into the fascia of the forearm. With the same object, Sayre leaves that portion of the olecranon to which the tendon is attached. The joint being forcibly flexed, and the forearm thrust back- wards, the lateral ligaments may now be carefully divided with the probe- pointed knife. The operation is completed by removing the condyles and Fig. 384. Fig. 385. Excised extremities of humerus and ulna. (From specimens in the museum of the Episcopal Hospital.) the articulating surfaces of the radius and ulna, with Butcher's saw. The tubercle of the radius should, if healthy, be left undisturbed, so as to pre- serve the attachment of the biceps tendon. Bigelow also preserves the external and internal condyles of the humerus. Some surgeons employ a transverse incision in addition to that which has been described, making a wound of this form I—, while others (as Butcher and Syme) add also a second longitudinal incision on the outside of the joint—H, thus forming two rectangular flaps. The simple longitudinal incision is, however, per- 1 Bruns, Trendelenburg, and Viilker recommend temporary resection of the olecranon, which they subsequently restore to its position. RADIUS AND ULNA. 683 Fig. 38G.—Result of excision of el- bow-joint. (From a patient in the Children's Hospital.) fectlv satisfactory in the majority of cases, and is better adapted for rapid healing than either of the others, having no tendency to gape. As soon as the bleeding has been checked, the wound should be lightly dressed, and the limb laid upon a pillow or well- padded splint, in a nearly straight position ; after a week or two, when consolidation has begun, the splint may be discarded, and the limb simply supported in a sling. The results of elbow-joint excision, when performed for chronic joint-disease, are com- monly very .satisfactory, 377 cases tabulated by Culbertson having given but 41 deaths, a mortality of only 10.8 per cent. Oilier re- ports 36 cases performed by the subperiosteal method, of which only 5 proved fatal. With regard to the condition of the limb after ex- cision, the statistical results are equally sat- isfactory; thus, according to Hodges, 77 out of 89 patients who recovered had useful arms, while in 94 out of 118 suc- cessful cases tabulated by- Heyfelder and Boeckel, the patients could make good use of their preserved limbs. Partial excision of the elbow-joint appears to be less successful than total excision, which should therefore commonly be preferred, even though all the articular extremities be not dis- eased. Twenty-one cases of partial excision embraced in Hodges's tables gave five deaths, three subsequent amputations, and only nine recoveries with useful limbs. My own record embraces 28 cases (4 partial operations) with 19 recoveries, 7 deaths (one after amputation), and 2 undetermined. The preserved limb was useful in all the successful cases. Radius and Ulna—Compton, in 1853, excised the whole ulna and greater part of the radius, while the whole radius has been excised by Chavasse, Field, and Car- nochan, and the whole ulna by the same surgeon, by Jones, Joseph Bell, Hutch- ison, and Fuqua. Erich- sen in one case excised the elbow-joint, together with the greater portion of the radius, while Williamson made a still more extensive resection, embracing the el- bow-joint and the entire ulna, The result in all of these cases appears to have been satisfactory, the pa- tients recovering with useful limbs. Partial excisions of one or both bones have been frequently performed, and usually with very good re- >ults^ The operation con- si*ts in making a longitudi- nal incision on the back of the forearm, in the line of the bone to be re- acted, the periosteum being if possible preserved, and the bone divided Fig. 387.—Deformity following excision of radius. 684 excisions. with chain-saw or cutting-pliers. I have twice removed, with an osteo- tome, the lower extremities of both radius and ulna for deformity and loss of function following fracture. The result in each case was satis- factory. Fig. 387, from an electrotype kindly given me by Dr. Hopkins shows the appearance of an arm from which the greater part of the radius had been removed 55 years previously by Rhea Barton. In spite of the marked deformity, the patient had regained almost perfect use of her limb. Kronlein records a case in which, after excision, an artificial radius of ivorv was inserted to take the place of the bone which was lost. Wrist___The lower extremity of the radius was excised by Cooper, of Bungay, in 1758, but complete excision of the wrist-joint seems to have been first performed by- the elder Moreau, in 1794. The articulation may be excised by means of one or two longitudinal incisions on the dorsum of the wrist, the carpal bones being removed piecemeal, or by Lister's modi- fication of Dubled's operation, which is thus performed : A radial incision begins about the middle of the dorsal aspect of the radius, on a level with the styloid process, and passes downwards and outwards towards the inner side of the metacarpo-phalangeal articulation of the thumb, but, on reaching the line of the radial border of the metacarpal bone of the index finger, diverges at an obtuse angle (Fig. 388), and passes downwards longitudinally for half the length of that bone; an ulnar incision begins two inches above the end of the ulna and immediately in front of that bone, passes downwards between the flexor carpi ulnaris and the ulna, and terminates at the middle of the palmar aspect of the fifth metacarpal. The only- tendons necessarily divided by this method are the extensors of the wrist. The trapezium is to be separated from the rest of the carpus by cutting with the bone-forceps be- fore the ulnar incision is made, but it is not to be removed till a later stage of the operation ; similarly, the pisi- form bone is to be separated and left attached to the flexor carpi ulnaris, while the hook of the unciform bone is also severed and left attached to the annular ligament. The tendons being then raised both before and behind the wrist, the anterior ligaments of the joint may be divided, and the cut- ting-pliers introduced first between the carpus and radius, and afterwards between the carpus and metacarpus. Its connections being thus divided, the whole carpus (except the trapezium and pisiform) may be pulled out with a pair of strong forceps. The articulating extremities of the radius and ulna can now be made to pro- trude through the ulnar incision, and can be retrenched as much as may be thoight desirable, the ulna being sawn obliquely so as to retain its styloid process and thus lessen the tendency to subsequent displacement. The articulating ends of the metacarpal bones are then protruded and ex- Fig. 388.—A. Radial artery. B. Tendon of extensor socundi internodii pollicis. C. Indi- cator. D. Extensor communis digitorum. E. Extensor minimi digiti. F. Extensor primi internodii pollicis. G. Extensor ossis meta- carpi pollicis. H. Extensor carpi radialis lon- gior. I. Extensor carpi radialis brevior. K. Extensor carpi ulnaris. LL. Line of radial incision. (Lister.) excision of the hip-joint. 685 cised, and the operation is completed by dissecting out the trapezium,1 and bv removing the articulating surface of the thumb, and as much of the pisiform and hook-like process of the unciform as may be found necessary. A portion of the ulnar wound is left unclosed for drainage, and the hand is kept during the after-treatment upon a splint fitted with cork supports for the palm and thumb, or, which would answer as well, an ordinary Bond's splint with the side pieces removed. The statistics of wrist-joint excision for disease are quite favorable, 85 terminated cases, tabulated by Culbertson, giving but ten deaths, and as many subsequent amputations. Hand.—The metacarpal bones or metacarpo-phalangeal joints may be excised by simple longitudinal incisions on the back of the hand, the ex- tensor tendons being held to one side, and the bone sections made with strong cutting-pliers. A similar procedure is required for excision of the inter-phalanaeal joints, except that in this case the articulation should be approached from the side. Hip—Excision of the hip-joint may be required in cases of injury (especially from gunshot wound), of hip-disease, aud possibly of necrosis, Fig. 389.-A. b. Line of incision for excision oi rheumatoid arthritis, but is not, hip-joint. (Heyfelder.) in my opinion, a suitable opera- tion in any of these conditions. Howe has successfully excised the hip for ununited fracture, and Yolk- mann, MacCormac, Penrose, and others, for unreduced dislocation. Ex- cision of the hip-joint was suggested by Charles White, in 1769, but was W. R. Williams, following Fergusson, employs a single incision on the ulnar side the wrist, and endeavors, as did Butcher, to preserve the trapezium, believing that e utility of the thumb in great measure depends upon its retention. 686 excisions. first practised by Anthony- White, in 1822. The first operation in this country appears to have been performed by Bigelow, in 1852. A simple longitudinal incision on the outside of the limb will usually give ready access to the joint, but may be supplemented, if necessary, by a transverse cut forming a H-. The incision which I myself prefer is that reconi- mended by 0. Heyfelder, which begins a little above and behind the great trochanter, towards which it passes in the line of the fibres of the gluteus maximus, and then curving around and behind the trochanter, passes downwards and slightly backwards, ending on the linea aspera between the insertions of the gluteus and vastus externus (Fig. 389). This in- cision forms two irregular flaps, the loosening of which affords abundant room for the subsequent steps of the operation, while no muscular fibres are divided transversely. If spontaneous dislocation have occurred, the head of the bone may be at once protruded through the wound, but under other circumstances the capsule must be opened, and the ligament- ous structures cautiously divided with the probe-pointed knife. Sayre lays great stress upon the importance of a subperiosteal excision, but my own experience leads me to agree with Holmes in thinking that the subperiosteal method presents no particular advantages in this situation. The head and neck of the bone being free, the femur is to be rotated first in one direction and then in the other, while the muscles attached to the trochanters are shaved off close to their insertions, and the limb is then forcibly adducted and pushed upwards, so as to make its upper extremity project through the wound. The femur may be divided with the chain- saw immediately- below the great trochanter, it being always advisable to remove this portion of bone, even if not diseased, as it is apt to become so subsequently, and to interfere with union by pro- truding through the wound. The acetabulum should then be carefully examined ; if healthy, it may be left untouched, but if carious or necrosed, it should be treely dealt with, loose pieces being extracted, and any part that is diseased, but not loose, removed with the gouge-forceps, trephine, or Hey's saw. It was formerly taught that interference with the acetabulum was unjustifiable, and that extensive disease of the pelvis there- fore forbade the hope of successful excision; it is now, however, well established, through the labors of Hancock, Erichsen, and others, that the acetabular form of the disease is almost equally amenable to operative treatment as the femoral, and the entire bony floor of the acetabulum and even large portions of the ischium and pubis have, accordingly, been safely removed. There is, as shown by Hancock, no"risk of opening the cavity of the pelvis in these operations, for its inner wall composed of fascia? and muscles which are thickened and infiltrated with lymph, forms an effectual bar- rier to prevent the possibility of such an occurrence. The after-treatment of hip-joint excision is very simple: free drainage must be secured for the wound, which should be lightly dressed—the pa- Fig. 391.—Sayre's cuirass for after-treatment of hip- joint excision. (Sayre.) 77 excision of the hip-joint. 687 tient being kept in bed, with the limb well abducted, so as to prevent any tendency to projection of the sawn extremity of the femur. Moderate extension may be made by means of a weight, while the limb is kept in place by the apposition of sand-bags. As soon as the wound is sufficiently consolidated, the patient should be allowed to get about with crutches. Prof. Sayre places the patient immediately after the operation in a wire "cuirass" padded to prevent excoriation, and provided with screws to make extension (Fig. 391). Re-excision has been occasionally practised with advantage, while amputation, subsequent to excision, has resulted favorably in at least twenty-two out of thirty-six cases1 in which has been done. Elaborate statistics of hip-joint excision have been published by several authors, myself included, but the largest number of cases yet tabulated is embraced in Dr. Culbertson's Prize Essay, published in 187G. I have myself performed the operation in 52 cases with 12 deaths. The following tables, compiled from Culbertson's, exhibit, in a form easy for reference, the statistics of the operation, as performed at different periods of life, and the comparative results, according as the acetabulum was or was not interfered with, or, in other words, of complete as com- pared with partial excision. Results of Hip-joint Excision at Different Ages. Mortality per Age. Total. Recovered. Died. 1 determined. 4 cent, of termi-nated cases. Under 5 years 51 29 18 38.3 Between 5 and 10 years 162 102 48 12 32.0 " 10 " 15 t< 85 40 35 10 46.7 " 15 " 20 !< 52 22 26 4 54.2 " 20 " 30 U 39 11 22 6 66.7 Over 30 years 26 9 14 3 60.9 Age not stated . 55 470 21 29 5 44 58.0 Aggregate 234 192 45.1 Comparative Results of Complete and Partial Excision. Form op Excision. Total. Recovered. Died. Complete excision Partial Form not stated Aggregate 177 90 241 124 52 20 470 234 77 97 18 192 Result un- Mortality pel- determined. cent- °,f termi- nated cases. 10 20 14 44 46.1 43.9 47.4 45.1 With regard to the utility of the limb after excision of the hip-joint, it may be said in general terms that a favorable result will be secured in three- fourths of the instances of recovery, the limb being reported as useful in li8 out of the above 234 successful cases. From the first of the preceding tables it is seen that the most favorable age for the 'operation is from five to ten years, the mortality increasing after puberty, and in adult life being *o large as to be almost prohibitory. Even at the most favorable period, the death-rate is almost one in three, the operation being thus nearly as 1 These eases were tabulated in the fifth edition of this work. 688 excisions. often followed by death as ligation of the third part of the subclavian or of the external iliac, and more often than amputation at the shoulder for all ages. The second table shows that complete is, upon the whole, very nearly as successful as partial excision, and that hence the acetabulum should be freely gouged in any case in which it is found to be diseased. The results of hip-joint excision, it will therefore be seen, are not very brilliant—one out of three dying under the most favorable circumstances ' and but three out of eight recovering with useful limbs. Ought we, then, to abandon the operation ? I answer, certainly not. The question is not so much, what does excision promise ? as, does any other mode of treat- ment promise as well ? What, in fact, can the opponents of hip-joint ex- cision offer instead ? The operation is indeed such a grave one that I have seldom felt that it was justifiable to resort to it in any case in which it was not evident that life would be endangered by persistence in expec- Fig. 392—Result ol hip-joint excision. (From a Fig. 393.—Excision of both hip- patient in the Episcopal Hospital.) joints. (From a patient in the Chil- dren's Hospital.) tant measures. But in cases of hip-disease in which suppuration has oc- curred, there usually, sooner or later, comes a time when the only alterna- tives are excision, amputation, or a prolonged and painful illness, terminated by death. These patients very rarely (at least in the class of cases which we see in hospital practice) recover under expectant treatment; they are carried from one hospital to another, and at last die worn out by suppura- tion or visceral disease, or are carried off from a life of pain and weari- ness by some intercurrent affection.2 No one, probably, at the present day, 1 The results of the operation in my own hands have been somewhat more favor- able, the deaths having been but one in four and a third for all ages. 2 Twelve cases noted by Gibert at the Hospital " Saiute Eugenie," gave one re- covery, three " not cured," and eight deaths. excision of the knee joint. 689 would think of amputating in any case of hip-disease to which excision was at all applicable; and, indeed, apart from the mutilation necessarily- entailed, the mortality after the operation is not inconsiderable—at least 11 out of 55 recorded cases1 amputated for hip-disease having terminated fatallv; so that excision is, in a good many instances, the surgeon's only available resource, and, as such, should be employed without hesitation. In this respect excision of the hip-joint differs from that of any other articulation of the bodyr, and, as justly remarked by Mr*. Holmes, " in cases which show a decided tendency to get worse, we may pretty confidently reckon all the recoveries after the operation as a clear gain." I have twice had occasion to resort to excision of both hip-joints in the same patient. The results as regards life were satisfactory, but the patients were not able to walk without crutches as long as they remained under my observation. (See Fig. 393.) Similar operations have been performed by Croft, Byrd, Sands, and Battle. Femur___Excision has been practised in the shaft of the femur for compound and ununited fracture, and for necrosis, but the operation is not, in my judgment, one to be recommended. The cuneiform and other opera- tions which have been employed for anchylosis of the hip and knee joints have already been referred to. Excision of the trochanter major has been successfully employed by several surgeons, myself included. Knee-joint___Excision of the knee-joint may be required in cases of chronic disease of that articulation, and may be occasionally justifiable in cases of compound fracture or dislocation, or of angular anchylosis. This operation appears to have been first performed by Filkin, in 1762 (the case terminating in re- covery), and was again suc- cessfully done by Park, in 1781. So little favor, how- ever, did the procedure meet with in the eyes of surgeons generally, that fifty years ago it had not been per- formed more than thirty- two times. Revived by Textor and by Fergusson, the last-named surgeon oper- ating for the first time in 1850, it has since been re- sorted to so frequently that its statistics are now more extensive than those of any other excision. The operation may be per- formed in several ways,2 the 1 See table in fifth edition of this work. 2 Treves, reviving the plan of Jeffray and Sedillot, 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 afterwards joined by sutures. The same surgeon, in operations for disease, makes a small H iucision, with additional lateral wounds for drainage, removing the patella. _ Golding- Bij'd, following Volkmann, divides the patella transversely (trans-patellar excision), and "rings the fragments together again with sutures of carbolized silk. 44 Figs. 394 and 395.—Extremities of femur and tibia removed by excision of knee-joint. (From specimens in the museum of the Episcopal Hospital.) 690 excisions. methods most deserving attention being by the H, the U, and the simple transverse incision. The H incision was first employed by Moreau, aud consists of two longitudinal incisions; one on either side of the joint, with a transverse cut passing immediately below the patella. The lateral in- cisions should be placed far back, so as to give ready access to the femoral condyles, and to insure free drainage subsequently. This method, which is preferred by Butcher, greatly facilitates the subsequent steps of the ope- ration, but has the disadvantage of making an unnecessarily large wound. The U, horseshoe, or semilunar, incision was first practised by Mac- kenzie, and is still preferred by many surgeons. This method consists in raising an anterior flap containing the patella, the base of the flap reach- ing to above the condyles. The ligamentum patellae is divided in the first incision, when, the crucial and lateral ligaments being cut, the articu- lating surface 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, and Fergusson. It makes a smaller wound than either of the other methods, and has proved quite satis- factory in seventy-six cases in which I have employed it. It is to be observed, however, than 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 is then made directly 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* 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 thitrh-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 beloto upjwards, 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 Pdniere'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 excision of the knee-joint. 691 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 Fig. 396.—Price's apparatus for after-treatment in excision of the knee. 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 or catgut suture, as originally employed by Gurdon Buck, and since resorted to by many other surgeons, or by means of steel or bone pins, as respectively recommended by Mr. Morrant Baker and Mr. Willett, or silver "dowels," as advised by Mr. Stoker. To prevent separation of the bones, Fenwick makes curved sections which fit together, and Davy saws the femur in the form of a wedge or tenon, to be impacted in a mor- tise-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. 396), and excellent cures have been obtained with Butch- er's box splint, or, as recommended by P. H. Watson, with a posterior moulded splint and an anterior wire rod to enable the limb to be suspended. The essential points to be secured are absolute immobility of the limb, and ready access to the wound ; and I have myself been abundantly satisfied with a simple bracketed wire splint (Fig. 307), 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- ed, as advised by Fig. 397.-Wire splint for excision of knee. Too forcible approximation of the bones caused fatal fat embolism in a case re- corded by Vogt. Fat embolism has also been observed by Lticke after excision of the hip. J 692 EXCISIONS. Butcher, by using in addition 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 ingeniously suggested by Swain, or, which I have found sufficient, a simple strip of adhesive plaster carried around the outside Figs. 398 and 399.—Excision of knee-joint for recurrent arthritis with partial anchylosis in bad position. (From a patient in the Episcopal Hospital.) of the limb and secured to the inner side of the splint. The object being to obtain firm bony union, the splint should be removed as seldom as possi- ble, and the first application should suffice, if possible, for at least a fort- night; and, indeed, I have frequently 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, Penieres, Picard, and many others. The most recent researches upon this subject are those of Culbertson, who has analyzed nearly 700 operations, of which no less than 603 were for chronic disease of the articulation. These G03 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 exhibit 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-amputation for disease in general. EXCISION OF THE ANKLE-JOINT. 693 The following table, compiled from Culberston'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. Mortality per Age. Total. Recovered. Died. determined. cent, of termi-nated cases. 1 to 5 years 19 11 7 1 38.9 ft " 10 " 106 SS 17 1 16.2 10 "15 " 99 81 18 17.2 15 " 20 " 84 58 25 i 30.1 20 " 25 " 67 40 26 l 39.4 ^"30 " 55 34 20 l 37.0 30 "40 " 65 38 27 ... 41.5 Over 40 " 19 9 10 52.6 Not stated . 89 60 28 l 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 steadily increases, till in adult life the operation is again one of a very serious nature. We may, therefore, probably say, with Holmes, that fourteen is, all things being considered, about the most favorable age— there being then comparatively little danger of consecutive shortening, while the operation is at the same time not attended with any particular risk to life. Excision of the knee-joint should not as a rule be performed during the first five years of life, while it must be deemed an extremely grave procedure in persons past the age of thirty. Of 76 operations in my hands, 67 have ended in recovery with useful limbs; 1 required re- excision; 2 ended in recovery after amputation; and only 6 have termi- nated fatally. 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 sequest- rotomy), and the procedure is then attended with some risk. Twenty- three cases to which I have references, including one of my own and those recorded by Fuqua, Walker, Dodd, and Page, gave three deaths, three subsequent amputations, and seventeen 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 subperiosteal abscess (see p. 642). The operation requires a single longitudinal incision, the bone being then divided with a chain saw, and wrenched from its epi- physeal 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 aversion of the foot by the use of a suitable splint. Ankle.—Excision of the ankle-joint, first employed by the elder Moreau m 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, better, by means of a semilunar incision passing around the lower border 694 EXCISIONS. 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 extensor 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- fig. 400.-Bracketed wire splint for ankle. cumstances 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. 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 op Operation. Total. ' Recovered. Died. 4 6 10 Result not determined. Mortality per cent, of termi-nated cases. Partial excision . . . 68 ; 57 Complete " . . . j 51 j 45 Undetermined . . . , 5 5 7 6.6 11.8 Aggregate . .124 107 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. Thirteen cases in my own hands have given ten recoveries, one subsequent amputation, 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. 1 Polaillon divides the fibula with a chain-saw above the external malleous, 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 doubt advantage. Liebrecht attacks the joint from behind, dividing the tendo Aohiln the ends of which he afterwards brings together with sutures. EXCISION OF THE BONES OF THE FOOT. 695 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 cuttiug across its neck with strong pliers, when the fragments may be successfully dislodged with the 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 patients submitted to total excision, 79 recovered with useful limbs, 2 were cured by amputation, and 19 died, while in 12 cases the result was not ascertained. The mortality of terminated cases was thus exactly 19 per cent. The same writer has collected 28 cases of partial excision of the astragalus, with 18 satisfactory recoveries, one cured by amputation, and one death. Poinsot has collected in all 144 cases, of which 26, or 18 per cent., terminated fatally. Excision of the Os Calcis is occasionally required in cases of caries or 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, aud 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 the bone, when, the ligaments of the calcaneo-cuboid joint being divided, the calcaneum itself can be slightly displaced inwards, so as to facilitate the division of the various ligaments between that bone and the astragalus. This being done, the calcaneum is twisted outward, and carefully separated from the soft parts on its inner side. The operation is completed 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 employ a single external incision, beginning as in Holmes's operation, but carried forwards to a point midway between the projection of the fifth metatarsal and the tip of the malleolus. Oilier recommends a subperiosteal excision, but from a recent discussion in the Clinical Society of London, it would appear that the result of the opera- tion has been usually most satisfactory when no attempt to preserve the periosteum has been made. The statistics of excision of the os calcis, which appears to have been first performed by Monteggia, in 1814, have been studied by Burrall, Polaillon, and Vincent. The last-named writer has collected 79 cases, which resulted as follows: 49 patients recovered with useful limbs, 5 re- covered, but without much use of the preserved member, 10 submitted to subsequent amputation, and 5 died, while the result in 10 cases was not as- certained. If we add 6 successful cases reported by McGuire and Poore, we shall have a total of 75 terminated cases, giving 55 recoveries with G96 ORTHOPAEDIC SURGERY. useful limbs, and but 5 deaths, a mortality of less than 7 per cent. Yin- cent's statistics show that subperiosteal excision is more dangerous than the ordinary operation, having given 3 deaths out of 23 cases. Mikulicz recom- mends, 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 recovery the patient walks as in pes equinus. Of 22 cases of this operation, including one of his own, tabulated by Hopkins, 17 ended in recovery, and 5 in relapse requiring further operation. No case proveds fatal. (See page 140.) 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 Conner has collected 108 cases, including several 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 surgeon 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 re- corded by H. M, Jones. When excision is resorted to, the lines of incision should be regulated by the position of external sinuses; no rules can be given which in such cases would admit of general application. The joint between the astragalus and calcaneum has been successfully excised by Annandale. CHAPTER XXXIV. ORTHOPAEDIC SURGERY. Orthopaedic1 surgery is that branch of surgical science which treats of the meaus 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 term is limited to a few particular kinds of deformity, as wry-neck, lateral curvature of the spine, club-hand, or club- foot, and contractions of joints not due to articular disease, while, on the other hand, no reference is intended to the age of the patient in whom these deformities occur. Among those who in this country have particularly illustrated this branch of surgery, may be mentioned Warren, Bigelow, 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, 1 From of0o'c (straight), and ira~; (child). WRY-NECK. 697 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. ]n 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, depending on the irritation of teething, or of intestinal parasites. Many of the cases which are considered congenital are, according to Little, due to injuries received during birth. When both sterno-cleido-mastoid muscles are involved, the affection will usually' be found to have a rheu- matic origin. Symptoms and Diagnosis—The symj)toms are easily recognized, the contracted muscles being tense and well defined ; frequently both por- tions of the sterno-cleido-mastoid seem equally rigid, but often the sternal portion is alone or principally involved. The diagnosis is usually easy ; the deformity may be closely simulated by the contraction of a cicatrix after a burn, or by disease of the cervical vertebrae ; in the former event, the nature of the case will be evident upon careful examination, while if spinal disease be present, the fact can be ascertained by observing the localized tenderness on pressure, and the pain produced by moving the spine or by pressing the head downwards, with perhaps the existence of inflammatory thickening and of partial motor paralysis. Treatment.—In the milder form of the affection, especially when of 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 Da Costa, by the hypodermic use of atropia ; in some'cases, in which the disease would appear to consist not so much in spasmodic contraction of the muscles on one side as of paralysis of those on the other, benefit may be derived from the employment of electricity, or from the endermic application of strychnia. Busey employs hypodermic injections of morphia, and enforced motion of the affected muscles while the patient is under the influence of ether. In severer and more obstinate cases, it will usually be necessary to resort to an operation, though if the degree of contraction be not very great, mechanical extension, by means of a suitable instrument, will occasionally suffice. The Operative Treatment of wry-neck consists in the subcutaneous division of one or both of the lower attachments of the affected sterno- cleido-mastoid muscle; the sternal portion may be divided by introducing an ordinary tenotome in front of the upper margin of the sternum, and about half an inch above the line of the clavicle, ar d, 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 698 ORTHOPAEDIC SURGERY. 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 days an apparatus may be applied to effect median- fig. 401.—Tenotome ical extension, while the cure is further promoted by the sys- tematic 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, returning to the old method of Roonhuysen and Sharp, divides the muscle by an open incision, then closing the wound and dressing it antiseptically. I have myself occasionally adopted this procedure, and believe that in re- lapsed cases it presents advantages over the subcutaneous operation. Various forms of mechanical apparatus are employed in the after-treat- ment of wry-neck; in young 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 byT 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 Jorg, 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 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 Muscles 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. 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 case-, portions of the spinal accessory nerve have been excised with at lea-t temporary benefit by 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 permanent, but in the other with only temporary advantage. Cures by nerve-stretching have also been recorded by F. Page and Mosetig-Moorhof, but in Lange's case the operation gave little if any relief. Schwartz rec- ommends stretching as preliminary to resection. Ligation of the spinal accessory nerve has been practiced by Collier and Deaver, and the posterior branches of the first three or four cervical nerves have been resected by Keen, Powers, and Noble Smith ; but all of these operations, though often of temporary benefit, commonly fail to effect a permanent cure. The actual cautery has proved effective in the hands of Mills and Roddick. LATERAL CURVATURE OF THE SPINE. 699 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 years of age. There are usually twocurves, 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 or twisting taking place in the direction of the convexity at each portion of the curve. The bodies of the vertebrae are thus more displaced than the spinous processes, which, as pointed out by Judson, are held in place by their lateral attachments, and which sometimes appear, even in advanced cases, to occupy almost their natural line. The disease affects at first only the ligaments and muscles of the spine, but, in long-continued cases, may give rise to compression or partial absorption of the intervertebral cartilages, or even of the bones themselves. Asa result of the twisting of the vertebra? which accompa- nies the lateral displacement (scoliosis), a certain degree of antero-poste- rior curvature is sometimes superadded—a rounded or hump-like projection occurring in the dorsal region, with a corresponding incurvation of the lumbar spine, the former constituting the condition known as cyphosis, and the latter that called lordosis. These are, indeed, but exaggerations of the natural curves met with in every adult spine. In some cases, especially among rachitic persons, they may exist without lateral displace- ment. Tuckey has described, under the name of acute lateral curvature, a condition which seems analogous to the so-called " hysterical" joint- affections described in Chapter XXXII. 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 and upper part of the body to settle downwards, and necessarily forcing the relaxed and weakened spine to yield at its least-resisting point. The physiological changes which occur in the female at the age of puberty, and the customary relinquishment, at that period of life, of the out-door sports of childhood, appear to act as powerful predisposing causes of the spinal relaxation referred to. The very constant character of the displacement— to the right in the dorsal and to the left in the lumbar region—is doubtless due to certain vicious habits and postures, such as supporting the whole weight on the right leg ("standing at ease," in the language of the drill- master), whereby the pelvis is rendered oblique, and the lumbar spine necessarily distorted to the left side ; to sitting habitually at a desk with the left shoulder depressed and the right elevated; to over-exertion of the right arm in sewing, etc. Though the dorsal curve is usually most apparent, it is really, according to Shaw, preceded in time of formation by the lumbar. The latter, however, does not become so quickly permanent, on account of the greater flexibility and elasticity of the part, which enable it to resist longer the occurrence of absorption of the articular processes and other secondary changes than can be done by the dorsal spine, fixed as that is by its connection by 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 700 ORTHOPEDIC SURGERY. 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 sit- ting, 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 scapula, and may, even at this earlv stage, recognize a slight deviation in the line of the vertebrae, by tracing down the spin- ous processes and marking each with pen and ink. It must be, moreover, remem- bered that the deviation of these processes by no means represents the degree of distor- tion of the bodies of the bones, the dis- placement of the latter being, I believe, invariably 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 posi- 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 markedly distorted, and serious functional disturbance, or even organic disease, may result from the consequent com- pression of the thoracic, abdominal, or pelvic viscera. Diagnosis—Lateral curvature may be distinguished from the graver condition known as antero-posterior curvature, or Pott's disease of the spine (which will be described hereafter), by the fact that in the latter affection the displacement is commonly angular, rarely lateral, and unattended with axial rotation of the vertebrae. There are besides, usually, marked immobility, thickening, and tenderness of the affected portion of the spine. From the spinal distortion of rickets, lateral curvature mav 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, cyphosisand 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 improve 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 open air, and may often derive great advantage from gymnastics, swinging by the hands from Fig. 402.—Lateral curvature of spine. (Erichsen.) DEFORMITIES OF THE UPPER EXTREMITY. 701 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 into 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, and lateral sus- pension over a transverse bar is employed by Lorenz and Redard. Fric- tion of the muscles on either side of the spine, either with the hand alone or with stimulating liniments, will often be of service, as will also the daily use of the cold salt douche. In severer cases it will probably be necessary to afford mechanical support by means of some form of appara- tus. A great many instruments have been devised for this purpose, the general principle of action being to elevate the shoulders by means of crutch-heads under the axilke (connected with a well-padded pelvic collar), with side-pieces to support and gradually replace the projecting vertebrae by applying pressure to the corresponding portions of the chest-walls. Such an apparatus should be, as a rule, worn during the day only. Sayre recommends 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 con- fining 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 Adams pre- fers, a splint made of " poroplastic" felt. If a case of lateral curvature be recognized at an early period, and promptly and judiciously treated, it may be, if not cured, at least kept in check until the critical period of adolescence has passed by, when there will be comparatively little tendency to increase of the deformity. It thus happens that, while a very large number of young girls suffer from incipient lateral curvature, its advanced stages are comparatively seldom seen—the disease being, as it were, " outgrown" in a great many instances. Myotomy, or subcutaneous division of the spinal muscles and aponeu- roses, for a long time almost entirely abandoned in the treatment of lateral curvature, has been revived by Sayre, who has in several cases divided the latissimus dorsi with alleged immediate benefit. I confess that the opera- tion seems to me unnecessarily heroic, and, indeed, as the disease is mainly dependent upon ligamentous and muscular relaxation, not contraction, I do not understand why such a procedure should be expected to prove ultimately successful. Deformities of the Upper Extremity. Contraction of the Shoulder___Duplay has described, under the name of scapulohumeral periarthritis (see page 665), an affection which consists in inflammatory thickening of the sub-acromial bursa and sub- 702 ORTHOPEDIC SURGERY. 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. 509, 571). In hysterical cases, the proper constitutional treatment for that condition should be employed, the arm being, if necessary, extended while the patient is in a state of anaesthesia, and then kept in a straight position for a few days. In the rheumatic form, when the contraction is perma- nent and accompanied with organic change, tenotomy may be required. The operation is performed by slipping a tenotome flatwise beneath the tendon of the biceps from within outwrards, so as to avoid the artery, and then, turning the edge of the knife forwards and upwards, effecting the section by cutting with a slight sawing motion while the arm is forcibly extended. The wound should then be closed and the arm placed in a sling, extension being applied after a few days by means of a screw-splint or weight. Contraction of the Forearm and Hand is occasionally met with as the result of excessive use of certain muscles, with disuse of others; the treatment consists in a change of occupation, with the employment of a straight splint, friction, galvanism, etc. Club-Hand is a rare affection, analogous to club-foot. It is usually complicated writh a deformed condition of the lower end of the radius, and sometimes of the carpal bones. Two forms of club-hand are met with, in one of, which the part is in a state of extreme flexion, and in the other of extension. The affection is sometimes congenital, but usually results from infantile paralysis, and is, according to Holmes, always accompanied by other deformities. The treatment consists in supplementing the action of the paralyzed muscles by means of India-rubber bands, attached to a light metal frame, and passing beneath a ring at the wrist. In inveterate cases, tenotomy may be required, followed, after the healing of the wound, by passive motion, aided by the use of friction and galvanism. An ingenious operation for lengthening contracted tendons, particularly applicable to those of the hand and forearm, has been suggested by Sporon, Rhoads, Lange, and Anderson, and practised also by Keen. The tendon is exposed by an open wound and split with a small knife through the requisite space, and then half cut through at each end of the longitudinal section so that it can be lengthened without entirely separating its ends, and fastened by sutures. I have myself resorted to this operation with a quite satis- factory result. 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 fasciae, 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 DEFORMITIES OF THE UPPER EXTREMITY. 703 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 effected by slipping a very small flat-edged tenotome beneath the skin—between it and the fascia—and Fig. 403.—Dupuytren's finger contraction. Fig. 404.—The same hand after operation. cutting downwards; the part should then be immediately extended, and kept in the straight position by means of a light splint worn continuously for three weeks, and afterwards only at night, for several weeks longer. This plan, which is that advised by Adams, I have resorted to with most gratifying success in three cases, from one of which the annexed illustra- tions are taken (Figs. 403, 404). Busch and Madelung advise that a tri- angular flap of skin should be dissected up, and the palmar fascia notched 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, Forbes divides subcutaneously the fibrous bands which unite its extensor tendon to those of the adjoining fingers. A similar operation is employed by R. H. Anderson and by F. W. Langdon. 704 ORTHOPAEDIC SURGERY. Trigger Finger—This is the name given to a condition in which a joint of a fiuger suddenly becomes locked, either in flexion or extension. The condition has been attributed to rheumatism, to tenosynovitis, to the presence of a " loose cartilage," aud, 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. Electricity, tenotomy, and section of the palmar fascia have been emploved as remedies, but without much benefit. A similar condition has been observed in the toes. Webbed Fingers__This annoying deformity may be remedied Im- perforating the base of the web and allowing the parts to cicatrize around a metal ring, when the rest of the web can be divided without risk of rcad- herence; byT a plastic operation, as employed by Barwell (who trans- planted flaps for the purpose from the patient's buttock); by Harris (who utilized for the purpose a strip of skin taken from the web itself); and bv 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 Vogel. Abbe records a case suc- cessfully treated by skin-grafting after Thiersch's method. 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, pectineus, tensor vaginae femoris, and rectus. Division of these muscles is performed in accordance with the principles of tenotomy in general, the knife being introduced behind the part to be divided, and the section then cautiously effected by cutting from behind forwards. Poore has reported a remarkable case of cross-legged progression, due to the con- traction following double hip-disease, and refers to four similar cases, one recorded by Esmarch (a case of double congenital dislocation), two by- Lucas, and one by Tyson. A sixth case came under my observation 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 hamstring tendon. The inner condyle of the femur is, as compared 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. In some cases there is hypertrophy of the inner tuberosity of the tibia. Macewen and Keetley believe that the deformity is rather in the shafts of the bones than in the epiphyses. The affection is probably never congenital, but comes on during childhood, and is apparently connected in many instances with a rachitic tendency. Both knees are usually 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. 405. An iron rod, hinged at the DEFORMITIES OF THE LOWER EXTREMITY. 705 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 externa] hamstring 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. 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 "tip-toe." 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 Grattan. Little, Schede, Ewens, and Annandale have, in aggravated cases, straightened the limbs by excising wedge-shaped pieces of bone, the three 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 sim- ilar case been successfully resorted to by Mr. Howse. Ogston simply saws through the projecting condyle and forcibly straightens the limb, while a similar operation, with the chisel and with antiseptic precautions, is practised by Barwell. 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. 405.—Apparatus for knock-knee. Fig. 406.—Macewen's osteotome. middle, while the latter removes from the condyles a wedge-shaped portion of bone. Macewen divides with a chisel or osteotome (Fig. 406) 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 on by one or other method having furnished, according to Poore, only- 6 deaths, while Macewen's method alone has, in 622 cases, given but 3 deaths. My own experience in these operations is limited to eleven cases, in one of which I operated (on both sides) by Ogston'splan, and in the others by Macewen's method. The latter I consider much the more satisfactory operation, and indeed this is generally acknowledged by surgeons who 45 706 ORTHOPEDIC SURGERY. have tried both. The result in all my cases was favorable. Figs. 407 and 408, from photographs, show the appearances before and after operation in one of my patients at the Children's Hospital. I have twice success- Figs. 407 and 408.—Result of Macewen's operation for knock-knee. (From a patient in the Children's Hospital.) 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. 40) and 410.—Result of osteotomy for bow-legs. (From a patient in 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 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 CONTRACTION OF THE KNEE. 707 fibula?, 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 tibia? and fibulae (the latter at both upper and lower ends), being divided atone operation. I have operated with good results in eleven cases, from one of which the annexed illustrations (Figs. 409 and 410) are taken ; in a twelfth case the patient died from tuberculous meningitis. Contraction of the Knee, dependent upon shortening of the ham- strings, may occur in connection with anchylosis of the joint, or indepen- dently; the treatment consists in division of the hamstring tendons, fol- lowed by gradual extension, with passive motion, friction, etc. Division of the Hamstring Tendons is thus performed: the patient being in the prone position, an assistant renders the parts tense by fully extending the limb, and the surgeon then introduces the tenotome flatwise on the inner side of the outer hamstring, or biceps tendon (which is to be first divided), through a puncture which in the adult should be an inch above the point at which the tendon joins the fibula. By keeping the knife close to the tendon, the risk of wounding the peroneal nerve is avoided, and the section is then effected by cautiously cutting towards the skin; 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 freer 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. 411.—Anterior curvature of Fig. 412.—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 space. After the operation, the wounds should be instantly closed with a firm compress (to prevent extravasation, or the entrance of Mr), and no attempt at forcible extension should be made until the parts are entirely healed, which usually requires a delay of four or five days. -Neglect of this precaution may give rise to wide-spread suppuration in the tissues of the ham. When cicatrization has occurred, gradual extension may be made by 708 ORTHOPAEDIC SURGERY. means of a weight, elastic bands, or screw apparatus, or in some few cases forcible extension may be preferably employed, the patient being, of course, in a state of anaesthesia. Recovery may be further promoted bv the assiduous practice of passive 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 keep this bone fixed when once the tibia has been divided. I have operated in five cases of this kind, Fig. 412 showing the result in one under my care at the Children's Hospital. Congenital Absence of the greater portion of both tibiae 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 mav 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 G ale a neo-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 ol 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.1 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, i* due the credit of first resorting to subcutaneous tenotomy as it is now practised, while to Gue*rin and Bonnet, in France, to Little, Tamplin, and Adams, in England, and to Detmold and Mutter, in this country, are in a great measure owing the general introduction and perfection of the pro- cedure. The process of repair after division of tendons consists, as shown by Adams, in the development, between the retracted ends, of a new material, which does not, as was formerly supposed, subsequently contract and bring down the shortened muscle, but remains permanently, though gradually assimilating itself in structure and appearance to the original tendon. 1 Treves lias recently recommended a return to the old method of operating—t>.v open incision—with antiseptic precautions. CLUB-FOOT. 709 Fig. 413.—Talipes equinus. (Pirrie.) 1. Talipes Equinus.—This is very seldom, if ever, a congenital affec- tion, but is, on the other hand, the most common non-congenital form of club-foot, occurring, according to Tamplin, in forty per cent of cases originating after birth, and in twenty-two and a half per cent, (or, according to Lonsdale and Adams, thirty-four per cent.) of all cases taken indiscriminately. The deformity in talipes equinus consists simply in an elevation of the heel, which may be so slight as merely to prevent the foot from being flexed bevond 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. 413. 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 sys- tem during dentition, or from the irritation of intestinal worms, though some cases de- pend upon general infantile paralysis; in adults, this form of club-foot may result from paralysis, from abscess or injury of the calf of the leg, or from habitually keeping the foot in a bad position (during the treatment of fractures, etc.), by which the patient acquires a "pointed toe." The treatment consists in the subcutaneous division of the tendo Achillis, about an inch above its point of insertion. The patient being prone, and the tendon rendered tense by depressing the foot, the tenotome is introduced flatwise (on either side, as most convenient), and carried across in close contact with the tendon, so as to avoid wounding the posterior tibial artery; the edge of the knife being then turned 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 sole us 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 transverse tarsal joint. In using this, as with all other forms of ortho- 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. 710 ORTHOPAEDIC SURGERY. paedic 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 application of the apparatus during the whole course of after-treatment; but when this is impossible, I have of late years found it more satisfactory to restore the foot at once to the normal position, and then apply a plaster-of-Paris bandage. The shoe can be adjusted a week or ten days subsequentlv, 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 Tamplin, 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 motion constituted by the astragalo-scaphoid and calcaneo-cuboidjoints, with an elevation of the posterior third by the contraction of the muscles of the calf. When the latter displacement is particularly marked, the affection receives the name of equino-varus. Fig. 414.—Talipes varus. (Fergisso.n.) Fig. 415.—Varus shoe, with jointed sole-plate. 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 in cases of ordinary severity, tenotomy should be resorted to, the best age for the operation being probably between the second and third months of life. lbe 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 advocates division of the muscular sub- stance of the abductor pollicis; Guenn, subcutaneous division of the internal lateral ligament of the ankle, and of the calcaneo-scaphoid or cal- caneo-cuboid ligament; and R. W. Parker subcutaneous section of the CLUB-FOOT. 711 inner tarsal ligaments, and especially of the astragalo-scaphoid. A. M. Phelps makes an open section of all the contracted tissues, and reports 161 successes obtained in this manner. The tibialis anticus tendon deviates from its normal direction, curving downwards and backwards across the inner malleolus, while the posterior tibial tendon passes from behind the inner ankle directly 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 com- press 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. 415). The second stage of treatment consists in dividing the tendo Achillis, and in subsequently bringing down the heel, as in a case of simple talipes equinus. Here, as in pes equinus, unless the surgeon can have the case under personal observation, it will be found better to divide all the con- tracted 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. 416.—Result of cuneiform excision of Fig. 417.—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, Konig, Rose, Poore, and Swan, has further extended the opera- tion to removal of a wedge-shaped portion of the tarsus. Davy reports 22 operations of this kind upon 18 patients, with only one death, and Swan 712 ORTHOPEDIC SURGERY. has operated in 34 cases. I adopted this plan with success in a case of inveterate varus of both feet, sent to me by Dr. A. S. Roberts (Fig. 416) but in another case (Fig. 417), in which I tried it, acute gangrene occurred, requiring amputation and followed by death. Davies-Colley has, in a case of varus, excised the cuboid, with portions of the astragalus, calcis, scaphoid, cuneiforms, and outer metatarsals ; while Lund has in a similar case suc- cessfully excised the astragalus on both sides. Davies-Colley's operation has been twice successfully employed by Dr. Fairbank. Mason 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 Vere- beTyi, Stokes, Margary, Raffa, Bceckel, Renton, Morton, and other sur- geons, myself included; and the cuboid (also successfully) by Poinsot. Gross, of Nancy, recommends that the head of the calcaneum should be removed as well as the astragalus. Fitzgerald contents himself with u tarsotomy, cutting across the astragalus and calcaneum with a chisel, and forcing the foot into place ; and Bradford cuts one or both bones with an osteotome, or removes from one or both a small wedge-shaped piece, hav- ing previously divided or stretched the contracted soft tissues. Of these various operations I am disposed to prefer excision of the astragalus alone, and indeed I regard this as the best remedy in relapsed cases. 3. Talipes Calcaneus (Fig. 418) 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 upon contraction Fig. 418.—Talipes of the muscles of outer part of the le; which is the revers nus, causing the on the heel. In si congenital variety cure may be effecte process of walking, stances tenotomy will be required, Fig. 419— Talipes valgus. (Pikrib.) the tendons to be divided being those of the tibialis anticus, extensor communis digitorum, extensor pro- prius pollicis, and peroneus tertius. The after-treatment consists in the application of an apparatus provided with an elastic spiral spring at the heel, to supplement the action of the tendo Achillis. Willett recommends 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 cases recorded by Walsham. This form of talipes is occasionally- combined with varus, constituting calcaneo-varus. 4. Talipes Valgus, flat-foot, or splay-foot, is rare as a congenital, but sufficiently common as an acquired, affection. The deformity is here the CLUB-FOOT. 713 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 heel may be elevated, constituting equino-valgus. Congenital cases of talipes valgus may often be cured by simple manipulation, or by bandaging the foot to an inside splint with a wedge-shaped pad, as in Dupuytren's mode of treating fractured fibula. In other instances, tenotomy will be required, the parts to be divided being the tendons of the peroneus longus and brevis, 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 produce gradual inversion, with a pad to restore the arch of the foot. Whitman employs a steel brace, made accurately to fit the foot and worn within the shoe ; while Roberts applies a plantar spring, worn in the same manner. Ellis recommends the "tiptoe" position, as in cases of knock-knee. Ogston, in inveterate 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 pa- tients. Stokes records a case successfully treated by partial excision of the head of the astragalus itself, and I have myself removed the entire astragalus with advantage under these circumstances. Gerster removes a wedge- shaped segment from the inner side of the tarsus. Trendelenburg and Meyer divide the tibia and fibula above the malleoli so as to compensate for the deformity by establishing a condition of artificial bow-leg. In par- alytic cases Parrish stitches together the tendons of the tibialis anticus and extensor pollicis, so as to make the latter supplement the action of the former, which is paralyzed. Weak Ankles, which often precede the development of acquired talipes valgus, should be treated by attention to the hygienic surroundings of the patient, and by the use of friction and the salt douche, with, if necessary, an elastic bandage, or light, metallic, lateral supports. On the Treatment of Club-foot without Dividing Tendons.—Barwell opposes the practice of tenotomy, in the treatment of talipes, on the ground that the affection is alwayTs the result of paralysis, and that divided 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 of mild cases, it will, as undoubtedly, fail in many of those which are-more severe ; and even in the slight cases, teno- tomy (which has not been proved to do any harm) certainly abbreviates the time required for treatment. Indeed, we may safely say, in the words of Mr. Adams, that the successful treatment of club-foot demands, in most cases, "a judicious combination of operative, mechanical, and physiologi- cal means." The chief advocate of Mr. Barwell's views, in this country, is Prof. Sayre, who is however too judicious a surgeon to recommend Barvyell's plan as an exclusive mode of treatment. Sayre's rule for de- termining whether or not a tendon should be divided, is to ancesthetize the patient and then, having put the parts on the stretch, to press with 714 DISEASES OF THE HEAD AND SPINE. the finger or thumb on the stretched tendon ; if this pressure produces reflex contractions, tenotomy is required. Dr. Newton M. Shaffer, of New York, has devised an ingenious appa- ratus for applying traction to the anterior part of the foot, and thus aiding in unfolding the tarsal arch; Dr. J. C. Hutchison and Mr. H. A. Reeves recommend the use of plaster-of-Paris bandages in the after-treatment of club-foot, and, as already mentioned, I have myself frequently followed this plan with good results in cases in which the patients were not goin" to remain under my constant supervision. Wolff employs a special mode of using the plaster bandage, cutting and splicing it at intervals of several days without removing the whole dressing, so as to effect gradual replace- ment of the parts in their normal position. 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 subcu- taneously, 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 re- sorted to. According 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 speaking of bunion (p. 562). Mr. Barker has successfully treated this deformity by simple osteotomy of the first metatarsal. For contraction with flexion (Hallux filexus1) Davies- ColleyT recommends excision of the proximal half of the first phalanx, and a similar operation is recommended by W. Anderson for hammer-toe. For the condition known as pigeon-toe, Hopkins employs an ingenious ar- rangement of wheels and springs concealed in the heel of the shoe, by which the pressure exerted in walking forcibly turns the anterior portion of the foot outwards. CHAPTER XXXV. 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. Recurrent epithe- lioma of the skull has been successfully treated by excision by Braun. 1 According to Lang, however, hallux flexus is but a symptom of one variety of flat- foot. TUMORS OF THE BRAIN. 715 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 symp- 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 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, origi- nating in the layers of osteal cells, and, clinically speaking, of a malignant character. The disease may originate either beneath the pericranium (outside the skull), or between the cranial wall and the dura mater, or, as happened in Tait's own case, in both situations simultaneously, the skull thus undergoing erosion on both sides, until the masses meet and amalga- mate, when pulsation is developed. The Diagnosis from vascular tumor of the scalp, which is the only disease with which the affection is likely to be confounded, may be made by observing that the growth cannot be moved laterally upon the skull, and (in cases in which the bone is perforated) can be often partially reduced within the cranial cavity. The existence of optic neuritis is regarded by 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 351.) 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. Similar operations have been performed by Curtis, Macewen, Horsley, Pean, Weir, Keen, McBurney, Zimmer, Wyeth, and other surgeons ; of 72 cases collected by Knapp, 31 proved fatal, a mortality rate of 43 per cent., but of 87 cases referred to by McBurney, 47 appear to have proved fatal, or 54 per cent.; moreover, as well remarked by Dana, a " successful" operation may leave the patient *till paralyzed, or even in a worse condition than he was before. The death-rate in cases of cerebral tumor has, according to McBurney, been SI per cent., and in those of cerebellar tumor no less than 77 per cent. Instead of removing, as has usually been done, a large portion of bone b\T the trephine and gouge-forceps, McBurney, following Wagner's suggestion, 716 DISEASES OF THE HEAD AND SPINE. cuts through the skull with a chisel in the line of the scalp incision, and then turns back a flap of bone and scalp together, replacing both when the operation is concluded. A small disc of bone is first removed by trephin- ing, to give a starting-point for the chisel, and to provide for drainage. Mudd and Clubbe have successfully removed hydatids from the brain. 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 contents. 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 Pre>- cott 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 situa- tion of the foramen magnum ; they are usually solitary, but occasionally multiple, varying in size from that of a pea to that of the head itself, and complicated with internal hydrocephalus. The sac of a meningocele may be single or multilocular, and the contained fluid mav 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 bv symptoms of cerebral compression; the tumor swells up and becomes tense when the child cries, aud some- times partakes of the motions of the brain. The affection is occasionally complicated with naevus, and not unfrequently with other congenital mal- formations. The Diagnosis from congenital cystic tumor, when the meningocele is sessile, is sometimes very difficult, but in most cases it may be made by observing the situation of the malformation, its variations of tension, and the fact that it is not movable upon the skull; if, however, the communi- cation 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 mav coexist. The Prognosis is unfavorable, the large majority7 of these cases terminat- ing fatally during infancy, though occasionally patients thus affected have survived to adult life. Death is usually preceded by convulsions, due to cerebral pressure, but in some cases ulceration or rupture occurs, when inflammation of the sac and general spinal meningitis are the immediate precursors of the fatal issue. The Treatment in most cases should (according to Holmes, who has devoted special attention to the subject) be limited to affording support and making gentle pressure, by means of a gutta-percha cap lined with cotton- wadding ; and in cases evidently complicated with general hydrocephalus, nothing further is admissible ; compression with a plate of sheet-lead proved successful in a case recorded by Hill. If the tumor be rapidly increasing, without general symptoms, repeated tappings may be resorted to, with precautions against the entrance of air; the aspirator has been thus successfully employed by J. F. West. In cases of meningocele, if pedunculated, iodine injections may be tried with some hope of benefit, and Noble Smith has reported a case cured in this way by applying the iodo-glycerine 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 reported by Lazzari, and ligation 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 PARACENTESIS CAPITIS. 717 cavity has become obliterated, the tumor may be excised; or even if a communication persist, the operation may be occasionally justifiable, the pedicle of the tumor in such a case being first compressed by means of a clamp, which should be allowed to remain for twenty-four hours. Alberti and Marshall have reported cases treated in this way, the former's case ending in recovery, but the latter's in death. A third case operated on bv Mittendorff terminated favorably. A case was reported some years ao-o by Dr. Leasure, in which a meningocele (or, as the author named it, hvdrencephalocele) 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 occasion- ally been productive of much benefit, the proportion of recoveries being Fig. 420.—Chronic hydrocephalus. (From a patient in the Children's Hospital.) about one in four, and at least ten cures having, according to Phocas, been effected by this procedure. 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 718 DISEASES OF THE HEAD AND SPINE. 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 operation bv the hands of an assistant. As soon as the instrument has been withdrawn, the puncture should be closed with an adhesive strip, and an elastic, per- forated, India-rubber cap (as advised by Holmes) tightly drawn over the head, so as to support the skull and prevent syncope. If no bad results follow the operation, it may be repeated at another point, after a few weeks' interval. Injections of iodine have been practised in these case-, 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. The introduction of a tube to effect drainage from the lateral ventricle is also, in my judgment, not to be recommended. Craniectomy for Mierocephalus.—Lannelongue, in the case of a microcephalic infant, removed a thin segment of the skull, parallel to the sagittal suture, so as to allow expansion of the cranial contents. The child recovered from the operation, and its mental condition is said to have been much improved. Similar operations have been performed by Lane, Keen, Trimbel, Park, Wyeth, Weir, Morrison, and others, but, upon the whole, the results of these experiments seem to me hardly to justify their risks. Of 60 cases referred to in a discussion before the New York Neuro- logical Society, no less than 21, or 35 per cent., proved fatal, and, as pointed out by Dr. G. M. Hammond, in no instance has the patient really been cured, but only transrerred from one degree of idiocy to another. Wagner has modified Lannelongue's procedure by separating a curved cranial flap with a chisel, fracturing its base, and keeping it permanently displaced so as to increase the size of the cranial cavity. Diseases of the Spine. Spina Bifida (Hydrorachis).—This is a congenital malformation, which consists in a deficiency of the spinous processes and laminae of one or more vertebras,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 cervico-dorsal region, however, according to Giraldes, contains no nervous filaments, and I was told by Dr. J. B. S. Jackson, that in numerous dis- sections of spinas bifidae, he had invariably found the cord itself to termi- nate 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; may be single or multiple; is usually of an oval shape ; and varies in size from that of a walnut to that of a child's head. 1 In rare cases observed by Emmet, Tbomas, 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; meningomyelocele, in which both cord and membranes are implicated ; and syringo 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-meuingocele, corresponding to the first; and hydrorachis interna, or hydro-myelocele, corresponding to the third. SPINA BIFIDA. 719 Fig. 421.—Spina bifida. (Druitt.) It may be sessile or pedunculated, sometimes lobulated, and is usually covered by a skin of more or less normal character, though in some in- stances there is no cutaneous investment, the sac-wall being constituted of the spinal dura mater itself, in which case ulceration is apt to occur. The tumor is tense and elastic when the child is in the upright position and during the action of expir- ation, becoming softer during inspiration and when the child is laid on its face. Fluctuation is sometimes observed, and partial reduction may often be effected by pressure — the bony aperture through which the protrusion has taken place being then perceptible to the touch. Spina bifida often coexists with other deformities, and is frequently complicated with 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 Lithgow, it would appear that a spontaneous cure has been effected by the channel of communi- cation 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 appearing 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 may be 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 he pedunculated, a small quantity of a solution of iodine may be cautiously injected, a plan which, with various modifications has been successfully employed by Brainard, of Chicago, Velpeau, J. Morton, Watt, Eate, Ewart, Lobker, and other surgeons. Woltering, 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- 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 86 cases since collected by the Committee of the London Clinical Society, and by C. A. Powers, only 50 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 720 DISEASES OF THE HEAD AND SPINE. committee, however, and Dr. Powers, report at least 40 cures out of 57 cases treated by the latter method. The use of the elastic ligature, with or with- out paracentesis, has been employed by Laroyenne, Ball, Cologncso, Baldos- sare, Mouchet, and Turetta, 7 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-elements are less apt to be involved. Excision, supplemented by the transplantation of a strip of periosteum from a rabbit, has been successfully resorted to by Mayo Robson, and by R. T. Hayes, of Rochester, X. Y., and the same operation with insertion of a piece of rabbit's bone has succeeded in the hands of Berger. Osteo- plastic operations have been successfully employed also by Dollinger, Senenko, and Bobroff, the two former surgeons utilizing one the vertebral laminae and the other the sacrum, and the latter transplanting a flap from the crista ilii. 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, cvstic or fatty, which originates within the spinal canal and protrudes through an aperture due to a deficiency in the vertebral laminae; and (3) a tumor containing foetal remains, constituting the malformation properly 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 Tumors, unconnected with the spine, but occupying the median line of the back, may closely simulate cases of spina bifida, but, as pointed out by T. Smith, 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 vertebrae, 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 vertebras 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 developed 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, 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 ANTERO-POSTERIOR CURVATURE OF THE SPINE. 721 a favorite situation of the residual abscess (see page 437). 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 637). Although, in the course of the disease, the spinal canal may be bent to aright 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 Fig. 422.— Antero-posterior curvature of spine. Fig. 423.—Caries of the vertebrae. (Liston.) (Liston.) circumstances; 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, medullization, and eburnation in different parts. In cases in which anchylosis is deficient (as may happen when the angular projection is not marked, the diseased vertebral bodies being then separated and prevented from coalescing), spinal meningitis may occur, leading to 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 ten- dency to fall forwards. The spinal column is somewhat stiffened, the patient moving it as a whole, and thus being unable readily to raise or turn himself in bed without assistance. Examination may reveal an undue prominence of some of the dorsal spines, with perhaps thickening of the surrounding tissues, and tenderness on pressure. Pain may be elicited by 4G 722 DISEASES OF THE HEAD AND SPINE. pressing on the head, or by making the patient jump from a stool to the floor, thus approximating the extremities of the vertebral column. Iu 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 ad- vances, paralysis may be developed, involving the lower or upper ex- tremities according to the part of the spine affected. Incontinence of fece> and retention of urine sometimes form further disagreeable complications Abscess sometimes occurs quite early in the course of the disease, and not unfrequently before the development of angular deformity. Paralysis 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 surrounding ligamentous structures, until the milder course of the latter affection reveals its true nature. From neuralgia of the spine, an affection analogous to the hys- terical knee-joint, the diagnosis mav 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 relied upon; at least, I have known it to fail in cases in which the deformity and other symptoms left no doubt as to the nature of the case. The diagnosis from morbus coxarius, and from sacro-iliac disease, has already^ been referred to. (See pages 659 and 662.) When the characteristic deformity appears, there is little difficulty in recognizing the nature of the affection. This deformity consists, as already mentioned, in a posterior angular projection of the diseased vertebrae, due to the 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 gibbosity7 of the spine is thus thrown into a plane behind that of the pelvi> 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 ex- amination might then give the impression that the case was one of lateral curvature; the diagnosis may be made by observing that in true spine- disease there is no axial rotation of the vertebrae, such as always exists in the other affection (see page 699). When the vertebrae involved are those of the cervical region, particularly the atlas and axis, the case may be mis- taken for one of wry-neck. The sterno-mastoid muscles are, under these circumstances, tense and prominent, and the neck stiff; while the patient often involuntarily supports the head with both hands, so as to guard against sudden movements. The diagnosis from wry-neck may be made by noting the localized tenderness and thickening of the spine, and the increase of pain by tapping or pressing on the head. The diagnosis of Abscesses arising from Spine-disease requires some attention. The situation of the abscess, in these cases, varies with the part of the vertebral column which is involved. Thus in disease of the cervical vertebrae, the pus may present itself at the back of the pharynx, ANTERO-POSTERIOR CURVATURE OF THE SPINE. 723 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. Ab- scess from disease of the upper dorsal vertebrae commonly makes its way downwards, along the course of the aorta and iliac arteries, presenting itself in the iliac fossa above Poupart's ligament, but may gravitate to the back of the pelvis, passing out through the sacro-sciatic notch into the gluteal region, may pass forwards along the ribs, opening at the side of the trunk, or may go directly backwards, forming a dorsal or lumbar ab- scess; finally, it may, in some rare cases, burst into the air-passages or gullet. When the lumbar and lower dorsal vertebrae are affected (the most common situation of the disease), the abscess usually descends in the sheath of the psoas muscle, on one or both sides, constituting the condition known as psoas abscess.1 This generally points in the front of the thigh beneath Poupart's ligament, but may burrow downwards to the ham, or even to the ankle. In other cases the pus may present itself in the lumbar region, in the perineum, on the outer side of the hip, in the iliac fossa, or in the inguinal canal; or it may even burst into the bowel or bladder. By care and attention it is usually possible to determine whether an abscess, occurring in any of these situations, be or be not dependent upon disease of the spine. It is, however, sometimes a matter of great difficulty to dis- tinguish between psoas and iliac abscess—the former commonly arising, as we have seen, from caries of the dorsal or lumbar vertebrae, while the latter originates in the areolar tissue of the iliac fossa, and may or may not be connected with disease of the bony pelvis. This difficulty is further increased by the circumstance that, while spinal abscess occasionally pre- sents itself, as we have seen, in the iliac region, an iliac abscess may, on the other hand, make its way into the sheath of the psoas muscle. Psoas abscess is, however, commonly a disease of early life, points below Poupart's ligament, is usually attended with irritation and rigidity of the psoas muscle, and often makes its appearance suddenly; while iliac abscess, on the other hand, occurs almost exclusively in adults, points above Poupart's ligament, and is gradually developed. Psoas and iliac abscesses must also be distinguished from inguinal aneurism which has become suddenly diffused, from femoral hernia, and from fatty, serous, or hydatid tumors. The diagnosis from aneurism 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 outside, and in abscess usually to the inside, of the tumor. Fatty and other tumors may be recognized by their not being reducible within the abdomen, and, if necessary, by the use of the 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 years ago, a psoas abscess caused ulceration of a branch of the internal iliac artery, leading to rapid death from hemorrhage. 1 Psoas abscess, however, according to Stanley, Bryant, and others, sometimes originates independently of spinal disease. 724 DISEASES OF THE HEAD AND SPINE. Treatment.—In the treatment of disease of the spine, rest of the part is of the utmost importance : if the cervical vertebrae be affected, the head must be carefully supported with sand-bags or other mechanical contriv- ance, so as to prevent an\T 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 projec- tion, for such attempts are liable to do harm by interfering with the occurrence of anchy- losis ; if, however, the part were very pain- ful, it might be proper to give a cautious trial to continuous double extension, as re- commended by J. Wood. The horizontal position must be rigidly maintained for many months, until indeed the surgeon can satisfy himself that bony union of the diseased vertebras 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 cauteryT) 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 remedy of painting the tincture of iodine on either side of the affected vertebrae will be quite sufficient. If there be much pain, tenderness, and other evidence of in- flammation, there can be no better local remedy than dry cold applied by means of an ice-bag. Noble Smith recommends drill- ing into the spinous processes. 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 CFig. 424), as recommended by 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, better than the plaster-of-Paris, while Vance and Hawkes em- ploy a paper jacket, and Wattuck, Lorenze, and Phelps one made by glue- ing strips of wood and linen together over a plaster cast. Stillman and Wyeth employ a double plaster jacket, with extending bars secured to perforated zinc plates placed between the layers of plaster, and a some- Fig. 424.—Sayre's suspension appa- ratus for application of the plaster-of- Paris bandage. ANTERO-POSTERIOR CURVATURE OF THE SPINE. 725 what similar device is adopted by Whitehead. H. C. Wood suggests that the patient should be suspended daily by the plaster 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 suspension 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 apparatus 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 vertebrae be involved, a firm but well-fitting leather collar, so arranged as to fix the neck and support the head and chin, may be employed, or an occipito- mental swing, suspended from Sayre's "jury mast" (Fig. 425), attached to the plaster or leather jacket, or to the ordinary " spinal appa- ratus," as may be preferred. In some cases Steele 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 employs an India-rubber collar which can be inflated after adjustment. The treatment of spinal abscess is that of cold or chronic abscesses in general (see page 437). 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 prognosis will then probably be more favorable than if the collection had been evacuated in the first instance. Even if the opening of a psoas abscess appear inevitable, it is better in most instances to leave the case to nature, rapid sinking not unfrequently following 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 carbolic acid, or, finally, the surgeon may open applying the ordinary antiseptic dressings. S. W. the abscess had been evacuated, its walls should be supported with ad- hesive 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 escape of pus from the spinal canal by partial resection of a vertebra, but the case terminated 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 vertebrae, whether necrosis or caries, submitted to direct treatment as similar affections of other bones. Operations of this kind have been performed by many surgeons, including Bceckel, Byrd, Davy, Macewen, Andrews, Chipault, Barker, Murray, and myself. Podres records a successful operation for caries of the cervical spine. The anti- septic lumbar incision of spinal abscesses is likewise recommended by Konig, Chiene, and Chavasse ; but it is not free from risk, as 28 cases Fig. 425.—Sayre's " jury mast" for disease of the cervical ver- tebra. out with a solution of and drain the abscess, Gross advised that after 726 DISEASES OF THE EYE. collected by Lacharriere give five deaths. The passage of a drainage-tube through or around the vertebrae, is advised by Vincent. The paraplegia of spinal disease (which is due either to pressure or to 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 proved effective in the hands of Mitchell, Wood, Sinkler, and others. Trephining or resection (lamnectomy) has been employed, under these circumstances, by Macewen and other surgeons, but the results have not been very satisfactory. Of 75 cases collected byr S. Lloyd, including one of his own, only 20 ended in recovery, in 11 there was some improve- ment, no benefit in an equal number, and 30 ended in death, one of these, however, from causes unconnected with the operation. In three cases the result was not ascertained. The mortality in terminated cases was there- fore over 40 per cent. Lane advises that after the operation iodoform should be applied directly to the diseased vertebrae. Arthritis occasionally attacks the articulations of the vertebrae, and, in the case of the occipito-atloid and alto-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 vertebrae is occasionally seen in cases of syphilitic ulceration, or as the result of gunshot or other injuries; and cases in which recovery has followed the discharge of large sequestra, under these circumstances, have been recorded by Wade, Keate, Syme, Mercogliano, Morehouse, 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 ar- thritis, as described by R W. Smith, Von Studen, and Sturge, the latter of whom proposes for the affection the name of spondylitis deformans. Tumors of the Spinal Cord__Mr. Victor 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 second operation recorded by the same surgeon terminated fatally, as did others in the hands of Sonnenburg, Gerster, and Deaver. Pescarolo reports a successful operation, and the symptoms were relieved in Pr. White's case, though no tumor was found. Extra-dural tumors of the cord have been successfully removed by Abbe, Jones, and Ilehen, but in Abbe's second case the patient died on the uinth day. CHAPTER XXXVI. 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 DISEASES OF THE CONJUNCTIVA. 727 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 descrip- tion 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- 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. Symptoms.—A sensation as of dust in the eye, with heat, smarting, and stiffness of the lids. The conjunctiva is brilliantly injected, the redness being quite superficial, and, at first, greatest at the circumference of the globe. Slight photophobia, with increased lachrymation, followed by muco- purulent discharge, which, becoming dry, causes the lids to adhere. Treatment.—Astringent lotions of alum or sulphate of zinc, or antiseptic washes of corrosive sublimate (gr. T^ to f|j) or boracic acid, with fre- quent ablutions with cold water] and washing the eyes in castile soap-suds, and, in severe cases, the application once or twice daily to the everted lids of a solution of nitrate of silver (gr. j-ij to f 3j). The lids may be smeared at night with vaseline, to prevent their adhering together. The constitu- tional treatment consists in regulating the digestive functions, and in im- proving 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; atropia should be instilled if there is corneal ulceration, but not otherwise. 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 passages—the lachrymal conjunctivitis of Galezowski. In the milder forms of the affection, especially when caused by errors of refrac- tion, the term Hyperaemia of the Conjunctiva is more suitable than conjunctivitis. Treatment.—The cause must, if possible, be removed, by taking away any 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 antiseptic washes, together with the occasional application of the alumin- iited copper (lapis divinus), are the best local remedies. The nares should always be examined for catarrhal conditions. 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 L. Connor, Heyl, and many other surgeons, however, advise douches of hot water in inflammatory affections of the eyes. 723 DISEASES OF THE EYE. of the yellow oxide of mercury (gr. iv-viij to 3j), or in dropping into the eye, thrice daily, a weak solution of the bichloride of the same metal. 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 page 48(i.) Ophthalmia Neonatorum—This form of the disease sets in com- monly from 12 to 48 hours after inoculation, the third day after birth being the most usual date at which the discharge is first noticed; it involve- 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 re- corded by Magnus, it may arise in utero. The severer forms of the disease are probably caused by the presence 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 purulent 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 8000), 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) may 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 vaseline to prevent their sticking together. Cold compresses should always be employed during the earlier stages, but very hot compresses may be sub- stituted if corneal ulceration threatens. Other local applications which have been used are the permanganate of potassium, by Power; alum (gr. vto f§j) ; carbolic acid ^ per cent., and the solutions recommended on page 486. 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, instillations of atropia should be practised ; if peripheral, a solution of sulphate of eserine should be used, and hot compresses should be assiduously applied. As a prophylactic measure, Cred£ advises that the eyelids 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 dropped into the conjunctival cul-de-sac; while Olshausen recom- mends the application of carbolic acid, beginning his treatment even before the child has been completely born. Weeks advises a solution of bichloride of mercury, used in the same manner, and Schmidt-Rimpler employs the aqua chlorinata; but many obstetricians rest satisfied with absolute clean- liness during delivery. Credo's method has yielded the best results. DIPHTHERITIC CONJUNCTIVITIS. 729 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 eminently contagious, and often prevails as an epidemic, in barracks, prisons, and schools. It may originate sporadically 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 per- 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 Bidder's bandage (page 486), 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 deter- gent applications, as recom- mended for catarrhal oph- thalmia, will probably prove sufficient, but if the disease assume a severe type, no time should be lost in adopt- ing those measures which were fully detailed in speak- ing of Ophthalmic Gonor- rhoea. (See page 486.) In order to cleanse the upper cul-de-sac of the conjunctiva, Pr. J. A. Andrews employs an eye speculum, the arms of which are hollow, and the claws furnished with nu- merous perforations through which medicated fluids may be injected. The application of copaiba to the lower eye- lids, cheeks, and temples, is recommended by A. R, Hall. Diphtheritic Conjunc- tivitis, 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, lead- ing to the death of the invaded tissues and tending to destroy the nutrition of the cornea, is rarelv met with in this country, but a few cases have been observed in the Children's Hospital of this city, and the disease has been well described by Dr. De Schweinitz and by Dr. Sattler. The treat- ment consists, in the earlier stages, in the application of iced compresses or hot fomentations, with frequent syringing with antiseptic solutions, and the instillation of atropia. Tweedy recommends the local use of a solution of quinia. Fieuzel applies lemon-juice, which is washed away and Fig. 426.—Diphtheritic conjunctivitis. (From a patient under the care of Dr. De Schweinitz, in the Children's Hos- pital.) 730 DISEASES OF THE EVE. followed by a two-percent, solution of nitrate of silver; and Galezowski employs the oil of Cade (one part to ten). The constitutional measures suited to diphtheria are indicated. 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 boraeic-acid solution. Caustics are contra-indicated. 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 swelling of the lids and of the mucous membrane, which is studded with numerous promineut follicles or granules, and is characterized by great photophobia 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 de- velopment 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 endemic 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, granular state of the palpebral conjunctiva, keep- ing up a chronic, muco-purulent discharge, causing pain, inducing, by friction, a vascular and hazy condition of the cornea, and, after absorption, leaving cicatricial changes in the lids. The following varieties of chronic trachoma, which should not be con- founded with hypertrophy of the conjunc- tival papillae, are recognized by systematic writers: (a) Papillary trachoma, in which the trachoma bodies or follicles (" granulations'") are scanty and hidden by hypertrophied conjunctival papill*. (b) Follicular trachoma, in which the spawn-like granules or follicles are the chief characteristic, (c) Mixed or dif- fuse trachoma, in which the follicles or granules lie among inflamed papillae, but are not hidden by them, (d) Cfatririal trachoma, in which the granulations are in abeyance and the scar tissue prominent, the cornea usually being more or less opaque. Trachoma is probably due to a microbe, but the trachoma-coccus 1 Thus used, the word " granulation" refers to the characteristic feature of the dis- ease, and not to surface granulations which may form during its progress, iun prominences seen in trachoma are not "granulations" in the ordinary pathologica sense of the word, though Raehlmann disputes this view . Fig. 427.—Granular lids. (Jones.' GRANULAR LIDS. 731 of Sattler and Michel has not yet been undoubtedly isolated. Patholog- ically, the trachoma bodies are either new growths of special character, or are derived from the natural lymphatic follicles; the former view has the strongest evidence in its favor. The granulations, for the most part con- fined to the palpebral conjunctiva, especially in the retrotarsal folds, but also occasionally in the caruncle and plica, arise insidiously, and often epidemically, as grayish-white bodies, varying in size, and from fancied resemblances called "sago-grain," " frog spawn," and " vesicular" granu- lations; thev are transmissible hy contagion. Chronic granular lids re- sult frequently from over-crowding, or from a dyscrasia which predisposes to the disease, and appear especially among certain races—the Irish, the Jews, etc.—while negroes, according to S. M. Burnett, are practically ex- empt. The inhabitants of certain regions, where the climate is damp, are particularly liable to the affection, but an altitude of 1000 feet confers com- parative immunity. 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 conjunctival mucous membrane is yellowish-red, unevenly rough, and contains the granules, situated according to the type assumed by the dis- ease. The cornea becomes nebulous, uneven, and" extremely vascular {Trachomatous Pannus), and ulceration sometimes occurs. Pannuscom- mences 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 indepen- dent 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 treatment of acute granulations does not materially differ from that of acute conjunctivitis. The treatment of chronic trachoma includes (1) the application to the granulations of astringents and caustics of such strength as shall, as Von Graefe taught, bring about their absorp- tion by increased nutritive tissue-changes and not by destruction, and (2) certain operative procedures. The best local applications are: 1. Solutions of bichloride of mercury (1-500 and 1-300) applied with a cotton mop to the everted lids once a day, while the conjunctival sac is irrigated frequently with a 1-8000 lotion of the same drug: suited to the stage of follicular eruption unasso- ciated with much discharge (Romiee, Gruaita, Staderini, and Arnauts) ; 2. nitrate of silver (gr. x or xx to f|j) applied in the usual way, with due care to neutralize the excess.: most beneficial in the stage of softening of the granulations and hypertrophy of the papillae, associated with muco-puru- lent discharge; 3. blue-stone, or sulphate of copper in crystal, carefully applied to all portions of the affected areas: useful in any stage except when there is much purulent discharge; and 4. boro-glyceride (30 to 50 percent.) applied in the usual manner with a mop of cotton : generally beneficial, but especially valuable in the later stages when there is a ten- dency to xerosis. In addition to the remedies which have just been named, the following drugs may be mentioned : Liquid carbolic acid (Collins) ; liquor potassae (Dixon); beta-naphthol (Panas); hydrastin (2 to 5 per cent.); iodoform, or aristol, in powder or salve ; an ointment of the yellow oxide of mercury; calomel ; iodide of silver (Sedan). Quinine has been used in the form of a collyriurn by Nagel and Prout, and by Bader in the 732 DISEASES OF THE EYE. form of a powder; chromic acid has a few advocates, but is a dangerous drug; boric acid in powder may be used with massage movements. In mild cases, or after an impression has been made with stronger caustics, a favorite astringent is tannin with glycerin (30 to 60 grains to the ounce), originally introduced by Eble in 1829. If chronic granular lids assume acute symptoms, the treatment is that applicable to a severe conjunctivitis. Pannus and ulceration of the cornea often disappear with the subsidence of the granulations. If they do not, frequent cleansing with tepid boric-acid lotion, leeches to the temple, atropine to keep the pupil dilated, and sometimes eserine, are indicated— the last only if there is no tendency to hyperaemia of the iris. Inveterate pannus without ulceration of the cornea, on the recommendation of De Wecker, is sometimes treated by producing a violent conjunctivitis of the membranous type with a 3 per cent, infusion of jequirity painted on the everted lids. It is safe only in stubborn cases with much impaired vision, although a few surgeons still advocate its virtues without these limita- tions. The method was introduced by De Wecker to substitute the old- fashioned inoculation of the conjunctiva with blennorrhagic pus, a pro- cedure justifiable under no circumstances. The operative measures employed in the treatment of granular lids which yield by far the best results are the following: 1. Excision of the retrotarsal folds, first systematically practised by Galezowki in 1874; in his opinion applicable to all cases where the trachoma granules are present in the folds of the fornix conjunctivae. 2. Removal of the trachoma gran- ules by expression, that is, exposure of the affected areas and squeezing out the follicles, either between the thumb-nails, as originally suggested by Hotz, or with specially devised forceps, as, for example, the fenestrated forceps of Prince, the concave forceps of Noyes, the roller forceps of Knapp, or the spoon-shaped forceps of Gruening. Knapp's forceps, working on the principle of a mangle, is the best instrument. The mode of applica- tion is as follows: The patient is etherized, the upper lid everted and held with fixation forceps, the infiltrated area is then scarified and one blade of the forceps pushed between the ocular and palpebral conjunctiva, and the other applied to the everted surface of the tarsus. The forceps is com- pressed with more or less force, drawn forward, and the infiltrated sub- stance squeezed out as the cylinders roll over the surfaces of the fold held between them. This manoeuvre is repeated until all the granules have been pressed out of the tissues. The best results are obtained by this method in follicular trachoma. 3. The destruction of the tissues by the use of elec- trolysis ; this is best done with the special apparatus devised by Lindsay Johnson. 4. Removal of the affected tissue by brushing it with a stiff bristle. brush. An ordinary tooth-brush in which the bristles have been cut down is used, and the trachoma masses are brushed out by rubbing it briskly over their surface. This method has been especially advocated by Manelescu, of Bucharest, and is sometimes called " brossage." 5. Destruction of the trachoma granulations by the use of the galvanic cautery. By this method each follicle is destroyed with the point of an electrode ; not of much use unless the granulations are discrete. 6. Removal of the granulations by means of scarification and rubbing with a brush, and the introduction of a strong germicide. This operation, known as " grattage," has been especially developed by Darier in Abadie's Clinique in Paris, and is par- ticularly urged in this country by Weeks, of New York. The operation is briefly as follows: The patient is etherized. If the palpebral fissure is narrow, a canthotomy is performed, the fornix conjunctivae is fully exposed and thoroughly scarified, and the exposed surface is scrubbed with a tooth- TUBERCULOUS ULCERATION OF THE CONJUNCTIVA. 733 brush which carries a solution of the bichloride of mercury, 1-500. The lids are freed from clot and the eyes bandaged antiseptically. In twenty- four hours the conjunctival surface is exposed and rubbed with a pledget of cotton dipped in a sublimate lotion, and this application is repeated daily for a couple of weeks. Of these various measures, expression, preceded by scarification, is the best, but in certain types of diffuse trachoma the method of grattage may be necessary. Syndectomy or peritomy, which is an operation consisting of the excision of a very narrow band of con- junctiva and sub-conjunctival tissue from around the cornea, may be prac- tised in cases of pannus which persist after the relief of granular lids. Canthotomy, or slitting up the outer canthus and stitching together the skin and mucous membrane above and below, so as to prevent readhesion, at one time much performed for the relief of granular lids, is applicable to cases where there is narrowing of the palpebral fissure, especially as a pre- liminary to the measures which have been recommended for the destruction of the granulations.1 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 hvpersemia, 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 disappear, the mucous membrane is as healthy as before the attack. Many writers, like Nettleship, 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 conjuncti- vitis from genuine trachoma. Atropine and Cocaine Conjunctivitis—The long-continued use of atropia sometimes produces a form of conjunctivitis (atropine conjuncti- vitis) which manifests itself as a hyperaemia 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. Kroemer 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 appearance 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 appears in the conjunctiva. The prognosis, as far as sight is concerned, is favorable, but the disease tends to return stubbornly year after year. In its treat- ment, the flattened granulations should be painted with strong sublimate lotions, or with boro-glyceride, and in severe cases destroyed by electrolysis ; internally, arsenic is indicated. Tuberculous Ulceration of the Conjunctiva, the cornea being unaffected, is a rare affection described by Sattler as occurring in the later Those interested in the various operations and procedures which have been ad- vised in the treatment of granular lids, may with profit consult Professor Sattler's monograph, " Die Trachome Behandlung, einst uud jetzt." Berlin, 1891. 734 DISEASES OF THE EYE. 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 galvanic 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-point being frequently from the plica semilunaris or caruncle. The amyloid tumors, according to Raehlmann, are inde- pendent 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 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, staphylomatous. 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, the growth almost invariably occupying 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. A rlt's theory, which regarded ulceration of the cornea as the primary cause of pterygium, has sometimes been called in question, and Fuchs thinks that a Pinguecula is the first stage in the development of the affection. The inciting causes usually given are the effects of dust, smoke, and heat. Bacteria have been invoked by Poncet, Lopez, and others, to explain the origin of pterygium. The treatment consists in excision, which is performed by seizing the pterygium with toothed forceps, raising if from the surface of the eye, and shaving it off from its corneal attach- ment, then turning it backwards and carefully dissecting it from its base; Fig. 428.—Fterygium. (Stellwag von c arion.) DISEASES OF THE CORNEA. 735 the growth is apt to recur, to prevent which the seat of attachment may be touched every two or three days with a crystal of blue-stone. Another operation, called transplantation, consists in dividing the corneal attach- ment, turning the pterygium back, and fixing its free extremity in an in- cision in the lower part 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. 428. 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 re- sults by tearing loose the pterygium with a strabismus-hook (evulsion). The gap after excision of a pterygium ma\r be supplied, as Hotz has sug- gested, by skin-grafting after Thiersch's method. Pinguecula is a small, yellowish elevation in the conjunctiva, usually situated near the margin of the cornea, and caused by a f - -"-----~i hyaline degeneration of the connective and elastic tissue. It requires no treatment, but, if it becomes disfiguring, may be excised, especially on ac- count of its possible relation to pterygium. 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 pointed stick of nitrate of silver. Sarcomata, (Pig. 429), 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, Fig. 429.—Sarcoma of the conjunctiva. (From a patient under the care of Dr. De Schweinitz.) 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, scrofula, or inherited or acquired syphilis, often secondary to conjunctival inflammation, occasionally an indication of disease of the deeper structures of the eye, but sometimes arising from no obvious cause. Both eyes 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 region (see page 745), with haziness of the cornea, dimness of vision, photophobia, lachrymation, pain, and a sensation of dust in the eye, with (in the stage of repair of certain forms) a red appearance of the cornea, due to its increased vascularity, the resulting condition of Pannus sometimes involving almost the whole cornea. In favorable cases this increased vascularity gradually fades away, and the 73G DISEASES OF THE EYE. Fig. 430.—Pannus. (Jones.) part resumes its normal appear- ance, but in other cases corneal ulcers are developed 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, atten- tion to the digestive functions, with the administration of tonics, such as iron and quinia, and of opium or belladonna, if there be much pain and photophobia, to- gether 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, par- ticularly belladonna or atropia, and in selected cases eserine, with counter-irritation, and in adults leeches to the temples, the eyes being protected from light by a shade or dark- colored glasses. Chronic Interstitial Keratitis, as was originally pointed out by Hutchinson, is a frequent manifestation of hereditary syphilis (see page 511). The proportion of cases in which syphilis has been demonstrated 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 appearance. 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, the " salmon patch" of Hutchinson, the " vascular keratitis" of some writers. Ciliary pain, iritis, and even secondary glaucoma, are not infrequent accompaniments. 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 appear un- favorable 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 tibiae, and chronic tumefaction of the post-cervical and epitrochlear 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, cer- tainly 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 chloride of iron, together with the bichlo- ride of mercury, are also necessary. Locally, atropia should be instilled, and, if iritis develop, leeches should be applied to the temple. If struma be present, cod-liver oil aud the phosphates are indicated; and if malaria be in any way suspected, as Sedan, of Toulon, has recommended, quinine and arsenic should be exhibited. In stubborn cases, good results have been reported from sub-conjunctival injections of corrosive sublimate. When SUPPURATIVE KERATITIS. 737 all irritation has subsided, absorption of the remaining opacity may be hastened by the local use of a salve of the yellow oxide of mercury, after the manner of Pagenstechen Phlyctenular Keratitis is an affection which is also known as Phlyctenular or Scrofulous Ophthalmia, and is sometimes inaccurately called Herpes Corneee; it frequently accompanies phlyctenular conjunc- tivitis (p. 727). This disease, which occurs in quite young children, is attended with intense photophobia and spasm of the orbicularis palpebra- rum (blepharospasm), which may render the induction of general anaes- thesia 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 heal- ing ulcers. When the phlyctenulae are arranged around the border of the cornea, the disease is named Marginal Keratitis; when, as sometimes happens, 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 alimentary tract, and, as Augagneur has pointed out, may be dependent upon the pres- ence of rhinitis. The treatment is essentially that of keratitis 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 insuffla- tion when the disease has become chronic. Provided that the patient is not taking iodide of potassium, the yellow oxide of mercury ointment (gr. j—3.1) is indicated in the later stages. The accompanying rhinitis must always be treated. The affection is apt to recur, and frequently produces permanent opacity or even perforation of the cornea. For the accompanying blepha- rospasm, 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 Hypo- pyon. 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 treat- ment consists in the use of tonics and anodynes, with good food and stim- ulants if necessary. Locally, atropia should be freely used, with a com- pressing 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 intraocular tension, and to evacuate the pus if hypopyon be present. If the abscess be central, an iridectomy may be performed opposite a clear portion of the cornea, 47 738 DISEASES OF THE EYE. Fig. 431.—Paracentesis cornea?. (Erichsen.) Paracentesis Corneae is performed by puncturing the cornea near its lower margin with a broad needle held flatwise, the point being kept well forward, so as to avoid wound- ing the lens; by rotating tin- needle slightly on its long axis, the opening is rendered patu- lous, allowing the slow escape of the aqueous humor and of any pus that may be present, The operation is completed bv restoring the needle to its original position, and slowlv withdrawing it. This little operation is usually facilitated by separating the lids with a stop-speculum, and steadying the eye with suitable fixation- forceps. General 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 primarily, as the result of depraved health and malnutrition. Hutchinson believes that they may be caused by gout. Several varieties of corneal ulcer are de- scribed by systematic writers, as the superficial and deep, the trans- parent 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, Infecting 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 perforation, previous to the occurrence of which, the membrane of Descemet, with, according to Stellwag, the posterior layer of the cornea, may bulge forwards through the site of the ulcer, forming a transparent vesicle which is called Keratocele or Hernia of the Cornea. During the stage of repair, in any case of corneal ulcer, enlarged vessels may be seen running from the margin to the ulcerated surface; should these vessels remain permanently after cicatrization, the condition usually known as chronic vascular ulcer results. Treatment.—The treatment of ulcers of the cornea usually requires the administration of tonics and good food, with attention to the 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, plain or medicated with belladonna ov 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, Grandcle'ment, Post, Ryerson, and other surgeons. HayTer recommends the employment of iodoform. In chronic cases, and after acute symptoms have subsided, stimulating appli- cations are proper, especially a salve of the yellow oxide of mercury. In sloughing ulcers the following measures are useful: Scraping the floor of the ulcer with a small curette and subsequently dusting in iodoform, the careful application to the ulcer of a 10 or 20 grain solution of nitrate of silver—an old mode of treatment strongly advocated by Brudenell Carter OPACITIES OF THE CORNEA. 739 and by Callan—and, finally, the application of the actual cautery. Syn- dectomy (see page 733) has been occasionally employed with advantage in the treatment of the crescentic ulcer, which is a very intractable form of the affection. Paracentesis corneae is often of use in cases of sloughing ulcer and hypopyon. This operation should be performed (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 cata- ract 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, and since strongly recommended by Neiden, Schweigger, Snell, Knapp, Gruening, and De Henne. 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 open air. The com- pressing bandage is desirable in any form of corneal ulceration in which perforation is threatened, provided that there be an absence of dacryocys- titis 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. Asa last resort Law- son recommends paring the edges of the fistula, and bringing them together with a fine silk suture. Opacities of the Cornea___Nebula is the slightest form of opacity, consisting of a mere filmy cloudiness which may be superficial or intersti- 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. Temporary opacity of the cornea may follow the use of cocaine as a local anaesthetic to the eye, and Jackson 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 inhala- tions 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, iodide of potassium, sulphate of sodium, or common, salt. A weak oint- ment of the red or yellow oxide of mercury is most frequently employed, particularly in the form of Pagenstecher's ointment, that surgeon having been the first to specially recommend this means of treating corneal opaci- ties. With this ointment as an adjuvant, or, according to some, with sim- ple vaseline, massage of the cornea is the most efficient means which we 740 DISEASES OF THE EYE. possess of clearing up its opacities. This method of treatment, since Pagenstecher's original recommendation, has been specially insisted upon by Snell and by Pfalz. It has been successfully carried out by De Schweinitz at the Philadelphia Hospital. The electrolytic treatment of corneal opacities was first advocated by Crussel in 1841, and has recently been revived, especially by Alleman. Leucoma, which is usually incura- ble, may require the formation of an artificial pupil opposite a clear portion of the cornea, Opacity resulting from the injudicious application of prepa- rations 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 opera- tion, the abraded surface should be protected by applying a drop of olive or castor oil, and by the use of cold water-dressing. The same treatment may be required if calcareous degeneration occur in an ordinary leucoma. In order to obviate the deformity caused by opacities of the cornea, Wecker, C. B. Taylor, Levis, and others recommend that the opaque spots should be tinted with various coloring-matters, as in the familiar operation of tattooing. Power, Gradenigo, Schoeler, and more recently Von Hippel, in Germany, and Webster Fox, Chisolm, and Strawbridge, who have repeated his operation in this country, go further, and, having removed the opaque portion, transplant a segment of a rabbit's or dopV cornea to supply the deficiency. These operations have occasionally been followed by irido-cyclitis, and should not be resorted to, therefore, without due caution. 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 ophthalmia. A few cases, however, are seen, perhaps of a syphilitic nature, and appearing in young subjects, in which the corneal dots form the principal lesion. Neuro-paralytic Keratitis is an ulceration of the cornea, which is seen in cases of paralysis 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. 42 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 Von Graefe as occurring in children who were subjects of encephalitis, but, according to Weeks, is seen in ill-nourished subjects independently of this disorder. Alanyr attempts have been made by Leber, Fraenkel, and Franke to culti- vate the bacillus which has been supposed to be its cause. A somewhat similar disease, according to Kollock, is common in the eyes of negro chil- dren in the South. Transverse Calcareous Film of the Cornea (Riband- like Keratitis, the keratite en bandelette of French writers, keratiti» trophica of Magnus) appears 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 people, or in those of subjects of increased intraocular pressure from irido-cyclitis or glaucoma. It may be mistaken for the opacity which occurs from the injudicious application of lead. Keratitis Bullosa is char- acterized by the formation upon 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 inflamma- tion of the uveal tract. Tangeman has observed periodicity in this affec- tion, and, suspecting malaria, has administered quinine with good result1- STAPHYLOMA. 741 Conical Cornea.—The cornea retains its transparency, but assumes a conical form, the apex of the projection 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 o-eneral 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 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 have achieved excellent results by the correction 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 kerato- eonus by the prolonged use of eserine and the application of a pressure bandage. In advanced cases, an operation is required, having for its object the substitution for the tissue at the apex of the cone of a contract- ing cicatrix, which shall diminish the excessive curvature. The plan sug- gested by Von Graefe is the formation of an ulcer on the apex of the protru- sion, by cutting off a small superficial flap and subsequently cauterizing the surface. The contraction which accompanies 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. Bowman's method consisted in cutting, with a trephine, a small disk from the apex of the cornea. Multiple punc- tures 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 galvanic 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, or a sclerotomy, which is prefer- able, 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 place, 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, andstaphyloma 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 Posterior Staphyloma is a projection of the posterior half of the eye. met with in severe cases of myopia. 742 DISEASES OF THE EYE. Fig 432.—Prolapse of the iris. (Miller.) weakened sclerotic (through which the dark hue of the ciliary body is per- ceptible), 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 he prevented. If the threatened perforation be central, the pupil should be dilated with atropia so as to keep the iris out of the way, while, on the other hand, if the ulcer be mar- ginal, eserine should be used to contract the pupil. The alternate use of these substances mav also prove useful in breaking up an anterior synechia. If prolapse of the iris have actually occurred, an attempt may be made to replace the protrusion with a delicate probe, aided by the instillation of atropia. If this fail, the pro- lapsed iris should be punctured, so as to let it col- lapse, a compressed bandage being then applied; or the prolapsed or staphylomatous iris may he punc- tured, and then excised close to the cornea with curved scissors, a compressing bandage being used as before. Finally, if the prolapse or staphyloma be extensive, a large iridectomy may be performed in an opposite direction, this operation diminishing the 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. 2. Complete Staphyloma of the Cornea signifies a staphyloma- 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 up the lens, and a curette to favor the evacuation of any part that is diffluent. Fully formed, complete staphyloma may be treated by abscission, or by enucleation, evisceration, or Mules's operation. Abscission may be performed by either Beer's, Critchett's, or De Week- er's method. The first consists in transfixing the staphyloma with a Beer's knife (Fig. 433), at the junction of the upper and middle thirds, and cutting down- wards. The remaining bridge of tissues is then divided with scissors, and the broad wound left to heal by granulation. Critchett's method consists in passing four or five curved needles, armed with silk, acros.- the base of the staphyloma, and then removing an elliptical seg- ment with probe-pointed scissor- introduced through a puncture made with a Beer's knife. The operation is completed by care- fully tying the sutures, when a linear wound results (Fig. 434). De Wecker's method consists in separating the conjunctiva all around the margin of the cornea, and then loosening it nearly to the equator oi Fig. 433.—Abscission of staphyloma. Carion.) (Stellwag von DISEASES OF THE SCLERA AND CILIARY BODY. 743 the ball. Four sutures of different colors are next passed through the conjunctiva, 3 millimetres from the margin of the wound. The staphyloma is then abscised, care being taken that the lens escapes. The sutures in the conjunctiva are tightened, and the conjunctiva is drawn over the wound. A subsequent tatooing of the conjunctival scar may obviate the necessity for an artificial eye. Fig. 434.—Critchett's operation for staphyloma. (Lawson.) Enucleation or Evisceration (the latter being preferable) is the proper method of treating complete staphyloma in most instances ; indeed, the foregoing methods are applicable only if the tension of the eye is normal or subnormal. These operations, together with Mules's modification, will be described on a later page. 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, enucleation 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 inflamma- tion 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 episcleritis, 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 importance 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 subduing the irritation by the use of atropia, and then employing collyriaof boracic acid. Power recommends the internal administration of a combination of 744 DISEASES OF THE EYE. aconite, eolchicum, and camphor, while De Wecker employs iodide of potassium and hypodermic injections of pilocarpine. Darier has recently strongly recommended colchicin in doses of gr. ^ to ^ Seely advocates the local use of eserine. Bull has employed with advantage the actual cautery. Massage, after the manner of Pagenstecher, has proved very bene- ficial. The rheumatic, strumous, or syphilitic taint, if present, must he com- bated with suitable remedies, and menstrual disorders should be corrected. Tumors of the Sclerotic—The following varieties have been re- ported: Fibroma, enchondroma (Knapp and Chisolm), sarcoma, osteoma. Small, primary, non-malignant growths may be dissected from their bed and the wound closed with sutures. Cyclitis (Inflammation of the Ciliary Body) is divided by systematic writers into three varieties—the plastic, serous, and suppurative—the latter being the graver form of the affection. Symptoms.—There are pain and tenderness in the ciliary region, with photophobia and lachry mation, impairment of vision, increased intraocular tension, sub-conjunctival injection (constituting a distinct pink zone around the cornea), cloudiness of the vitreous, dilatation of the veins of the iris, inactivity or distortion of the pupil (from coincident iritis), with, perhaps, turbidity of the aqueous humor, and, in the worst cases, hypopyon. Cyclitis may appear as a primary affection, without relation to any morbid diathesis, and is commonly the result of injury; its plastic and purulent forms may follow cataract extraction. Syphilitic inflammation may give rise to cyclitis, and Hutchinson has described the disorder as resulting from gout in a previous 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 production of sympathetic ophthalmitis 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 stim- ulants if necessary. Quinia may usually be given with advantage, and in all syphilitic cases it is proper to administer mercury, either by inunction, or internally in combination with opium. Iodide of potassium is usually indicated. Frequent instillations of atropia should be practised through- out 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 beneficial at an early stage of the serous type 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 implication. Diseases of the Iris. Iritis, or Inflammation of the Iris, may be a primary or a secondary affection. Primary iritis maybe due to some systemic disease, such as syphilis, gonorrhoea, diabetes, gout, or rheumatism, or may result from exposure to cold, from injuries, etc. When secondarily 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 cornea, choroid,1 etc. Different classi- 1 Hence some systematic writers describe choroido-iritis separately from irido- choroiditis. DISEASES OF THE IRIS. 715 fications of iritis are adopted by authors, the best being into Plastic, Serous, and Parenchymatous Iritis. Symptoms.—The following symptoms are common to all forms of iritis : (1) Marked sub-conjunctival injection, giving rise to the characteristic ciliary zone, which is easily recognized by its pink color, its deep sub-con- junctival character, aud the radiating course of the enlarged vessels. It is often accompanied by general suffusion of the conjunctiva, and sometimes bv 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 complete, the pupil is not at all dilatable, and soon becomes occluded by in- flammatory lymph. In .serous iritis, how- FlG. 435-iritis: showing sub-con- ever, the pupil is often abnormally dilated. junctival injection forming the cili- (3) The iris loses its natural lustre, and be- aryzone. (Pirrie.) comes discolored ; its striated appearance is obscured, owing to inflammatory swelling; its vessels may become en- larged and varicose ; while beads of lymph may perhaps be detected upon its surface. The change of color is even greater apparently than in reality, owing to the state of the aqueous humor, which is often turbid from the admixture of flocculent lymph or pus. This may accumulate in such quantities as to form a hypopyon. (4) Vision is impaired, partly by the diminished 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. 744). (5) Pain is usually a prominent symptom of iritis, though in some cases, particularly of the syphilitic form of the affection, it is less marked than in others. 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, assum- ing a neuralgic character, and being worst at night. Tenderness in the ciliary region indicates the presence of cyclitis. (6) Photophobia and lachrymation are not usually very intense—much less so, indeed, than in many cases of keratitis. Plastic iritis when it presents the symptoms above described in a mild form is called simple or idiopathic iritis. Parenchymatous iritis usually appears in a severe form, and when suppuration occurs, leading some- times to perforation of the cornea and permanent loss of sight, is called purulent iritis. Serous iritis, or, as Priestley Smith prefers to call it, serous cyclitis, is especially characterized by the absence of lymphy de- posits, and by an increase in the amount of aqueous humor, leading to augmented intraocular tension and consequent dilatation of the pupil. Serous iritis often accompanies choroiditis and retinitis, and is the form sometimes assumed by Sympathetic Ophthalmitis; it is also seen in con- nection with hereditary syphilis (see page ft 11). Rheumatic iritis be- longs to the plastic variety, which type is often associated with sclero- titis in cases of gonorrhoeal rheumatism (page 488). Gonorrhoeal iritis is a rare affection, and does not coincide with nor immediately follow the gonorrhoeal attack; an arthritis of the knee, or sometimes of the ankle, always intervenes. True syphilitic iritis belongs to the parenchymatous 746 DISEASES OF THE EVE. variety of the affection, being an accompaniment of secondary syphilis is characterized by a deposit of yellowish-red nodules on the ciliary or pupillary margin of the iris, comparable to papules or condylomata, and hence is called iritis papulosa. On the other hand, at this stage (from the second to ninth month after primary infection) an ordinary iritis may develop, presenting no clinical characteristics essentially differing from those of simple plastic iritis, yet due to the syphilitic taint and yielding to anti-syphilitic remedies. Finally, in the late or tertiary stages of syphilis, iritis, unassociated with nodules, may appear as the result of a relapse of a plastic iritis in an early stage, owing to a failure in the ab- sorption of the original synechias; or, exceptionally, large yellowish nodules may develop on the ciliary border of the iris, strictly analogous to gummata, when the affection becomes a true gummatous iritis. Schmidt- Rimpler describes, under the name of spongy or fibrinous iritis, a form of the disease 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 parents are liable to a destructive form of iritis associated with disease of the vitreous. Iritis may also be caused by scrofula, diabetes, and acute infectious diseases. Any form of iritis may be met with as a recurrent affection, particularly in persons affected with rheumatism or gout, the tendency to relapse 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 plastic 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 f3j), 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 adhesions 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. Hypodermic injections of morphia may be administered to relieve pain, and the same remedy may bo em- ployed as an antidote in the rare event of a poisonous effect being produced by the passage of atropia through the lachrymal puncta into the throat. Leeches to the temple are often serviceable in relieving the intense ciliary neuralgia, and are also of use in lessening 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 particularly indicated if the aqueous humor be cloudy, or if hypopyon be present. 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 potas- sium, either alone or in conjunction with corrosive sublimate. It may be given internally, in combination with opium, or may be employed bv inunction. Iodide of potassium, oil of turpentine, and eolchicum and COLOBOMA OF THE IRIS. 747 salicylate of sodium are particularly useful in cases of gouty and rheu- matic iritis. Copaiba is recommended by Macnamara, Hall, and other Indian surgeons. Diaphoresis with pilocarpine often affords relief. Finally, iridectomy may be required, if there be extensive and firm adhesions between the iris and capsule of the lens, or if, as in some cases of serous iritis, there be a marked increase of intraocular tension. In recurrent 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 pre- sent 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 primary affection; and excision of the growth alone, by an operation analogous to that of iridectomy, has been successfully practised by Kipp and 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's case ; gummata, already referred to ; and, rarely, naevi, leprosy nodules, and lipomata (Meyer). 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 accom- modation. The accompanying impairment of vision, if due to mydriasis alone, may be relieved by the use of a diaphragm with a pin-hole perfora- tion; while the paralysis of accommodation will often yield to the appli- cation of a blister behind the ear and the administration of iodide of potassium. In chronic cases, a weak solution of eserine 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 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 pass like cords across the pupil, and may be mistaken for the synechias 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. 748 DISEASES OF THE EYE. 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) or as a preliminary to extraction of cataract, the section should, as a rule* be made upwards; though, as the outward section is an easier procedure' this may be sometimes preferred by an inexperienced operator. The ad- vantage of an upward iridectomy is that the lid subsequently covers the seat of operation, thus cutting off the irregularly refracted peripheral ravs of light, and at the same time partially hiding the resulting deformity. If, on the other hand, an iridectomy is to be performed as a means of making an artificial pupil, a small inward section is preferable—the visual line cutting the cornea on the inner side of its central point—though, in cases of corneal opacity, the surgeon may be forced to make his section at ap- point opposite to which the cornea may happen to be clear. Iridectomy is thus performed : The patient being in the recumbent posi- tion, and under the influence either of a general anaesthetic or of the instil- lation of cocaine, the surgeon separates the lids by means of a Liebreich's, Xoyes's, or ordinary spring-stop speculum (Fig. 434"), and, standing be- hind the patient's head, fixes the eye by seizing with firm catch-forceps the conjunctiva and subjacent fascia, at a point directly opposite to that of the proposed section. A lance-shaped keratome or iridectomy knife (Fiwn into a fluid vitreous—the lens must be instantly extracted with a suitable spoon or hook, and a compressing bandage applied ; (4) prolapse of the iris mav occur—to be remedied by gently repressing the protruding portion with "a fine probe, or by pressing with the edge of the lid on the cornea; if this fail, the prolapsed portion should be seized with forceps and excised; (5) portions of the cortical matter of the lens may be detached during its exit—these should, if possible, be removed in the manner already described, or by irrigation, after the manner of McKeown. If, from its transparency, the cortical matter at first escape observation, subsequently swelling and producing irritation, atropia must be freely used; it may even be necessary to make a small corneal incision, facilitating the escape of the remaining lens substance byr means of the curette or suction apparatus (see page 757). The escape of a considerable quantity (more than one-third) of the vitreous humor is usually followed by loss of the eye, and an equally bad result attends deep intraocular hemorrhage, which may occur during the operation, or some hours subsequently. Failure after 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 con- ducted 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, aud the compressing bandage, if suppuration occur. Collins and Nettleship advise the applica- tion of the galvanic cautery along the line of infiltration, and frequent bathing with warm antiseptic solutions, the eyTe remaining uubandaged. The chief danger is from prolapse of the iris. If this be detected a few hours after its occurrence, the prolapse should be cut off; if only after two or three days, it should be let alone until the eye is white and quiet. Historically, the flap operation is the earliest. It was superseded by the peripheral linear method and its various modifications, with iridectomy. Within the last few years, however, a disposition has arisen to return to the flap or simple operation just described, which is now strongly advocated by Knapp and Bull, of New York; by Panas, Abadie, Galezowski, and many other French surgeons; by Schvveigger, in Germany; and by Powers and others in England. Strict antisepsis, with the use of cocaine, has greatly aided a return to this method of operating. Linear Extraction__In this operation (which originated with Von Graefe and has been modified by Waldau, Critchett, and others), anaes- thesia, 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 upper 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, PERIPHERAL LINEAR EXTRACTION. 755 cautiously introducing delicate iris forceps, makes a broad iridectomy as directed at page 748; or the iridectomy may be omitted (simple linear extraction). The capsule of the lens is next freely lacerated with the cystotome, and the lens itself drawn out with a silver spoon (Fig. 443), provided with a barbed or recurrent edge, which allows it to slip easily between the lens and the posterior cap- sule, 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. Fia ^-t™"™ sP°°as- 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 yet 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 .„^„-, a^^^k border of the cornea, and opens the •^^BH^^^^^^^^^^^SaTGEMRIC/ extreme periphery of the anterior fig. 444.—von Graefe's cataract knife. chamber with a narrow knife repre- sented at Fig. 444 in its actual size, by an incision A B (10 millimetres, 4^-4| lines long) through the sclerotic, at the point A (Fig. 445), 1 milli- metre 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 1 or 8 millimetres into the anterior chamber, its handle is depressed, counter-puncturation at B effected, the knife edge directed obliquely for- wards, and the section completed by a gentle 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 corresponding with the entire length of the wound being excised, as in the original Yon Graefe operation, or a smaller segment being removed. The instrument employed for catching the iris is the ordinary iris-forceps, or, which Meyer and Weber prefer, a blunt hook. Capsulot- omy is next performed in the manner already described. 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, his own modification of Mathieu's forceps being preferred by Knapp.2 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 . The incision is usually said to be linear (whence the name of the operation), but tins 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 °^frmti?n: The cur^e in Graefe's incision is that of the eye itself. This instrument has been still further improved by Eugene Smith, of Detroit. 756 DISEASES OF THE EYE. 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 spoon is given a slight turn (so that its upper border buries itself a little in the outer surface of the cornea) at the same time that it is moved a little upwards, in consequence of which the Fig. 445.—Diagram of von Graefe's equator of the lens presents itself at the operation for cataract.. (Laurence.) wound. 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 spoon, 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'754. 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 preferred) a blunt hook (Fig. 44G). The after-treatment in this and in the traction Fig. 446.—Von Graefe's hook. 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 accom- modation 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 continuously7 until all signs of inflammation have passed 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 hj the peripheral position of the wound ; and the risk of cyclitis and consequent sympathetic danger to the other eye. For these reasons the peripheral linear incision has been abandoned 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 (corneal 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- 1 McKeown 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. SUCTION OPERATION FOR CATARACT. 757 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 opera- tion are conducted as in Graefe's method. Swanzy recommends that a so- lution 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 be- hind 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 ordinarilv to be preferred for the removal of soft cataracts. If thought proper, anaesthesia may be employed, but it is not usually re- quired. 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 -_ --- lCfl^"^ lens, and not to lacerate the capsule too freely in ^eh^^d the first operation, lest the lens substance, swell- FlG" 447-Bo"man's stop" 1166(116 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- Fig. 448.—Hays's knife-needle. located, \t 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." It 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 H harton Jones practises an operation, under the name of discission from behind in which the needle is introduced through the sclerotic, behind the ins^ and made to lacerate the posterior wall of the capsule. Suction Method—This operation, which was introduced by Teale, is specially adapted to cases of fluid cataract, such as are frequently met with in diabetic patients. Mr. Teale used a " suction curette," consisting of a curette roofed in to within a line of its extremity, with a handle and a piece or. India-rubber tubing furnished with a mouth-piece. The anterior upsule of the lens being lacerated with two needles, the curette is intro- auced through a small corneal wound into the area of the pupil, and the num lens matter sucked out by the application of the operator's mouth. -hi. liowman has devised a "suction syringe," which is in some respects ori cSLT^I0,", is -thuS essentlall>' converted into the true " linear extraction" which originated in 1811 with Gibson, of Manchester. 758 DISEASES OF THE EYE. 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 remain- ing capsule, containing, perhaps, some portions of lenticular matter in- closed within its layers; the obstruction may be aggravated by the pres- ence of nodules of inflammatory lymph. Xo operation should be prac- tised 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 ; Knapp, however, who opens the capsule peripherally, performs an early secondary discission with a knife-needle, and looks upon it as the final act of the operation of extraction. The safest mode of treating secondary or capsular opacities is to tear through the occlud- ing membrane with a Hays's needle, introduced through the cornea. If the capsule be very dense and resisting, two needles, introduced at opposite sides of the cornea, may be used, as advised by Bowman—one serving to fix the membrane while laceration is effected with the other. Other plans are to divide the capsule with delicate " canula-scissors" (Fig. 449), to tear it with toothed forceps, as practised 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 Fig. 449.—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 freelv 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 prefers the excision of a piece of capsule and iris to all other methods. After these, as after other cata- ract operations, the pupils should be kept for some time well dilated with atropia. All operations for after-cataract are attended with danger of iritis, irido-cyclitis, and secondary glaucoma : hence, great care should be taken to avoid traction on the membrane and deep entrance of the needle into the vitreous. 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. These terms are ordinarily applied to all cases of partial or total blindnc- 1 Etymologically, the words are synonymous, bath signifying, literally, dimness of vision. THE OPHTHALMOSCOPE. 759 which are dependent neither on external obstructions (such as cataract or opaque cornea) nor upon optical defects of the eye, but are limited by Von Graefe and many other modern ophthalmologists to cases of lost or impaired vision which are caused by primary atrophy of the optic nerve, or by such irregularity 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 deeper 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 lamp is reflected into the patient's eye, and thence back to that of the surgeon, who looks through the central perforation. Liebreich's portable ophthalmoscope, which is 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 Fig. 450.—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. 450), 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 special cases. 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 homatropine. 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 760 DISEASES OF THE EYE. little manoeuvring, to catch the rays from the lamp and reflect them directly into the patient's eye, the pupillary space of which now appears of a red- dish-yellow color. 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 eve which he is observing, fixing it in that position by resting his fingers on the patient's forehead. By now moving his own head a little backwards or forwards, the 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 everv part is inverted. In the direct method of examination, as shown in Fig. 451, 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 Fig. 451.—Use of the ophthalmoscope. (After Loring.) 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 is within 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, ap- pears as a pinkish, white, or gray disk, often containing in its centre a CHANGES IN THE VITREOUS HUMOR. 761 depression called the physiological cup, and 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 pul- sation of the retinal arteries, on the other hand, is an evidence of increased intraocular pressure, and a symptom of glaucoma, or of various types of heart disease. The macula 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, its centre being occupied by a bright dot, the fovea centralis, or a whitish ring or halo. The macula lutea is frequently the seat of hemorrhagic extravasa- tions or other lesions. By the direct method, in addition to ascertaining 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 correspond- ing 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 condition. Dense membranous opacities have been successfully treated by Von Graefe by means of a needle-operation, as in cases of capsular cata- ract, 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, «nd 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 con- tinuous galvanic current is recommended in these cases by Onimus and Carnus, 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 persist 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 762 DISEASES OF THE EYE. 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 Eales, 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 depletion, with regulation of the circulation, and especially of the portal circulation, 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 appearance when examined with the ophthalmo- scope ; the condition is then called synchisis scintillans Fluid vitreous mayr 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 caused by a penetrating injury or the presence of a foreign body, or which arises in connection with purulent choroiditis. Hansell has described cases of spon- taneous 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 ophthalmo- scope 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 origiu is obscure. It is associated with various conditions of disturbance of the general health, aud has been seen in association with syphilis, although not the form of choroiditis usually caused by that affection. Hull, 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 hyperaemia. In addition to the variety of choroiditis just mentioned, it is important to distinguish the following clinical forms of choroidal disease :— 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 periphery ; 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 of the retina has become absorbed, exposing the vascular network of the choroid (diffuse exudative choroido-retinitis). 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 CHANGES IN THE CHOROID. 763 syphilis, but in some instances depends upon an inherited syphilitic taint. As Hutchinson has pointed out, moreover, disseminated choroiditis affect- ing both eyes is occasionally encountered as a family disease, indepen- dently of syphilis, and associated with disorders of the central nervous svstem. The treatment should consist in a mild but prolonged 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-ch.oroiditis posterior is also applied to this variety of cho- roidal change, just as anterior scierotico-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 staphyiomatous bulging and gradual loss of vision, by opacity of the vitreous and cornea (see pp. 742, 743). Semi-atrophic and atrophic crescents also appear at the outer margin of the optic nerve in astigmatic eyes, and in such as are undergoing change owing to the distention of their coats under the influ- ence of close eye-work, aggravated by imperfectly or improperly corrected errors of refraction. In superficial atrophy of the choroid the pigment epithelium is absorbed, and the larger vessels become distinct. Such epi- thelial choroiditis often covers large areas in the eye-ground. Cental 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, which is marked by the appearance of numerous white, glistening dots, somewhat resembling the earlier stages of albuminuric retinitis, and is 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 774). 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 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 Risley, should be looked upon as one of the causes of degeneration of the lens; 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 764 DISEASES OF THE EYE. the effused blood shows itself in the form of a long line of atrophy situated in the central region (see page 376) Bony Deposits are occasionally found in the choroid, apparently 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 within 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 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 been reported by Schiess-Gemuseus. Congenital Defects of the Choroid.— Coloboma of the choroid is a con- genital deficiency of the lower part of this membrane, and appears 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 nystagmus. 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 affectious 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, or may result from disturbances of the circulation as the result of pressure on the orbit; the pernicious forms of anaemia 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. CHANGES IN THE RETINA. 765 Betinal Anaesthesia (Neurasthenic asthenopia) is seen among children about the age of puberty, and among hysterical and chlorotic women, especially if the subjects of uterine disorders. It is characterized by fluc- tuating visual acuity, attacks of dim sight, the rapid disappearance of objects 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 improperly focussed ; it causes dread of light, pain, and blepharospasm. It may be associated with neurasthenic 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 deposit of pigment— either as a symptom of the special type of the disease, or as a result of the absorption 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 varieties 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 imperfect differentiation of its margins, and sometimes hemor- rhages. 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 retina, beginning in the periphery, and, because arranged in stellate spots, with intercommunicating processes, often compared to the so-called "bone-corpuscles." Kight-blindness is one of the most prominent symp- toms, and is accompanied by progressive contraction of the field of vision, which goes on until the disease, which is incurable, produces total blind- ness; though, as the course of the affection is very7 slow, old age may be attained before this consummation is reached. Strychnia may be given in the treatment of this affection, and temporary7 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 England. Arlt has given the name Retinitis Nyctalopica 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. Albuminuric Retinitis appears usually with the chronic types of renal affection, especially with that variety known as interstitial nephritis, but is seen also with the albuminuria of pregnancy. It begins usually with a grouping of yellowish dots, somewhat radially arranged, around the macula, and goes on to extensive involvement of the retina, with the oc- currence of fatty degeneration, hemorrhages, and implication of the optic disk, producing a picture, of the highest grade of papillo-retinitis. Some- times the retinal lesions predominate; in other instances the optic disk 766 DISEASES OF THE EYE. 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 adapted 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 preo-- nancy, Pooley, Risley7, and other surgeons have recommended the induc- tion 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 especially discussed by Hirschberg, in Germany, and by Moore, in this country. Leucocythaemic Retinitis is a rare affection which, according to Leber, appears in not more than one-fourth of all cases of leucocythaemia, and generally with the splenic variety of the affection. When fully developed, this disorder presents 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 numerous linear hemorrhages from other causes, such as heart-disease, gout, atheroma of the retinal vessels, thrombosis of the trunk of the cen- tral 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 hemorrhages occur in the macular region, probably from rupture of an artery7, 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 perhaps be derived from the use of iodide of potassium in hastening the absorption of the effused clots. Detach ment of the Retina may occur in cases of extreme posterior staphy- loma, or may be due to loss of vitreous, to hemorrhage or serous effusion, or to the growth of tumors of the choroid. Nordenson's researches 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 be made to evacuate the subretinal fluid (as originally suggested by Sichel) by puncturing the sclerotic with one or two needles, passed through the sclerotic and vitreous, as advised by ] on Graefe and Bowman; or with a delicate trocar, as recommended by De Wecker, who at one time employed drainage of the subretinal space by the introduction of a gold or catgut thread; Galezowski prefers aspiration without drainage. The best operation is scleral puncture, made with a narrow Graefe's knife thrust directly through the sclera and choroid, and turned slightly upon its axis during withdrawal, the subretinal fluid being allowed to drain away. Iridectomy and sclerotomy (Wolfe, Abadie) have been employed in cases of retinal detachment, but are condemned by Landolt. Schoeler's method consists in injecting iodine into the subretinal space; his own reports are favorable, but many cases have terminated badly in other hands. Dianoux and Green have derived advantage from the hypodermic injection of pilocarpine, which is the best medicinal treat- ment, and may be alternated with the use of diuretic doses of the sahcy- CHANGES IN THE OPTIC PAPILLA. 767 lates; Guaita records amelioration from instillations of eserine. The dorsal position and a compressing bandage have sometimes proved useful. Embolism of the Central Artery of the Retina produces 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 spot in the neighborhood of the macula lutea. Embolism of the retinal artery often depends upon the existence of cardiac valvular disease of the left side. It produces 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 ex- cision 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 gran- ular layer of the retina, which is usually detached ; it often fills the eye- ball 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 recommended is early excision, which may be required in the case of both eyes, if both be affected. The disease often recurs in the orbit. In young children, in- flammatory 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 congested or inflamed disk, without reference to its etiology. This name is employed also by Gowers, Nettleship, Swanzy, and Deutschmann. The optic papilla is at first swollen and congested, afterwards assuming the peculiar " woolly" appearance; the veins are distended and tortuous; the arteries grow smaller and are hidden in the grayish swelling, the striae 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 neuritis may be monocular) anaemia, syphilis, uraemia, 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 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. 768 DISEASES OF THE EYE. causes dropsy of the intersheath of the optic nerve (which is nearlv always found on careful examination) by forcing the subarachnoid fluid along this subvaginal lymph space. Deutschmann's theory (1887) 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 upon compression, but the compression upon the papillitis. The ascending course of the neuritis has been denied by Edmunds ard Lawford, who with Gowers, 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 commonly 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, a much more marked and abrupt form of cupping is observed; the most distinctive characteristic of this condition is the bending of the retinal vessels at the margin of the optic disk, the whole of which is occupied by the glauco- matous 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 my7xoma, 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 and Ayres. Atrophy of the Optic Nerve.—This is divided by systematic writers into primary, secondary, and consecutive or post-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 pregnancy); 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 amblyopia), 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, Xorris, and Habershon ; and in rare cases it has been associated with persistent dropping of watery fluid from the nose, as re- corded by Nettleship, Priestley 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 structures concerned in vision, or, in perma- nent cases, atrophy of the fibres of the optic nerve. In advanced atrophy NYCTALOPIA, OR NIGHT-BLINDNESS. 769 from cerebral disease the pupils are usually dilated; in spinal disease, es- pecially in locomotor ataxia, even though the degeneration of the uerve 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 may 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 follow- ing 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 perception for red and green is lost, the periphery of the field being normal. Similar scotomata are found associated with retro-bulbar neuritis from other causes, and have been ob- served in locomotor ataxia. The treatment of optic atrophy7 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, Chisolm, Bull, and Harlan 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 T^ to i grain daily, in divided doses. Quaglino and Bull speak favorably7 of the use of bromide of potassium in cases of alcoholic amblyopia. Inhalations of nitrite of amyl have been successfully used by Swanzy. Parnard has stretched both optic nerves, but with little if any benefit. Galvanism has also been employ7ed, but without much avail. Amblyopia from Extra-ocular Causes and Functional Disturbances or Vision. Nyctalopia,1 or Night-Blindness, is a functional condition, consist- ing in a diminished sensibility of the retina, due apparently to excessive exposure of the eyes 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 spring or early summer, as noted by Snell and Nettleship. 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 symptom; in true nyctalopia no morbid changes whatever are revealed by the ophthalmoscope. The treatment consists in the adminis- tration of tonics, especially cod-liver oil, with the use of dark-colored glasses to protect the eyes. If the disease can be traced to scurvy, or to malarial fever, remedies suitable to those affections must be employed. Instillation of a solution of strychnia (gr. i-f^j) is recommended by Walker. 1 From the Greek word tvxraXiu^ (vu£ aXac'j- S>^), signifying literally "night-blind- eye, ' or one who cannot see at night. Hemeralopia is the opposite condition, signify- ing an inability to see during the day. These terms have been commonly misapplied hy ophthalmic writers, their proper meanings being reversed. (See interesting papers oL ?reenhi11 and Prof- Tweedy in the Ophthalmic Hospital Reports, vol. x. pp. 49 770 DISEASES OF THE EYE. 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 occasional hemor- rhages into the conjunctiva; the eyes should be shielded by colored glasses and tonics administered if the patient'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, Acritochro- 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 appearing as white, black, or gray. 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 appear too large, have been seen in hysterical cases, and the former is not infrequently caused by syphilitic 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 explaining the principal terms employed. Emmetropia__This is the normal condition ; an eye is emmetropic when parallel rays are converged to a focus on the retina by the 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 pos- terior staphyloma. This condition requires the use of concave glasses. Spasm of the ciliary muscle often simulates myopia, and hence the nietn- ANISOMETROPIA. 771 odical use of atropia, as recommended by Schiess, Windsor, and Derby, is advisable. Hypermetropia, or Hyperopia, is a condition exactly the reverse of the preceding; here, distant 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, hypermetropia and imperfect equipoise of the external eve muscles are often associated with nervous disorders, particularly chorea and epilepsy. Headache is a constant symptom. Hypermetropia requires the use of convex glasses. The local use of Calabar bean is recommended by Magnus. Ametropia1 is a general term embracing both of the preceding condi- tions, as well as astigmatism ; it is therefore the opposite of emmetropia. For its intelligent correction by suitable glasses, atropia, or some other mydriatic,2 should first be employed, provided that the patient is under forty, and that there is no increased intraocular tension. 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 astigmatism); 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 curva- ture 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 remedy7 for regular astigmatism is the use of cylindrical "lasses, measured after the ciliary muscle has been completely7 paralyzed by a suitable mydriatic, or by measuring the radius of curvature of the cornea in its two principal meridians with an ophthalmometer, the most practical instrument being the one devised by Javal and Schiotz. Many persons have slightly astigmatic vision without knowing it, but in numer- ous patients even moderate degrees of this refractive defect produce violent headache and a variety of reflex disturbances. Anisometropia is the term which designates the state in which the refraction of the two eyes is unequal. 1 For a convenient mode of determining the deyree 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, tor measuring the refraction of the eye without the use of lenses. A convenient mode nt estimating the refractive condition of the eye is known as tlie shadow-test; if a lamp lie placed above the patient's head, and the fundus oculi be illuminated by an oph- thalmoscopic mirror of 10-inch focal length (25 cm.), 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 j»am mirror, which has been especially well studied in this country by Edward Jackson, these movements are exactly reversed. By ascertaining the strength of the 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. As a mydriatic for use in correcting errors of refraction, Risley prefers a two- gram solution of sulphate of hyosjyamia, or a six-grain solution of homatropine ivdrobromate. Jackson recommends cumulative instillations of homatropine, and eochweinitz and Hare have further proved its value both clinically and experi- mentally. 772 DISEASES OF THE EYE. Aphakia is an anomalous state of refraction caused by the absence of the crystalline lens, as after cataract operations. Aphakia renders the normal eye markedly hypermetropic, while it diminishes myopia, and may even make a myopic eye emmetropic. The remedy for aphakia (which is accompanied by loss of accommodation) is the use of powerful convex lenses. Presbyopia is a diminution of the range of accommodation, interfer- ing with vision of near objects, while distant vision remains unimpaired. Presbyopia is an almost constant attendant upon old age, and can scarcely be looked upon as abnormal: the treatment consists in the use of convex glasses. Paralysis and Spasm of the Ciliary Muscles may each be a cause of loss of accommodation. The Caiabar 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 and astigmatism (accommodative asthenopia), upon a disturbance of the normal balance of the external ocular muscles (muscular asthenopia), which creates a ten- dency for the visual lines to depart from parallelism (insufficiency of the old, heterophoria} of the new classification), or upon a neurotic condition associated with functional disturbance of the retina (neurasthenic asthen- opia). The first condition requires the use of suitable (convex or cylin- drical) glasses; the second may demand tenotomy of the opposing muscle, provided this possesses distinct preponderance, or the use of appropriate prisms; and the third, in addition to proper glasses, calls for measures selected to relieve the general nervous depression. As pointed out by S. W. Mitchell, Higgens, Carter, Piorry, and other writers, asthenopia may give rise to cerebral symptoms, such as headache, giddiness, etc., and may thus be mistaken for intracranial disease. Insuffi- ciency of the vertical muscles (hyperphoria.) has been especially studied as a cause of functional nervous disorders by Stevens, Ranney, and Webster. Glaucoma. Glaucoma is the term which was formerly applied to all cases of im- paired vision accompanied by a greenish hue of the pupil, and not mani- festly due to lesions situated in front of the iris. The affection was vari- ously supposed to consist in an abnormal condition of the vitreous, retina, optic nerve, or choroid, but its pathology was not well understood until quite recently. Yon Graefe, who showed that all the symptoms of this formidable disease were due to increased intraocular tension, believed that this was due to the augmented volume of the vitreous and aqueous humoi> probably originating in an irido-choroiditis. It is impossible to discuss in this place the numerous theories which have been brought forward to explain the mechanism of glaucoma, or the numerous investigations which have of late been undertaken to elucidate the pathology of this serious disease. The labors of Max Knies, Adolph Weber, Braily, 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; serosity7 of the fluids plays an important part in those forms which present a deep anterior chamber and a wide "ultra- 1 The classification of Stevens has been largely adopted : Heterophoria, or a tendJ^ of the visual lines from parallelism, is divided into exophoria (insufficiency oi > intemi), esophoria (insufficiency of the externi), and hyperphoria (insufficiency o vertical muscles). The state of physiological equilibrium is called orthophoria. GLAUCOMA. 773 tion angle;" and obstruction at the "filtration angle"—or angle of the anterior chamber—is a part of the glaucomatous process in the vast major- ity 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 ciliary7 vessels; diminution in the size of the anterior chamber; sluggishness and dilatation of the pupil (which has a "•reen hue); partial atrophy of the iris ; and lastly opacity of the crystal- line lens. By the ophthalmoscope, the retinal arteries are seen to pulsate ; the optic papilla presents the characteristic glaucomatous cup (page 768), and is surrounded by a yellowish band (glaucomatous halo); the vitreous appears cloudy ; and hemorrhages into the deep structures of the eye may be observed. Vision is usually hypermetropic and presbyopic; the field of vision becomes contracted, especially in its nasal half; amblyopia, at first periodic, ends in complete amaurosis ; halos or prismatic spectra are seen on looking at the flame of a candle ; and pain, more or less intense, is felt in the eyeball, and along the course of the optic nerve. Glaucoma is usually met with in persons past the middle period of life, and 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 commoner in men. It may arise spontaneously, or may be due to some injury, or antecedent inflammation or disturbance of the general circula- tion, resulting 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 neuralgia of the fifth nerve. Schoen and Theobald argue in favor of astigmatism, where the meridian of least refraction is vertical, or nearly so, as a factor in the production of glaucoma ; and obstruction of the cir- cumlental 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 hypermetropia, or abnormal enlargement of the ciliary processes— facts especially dwelt upon by Priestley Smith. Various forms of the disease are recognized 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 symp- toms—paiu.lachryniation, and discoloration of the iris—but which steadily advances with increased failure of central sight and contraction of the field of vision; the consecutive or secondary glaucoma, caused by intraocular tumors, dislocation of the lens, serous iritis, and extensive posterior syn- echias; and, finally, the so-called hemorrhagic glaucoma, in which the earliest symptom is the occurrence of hemorrhages into the retina. Diagnosis.—It is of the utmost importance that acute glaucoma should be recognized, if possible, in its very7 incipiency. The most usual pre- monitory symptoms are failure in the amplitude of accommodation and frequent desire to change the reading glasses, periods of temporary obscu- ration 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 instil- lation of atropia, which under all circumstances is contraindicated—and for rheumatic ophthalmia. The dilated 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 symp- toms which should prevent so fatal an error. 774 DISEASES OF THE EYE. 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. In the majority of instances no time should be lost in resorting to iridec- tomy, which, under these circumstances, should be performed as directed at page 748. The benefits to be expected from this operation, for the introduction of which we are indebted to Von Graefe, are in inverse pro- portion to the duration of the disease ; thus, if employed during the form- ing 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 recognized, comparatively little can be ex- pected from any mode of treatment. Xettleship believes that the state of the pupil and its reaction to eserine furnish a good prognostic guide for operative interference in chronic glaucoma. Here also, as elsewhere, an early operation, before much contraction 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, repeated paracentesis of the cornea is highly recommended by Sperino ; trephining the cornea has been tried by Argyll Robertson ; stretching the external nasal nerve by Badal, Trousseau, and W. 0. 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, except where punctured, are left undivided. The weight of testimony in favor of iridectomy is, however, such that the surgeon will usually hesitate to delay the latter operation while experi- menting 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 idiopathic ; may follow perforation of the cornea from deep ulcers, especially those associated with smallpox ; or may be an incident of pyaemia, 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 deep-seated inflammation generally, with such special phenomena as are traceable to the implication of the va- rious ocular tissues. The disease usually terminates in suppuration and rupture of the globe, or in sloughing of the cornea. The treatment during the early stages consists in the use of cold applications to allay pain, with local depletion, scarification of the conjunctiva, and instillation of atropia. If there be much tension, the cornea may be tapped with advantage. Spencer Watson recommends, under the name of keratectomy, the estab- lishment of a corneal fistula. When suppuration has occurred, warm should SYMPATHETIC IRRITATION AND OPHTHALMITIS. 775 be substituted for cold applications, and a free incision should be made into the sclerotic as soon as the presence of pus is detected, while quinine may be exhibited internally, and morphia, if there be much pain. 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 purulent inflammation, some operators declining to perform excision under such circumstances, in the belief that meningitis 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. Higgens, they often follow the operation of scle- rotomy, and Gunn has shown that sympathetic ophthalmitis may follow perforation of the cornea with implication of the iris, rupture of the ciliary region with blunt instruments, old corneal ulceration, cataract extraction, and the needle operation, when associated with iritis. Sympathetic Irrita- tion, or Sympathetic Neurosis, is a functional disturbance, and is character- ized by weakness of the sympathizing eye, failure of accommodation, tem- porary 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 some- times 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 com- mon form it appears as a severe iridocyclitis, though it may occur as a serous iritis, or as a retino-choroiditis. WThile sympathetic ophthalmitis may originate in an attack of irritation, such is not necessarily the case, as it more usually begins without 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 path of the morbid.changes which precede the inflammation fully mapped out. The old hypothesis of transmission by the ciliary nerves has largely been aban- doned for the theory of infection, which has received much support from the researches of Deutschmann and of Gifford. 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 inflammation 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 ophthalmitis, 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 eye be so great as to render it useless, excision should be unhesitatingly performed. The same operation would, of course, be indicated, should the case be first seen when the second eye is becoming involved. If the injured eye still retains some sight, at the time of the occurrence of sympathetic symptoms, enucleation must not be performed ; for it has sometimes hap- pened, under these circumstances, that the eye first affected has in the end proved more useful than the other. Nor should the sympathetically affected eye be hastily operated on; it is better to wait until the subsidence of acute 776 DISEASES OF THE EYE. symptoms, and then, if necessary, extract the lens and make an artificial pupil, unless the tension is inordinately raised, when a scleral incision may be practised. The general treatment of sympathetic ophthalmitis consists 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. The substitutes for enucleation under these circum- stances are optic neurectomy and evisceration. 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 and divided, when, the eye being drawn forwards and outwards, the optic nerve can be cut with long and narrow scissors, curved on the flat. The eye being removed, hemorrhage is to be checked by the application of cold, when, if thought proper, the conjunctival wound may be closed with a silk suture. This, however, should not be done when the operation is performed upon an inflamed eye, as a free vent should then be provided for the dis- charges. Careful antiseptic precautions, especially irrigation with a bichloride solution, should be employed in connection with enucleation. The after- dressing may consist in dusting the interior of the orbit with powdered iodoform, placing, 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 adapted. Various substitutes for enucleation have been suggested: (1) Abscission, as in Staphyloma, has already been described on page 742; (2) Eviscera- tion, or Exenteration, an operation revived and advocated about the same time by Graefe and by Mules, and adopted in this country by Michel, con- sists in an evacuation of the contents of the eye from within the sclerotic, and the closure of the sclero-conjunctival wound with sutures, thus form- ing a movable stump 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 split 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 inflammation, while yielding a better stump. Frost and Lang have proposed the introduction of Mules's sphere into Tenon's capsule, after ordinary enucleation, closing the muscles and conjunctiva over it in the usual way7. (3) Oplico-ciliary Neurotomy, or simple division of the optic as well as the ciliary nerves, has been abandoned by most operators, but resection of the optic nerve, or Optico-ciliary Neurectomy, is performed by De Wecker, Schweiggers, and other surgeons. In some cases of malignant disease, it may be necessary to extirpate, the whole contents of the orbit. This may be done by dividing the exter- nal commissure of the lids, incising the conjunctiva, severing the levator palpebrae, attachments of the oblique muscles, and all other orbital con- nections of the eye, and then, drawing the globe upwards, cutting the optic nerve with curved scissors, introduced on the outer side. The lachrymal gland should be also removed, if it be diseased. STRABISMUS. 777 Strabismus, Strabismus, or Squint, is defined by Donders as a "deviation in the direction of the eyes, in consequence of which the two yellow spots receive images from different objects." 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 sev- eral varieties, as periodic, persistent, alternating, and monocular. Stra- bismus is usually convergent (cross-eyes), or divergent—the former being commonly associated with hypermetropia, 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 squinting eye is amblyopic, generally, it has been believed, from want of use (amblyopia ex anopsia). Certain observers teach, however, and their view is probably correct, that this amblyopia is congenital, and actually one of the factors in the production of the strabismus. Treatment.—If the affection be periodic, an attempt should be made to effect a cure by the continued use of atropia, followed by the use of glasses to remedy the defect in refraction, etc. If the strabismus be persistent, and not dependent on mechanical causes, such as the contraction of a cicatrix, or the pressure of a tumor, an operation may be resorted to, one or both in- ternal or external recti muscles being divided, according to the nature and extent of the squint. Before having re- course to an operation, the surgeon should (in case of concomitant squint) deter- mine which eye is primarily affected, and the degree of convergence or divergence, as ~'"""tv ^t the Case may be; the former Fig. 452.—Galezowski's strabismometer. point may conveniently7 be ascertained by repeatedly causing the patient to close both eyes and sud- denly open them, that eye which constantly or habitually deviates from the straight position being the one primarily affected. The degree of squinting can be ascertained by using the strabismometer devised by Laurens, or that of Galezowski, but in the absence of these instruments, may be simply determined by marking on the lower lid points corre- sponding 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 eyes. The object to be accomplished in an operation for strabismus, is to alter the point of attachment of the divided tendon, and thus diminish the range of motion which it can impart to the eye: hence the importance of ascer- taining the degree of deviation, that the separation of the tendon from its 778 DISEASES OF THE EYE. 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 it renders tense by drawing it forwards and outwards; the scissors are next introduced closed, and then opened, so as to place one blade behind, and the latter in front of the tendon, which is subsequently divided sub- conjunctivally, close to its sclerotic attachment, by a number of slight cuts. A counter-opening in the conjunctiva, to allow the escape of blood, mav be made, as is done by Bowman, by cutting with the scissors on the point of the hook before this is withdrawn. The above is known as the sub-con- junctival operation, and was introduced by Critcbett. 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 fig. 453.-strabismus hook. can reguiate the effect of the operation by separating more or less freely the sub-conjunctival fascia from the ten- don to be divided, thus allowing the greater or less retraction of the latter. The application of a suture also serves to lessen the effect of the operation. At least three degrees of convergence should be allowed to remain, as otherwise there will be danger of divergence in later life, since the effect of the operation slowly increases. The External Rectus Tendon may be divided by an operation analogous to that above described. Considerable difference of opinion exists among surgeons as to whether both eyes should be operated on simultaneously (when both require operation), or whether the second operation should be postponed until after an interval of several days. Probably a safe rule is that given by Wells, to wait and observe the effect of the first operation, in cases of deviation of less than five lines ; by this precaution the surgeon can form an estimate as to how much remains to be accomplished in the second operation. Stevens, of New York, has especially developed a system of operation, in which graduated tenotomies are performed for the purpose of correcting those conditions which are usually denominated insufficiencies of the ocular muscles, but for which he proposes the generic name heterophoria, and by the correction of which he has reported brilliant successes in the treatment of numerous functional nervous disturbances ascribed to these anomalous conditions. With a pair of small, narrow- bladed scissors, a transverse incision is made through the conjunctiva, 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 tendinous expansion exactly on the sclera. This opening is then enlarged by careful cuts with the scissors towards each edge, keeping 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 nature of the case. General Anaesthesia is, as a rule, undesirable in squint operations, though it may be employed in cases of children, or in those of nervous adults; it is in these cases that the local use of cocaine, which may be injected sub-conjunctivally, has gained some of its most brilliant successes. The after-treatment in cases of strabismus consists in the application of an ordinary light antiseptic dressing for a few days. PARALYSIS of the ocular muscles. 779 Suitably adjusted glasses, fully correcting the error of refraction, must be worn after strabotomy, and these may indeed sometimes, if combined with prisms, suffice to effect a cure without operation in cases of periodic squint. Children under six years of age should never be subjected to strabotomy, and in all cases a faithful trial of correcting lenses should be made before resorting to an operation. 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 partially overcome by operative procedure. 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, by 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 myopia, or to those instances of convergent strabismus in which it is desirable to com- bine advancement of the external rectus with tenotomy of the internus. The insertion of the tendon is exposed, and the strip of conjunctiva be- tween 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, and of A. E. Prince, who secures an unyielding anterior fixation-point by7 utilizing the dense episcleral tissue, securing the muscle and regulating the effect by a skil- fully devised "pulley-suture." Advancement 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 Knapp. 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) limita- tion 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 Gowers, in regard to diplopia, is that when the pro- 780 diseases of the eye. 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.) Treatment.—This must be directed to removing the cause of the paraly- sis, and, as in many instances syphilis is present, mercury and iodide of potassium deserve extended trial. At a later period the use of strychnia is indicated, while in rheumatic palsies the salicylates may be exhibited; faradization has been resorted to by R. B. Carter. According to Alfred Graefe, very few cases of paraly7tic squint are suitable for surgical inter- ference. He thus classifies the operations : Advancement of the paralyzed 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 adapted 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 depends upon degenerative changes affecting the nuclei of origin of the implicated 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 cer- tain 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 appears in the following forms: (1) Pupil alone affected (paralytic myosis and mydriasis); (2j paralysis of the iris (iridoplegia); (3) paralysis of accommodation (cyclo- plegia), often seen after diphtheria ; (4) paralysis 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 ey7e, which he believes to be due to disease (probably syphi- litic) of the lenticular ganglion. Diseases of the Eyelids. Blepharitis (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 most important varieties are the hyperaemic, sebor- rhceic, eczematous, and acne forms. In severe cases the palpebral edges are red, thickened, and ulcerated, and become glued together by the drying of the accumulating secretion, the affection giving rise to the condition known as Lippitudo or Blear-eye. The puncta lachrymalia are often everted or obliterated, causing a constant stillicidium of tears, which excoriate the skin and add to the patient's discomfort. This affection is, according to Roosa, often dependent on the existence of ametropia.' The treatment consists in removing the dried secretion by warm alkaline fomentations, and smearing the edges of the lids with dilute citrine oint- ment,1 or that of the yellow oxide of mercury. Resorcin and sulphur 1 Ung. hydrargyri nitrat. 3j '. Ung. aq. rosae 3viJ- M. trichiasis and distichiasis. 781 salves are suited to the varieties due to seborrhcea and acne. In severer cases the local application of nitrate of silver will be of service, and, if the puncta be everted or obliterated, the canaliculi should be freely slit up, the incision being directed inwards. As this affection commonly occurs in scrofulous children, cod-liver oil may be properly administered in most cases. If the patient be ametropic, relief may be afforded by the instilla- tion 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 (Phtheiriasis Palpebrarum) appears, as a rare affection, when the pediculus pubis invades the eyelashes. The ciliae have the appearance of being dusted over with a dark-brown powder. The affection gives rise to intense itching. The parasites may be destroyed by 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 eyes, or of exposure to too bright a light, as to the glare reflected from snow. When situated just within the edge of the lid, it produces pain by pressing on the globe; relief may be sometimes afforded under these 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, produce great irritation by friction on the conjunctiva and cornea, the latter becoming in extreme cases cloudy and vascular. In distichiasis a complete double row of lashes exists, the inner row being inverted, and producing great irritation as in the previous case. The treatment of either affection consists in carefully extracting with cilia forceps the offending lashes, or, if only7 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-shaped strip bearing the cilia, is objectionable as depriving the eye of its natural means of protection, and as leading to cicatricial contraction. 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. Electro- lysis has been proposed as a remedy, for this condition by Michel, of Mis- souri, Benson, and Taylor. For complete distichiasis, Transplantation should be employed, one of the best forms of this procedure being the Jaesche-Arlt operation, in which, after the lid is fixed with a Knapp's or Snellen's clamp (Fig. 454), 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 operations have been proposed by Spencer Watson, Gayet, 782 diseases of the eye. 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 B. Van Nillingen has sought to obviate by the intro- duction of his tarso-cheiloplastic operation. In this, after splitting the lid in the usual manner, a strip of mucous membrane from the patient's under lip is transplanted into the gap in the intermarginal space. The treat- Fig. 454.—Knapp's clamp. ment of trichiasis and entropion by the transplantation of buccal mucous membrane is advocated and largely practised by A. H. 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 orbicularis muscle, thus pro- ducing eversion as in the operation for entropion. Entropion, or Inversion of the Lids, may result simply from spas- 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 proper 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 operations, such as(l) 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—^e skin wound being subsequently closed with stitches; (3) complete divi- sion of the cartilage from the conjunctival surface along a line parallel with, and three millimetres from, the free border of the lid, as recom- mended by Burow ; a puncture is made parallel to the edge of the lid at the outer end, a delicate grooved director is passed in along the outer sur- face of the cartilage, that is, between it and the orbicularis muscle, and then the cartilage is divided, either with, scissors or scalpel; (4) excising a narrow oval piece extending the whole length of the cartilage, as advised by Berlin ; (5) 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 ; (6) the introduction of two or three threads in a longitudinal direction through the cutaneous 1 Dr. Harlan reports an obstinate case of blepharospasm cured by inhalations of nitrite of aniyl. 2 Schneller has modified thi9 operation by circumscribing, without excising, an elliptical strip of skin, anr), having loosened the lateral portions, uniting them witu sutures above the central portion, whioh is thus covered in and serves as a splint to gives firmness to the part. ECTROPION. 783 surface of the lid, the ligatures embracing 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;1 (1) the excision of a triangular portion of skin, with or with- out a part of the subjacent cartilage, as recommended by Von Graefe; (8) Fig. 455.—Entropion forceps. the removal of the whole row of cilia, as described in speaking of trichiasis; (9) transplantation of the cilia to a better position on the lid, as practised in various ways by Arlt, Jaesche, Warlomont and McKeown ; or (10) splitting the lid into an anterior and posterior layer, and inserting a strip of mucous membrane taken from the patient's lip, as advised by Van Mil- lingen. As a preliminary to any of these operations, it will often be ad- visable to slit up the external canthus (canthoplasty), re-adhesion being prevented by uniting the skin and mucous membrane 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 accompanies, or may appear as a chronic affection, result- ing from ophthalmia tarsi, chronic conjunctivitis, etc. Under these circum- stances, the treatment consists in the application of nitrate of silver to the mucous membrane just within the line of eversion, with slitting of the canaliculi if the puncta be everted or occluded. If the ectropion be aided by relaxation of the tissues, as in old people, excision of a V-shaped piece of the whole thickness of the lid (Figs. 456 and 457), or of a horizontal strip of the most everted portion 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 proce- dure of Argyll Robertson, in which a piece of sheet lead, shaped to resem- ble the normal tarsus, is placed beneath ligatures in the conjunctival cul- de-sac. Ectropion from the contraction of cicatrices, abscesses, etc., usually requires a plastic operation (blepharoplasty),2 which consists in embracing the vicious cicatrix, if small, in a V-shaped incision, separating the flap, and pushing it up into place 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 forehead in the case of the upper, 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 A somewhat similar operation is employed by Solomon, and is said to have been devised by Snellen, of Utrecht. C. S. Bull advises kneading and traction of the cicatrix, as a preliminary to any operation of blepharoplasty. 784 DISEASES OF THE EYE. and Wolfe, and successfully practised by Wadsworth, Von Zehender, Aub, Reeve, Abbott, Noyes, Mathewson, Ely, E. Smith, Tosswill, and other sur- Figs. 456 and 457.—Adams's operation for ectropion. (Lawson.) geons, which consists in transplanting skin without a pedicle from a distant part, the flap being shaved down so as to assimilate the operation to Reverdin's transplantation of cuticle. Preputial grafts are suggested by- Jeffries, of Boston. The Taliacotian method has succeeded in the hands of R. H 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 palpebral 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 approximated transversely7, so as to place the part under con- trol of the occipito-frontalis muscle, which sends fibres to the upper portion of the orbicularis—or in the introduction of ligatures (Pagenstecher) as described in speaking of entropion. In paralytic cases, the endermic appli- cation of strychnia has been occasionally resorted to with advantage Dr Van Bidder, of New York, recommends the employment of a delicate Iudia- rubber band, fastened with collodion and isinglass plaster to the edge of the lid and to the forehead, so as to supplement the paralyzed 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 depends on paralysis of the orbicular muscle from some local affection of the portio dura, or from intra- cranial causes If the affection appear to result from the 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 exposure to cold; while, if a syphilitic origin be suspected, the iodide of potassium should be administered. If the lagophthalmos result from mechanical causes, such as exophthalmic goitre, and the exposure cause 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. EPICANTHUS. 785 Syniblepharon is a morbid adhesion of the eyelid to the eyeball, resulting usually from the cicatrization of burns, ulcers, etc. The treat- ment consists in (1) dividing the adhesions, and uniting the cut edges of conjunctiva with sutures (Wilde); (2) covering the raw surface, left after severing the adhe- sions, with flaps of healthy conjunctiva taken from unaffected parts of the eyeball (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 the lip (Meighan); (3) dissecting back the synible- pharon as far as the retrotarsal fold, doub- ling it upon itself so as to oppose a mucous surface tO the globe, and fixing it in this FiG.458.-Symblepharon. (Mackenzie.) position by means of a ligature which is armed with two needles and passed through the lid from within outwards (Arlt); or (4) employing delicate flaps taken from the cheek or forehead, and inverted so as to turn the cutaneous surface toward the eyeball, as successfully done by Gr. E. Post. Harlan also has devised an operation applicable to extensive symblepharon of the lower lid, which provides a covering of skin, instead of mucous membrane, for the palpebral surface. Anchyloblepharon 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 collo- dion. Blepharophimosis, or a contraction of the external commissure and consequent narrowing of the palpebral fissure, requires the operation of canthoplasty or canthotomv. (See page 733.) Tumors of the Eyelids—Sebaceous, Vascular, and other Tumors occur on the eyelids, and are to be treated as similar growths in other situations. The Chalazion, or common tarsal tumor, appears to origi- nate in a distended state of a Meibomian follicle, and often suppurates; the treatment consists in making an incision on the conjunctival surface and squeezing out the contents of the mass. 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 mod- ified 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 neighborhood of tumors of the lids greatly facilitates their removal. Sarcoma of the lid sometimes closely7 simulates chalazion, as in a case recorded by Randall. Chisolm recommends, in all cases of palpebral cyst, simple puncture followed by the evacuation of the cyst contents, and subse- quent cauterization of the cavity with a silver probe dipped in nitric acid. Epieanthus is a congenital affection in which a crescentic fold of skin overlaps the inner canthus of the eye, producing considerable deformity ; 1 Wolfe, Dufour, Calhoun, Noyes, Callan, Brown, Little, and Parker have operated successfully by transplanting portions of conjunctiva from rabbits, and Hotz has suc- cessfully used Thiersch's method of skin-grafting for the same purpose. De Schweinitz has reported good results from the same procedure. 50 786 DISEASES OF THE EYE. the treatment consists in excising a longitudinal fold of skin and bringing the edges of the wound together with sutures, so that the subsequent contraction may expose the previously hidden canthus. Coloboma of the Lids is a congenital fissure, which 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 he inflamed (Dacryo-adenitis), or may be the seat of hypertrophy, or of various wior- bid growths. These affections are, however, rare, and their treatment presents no features calling for special comment. Noyes has recentlv removed the gland for spontaneous prolapsus. Fistula of the Lachrymal Gland may result from abscess or wound of this part; it may be treated by paring the edges and introducing a suture, by the application of caustic or the galvanic cautery, or by establishing a free communication with the 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 upper 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 palpe- 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 Stillicidium Lacrymarum, which is the overflow from obstruction of the canaliculi or nasal duct. Excessive lachrymation may be a symptom of various inflammatory con- ditions of the eye, or may result from the presence of foreign bodies, entropion, etc., under which circumstances its treatment requires, of course, the removal of the cause to which the epiphora is due. Obstruction of the 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 probe-pointed canali- culus knife. The same operation is required in cases of eversion or oblit- eration of the puncta lacrymalia. The lower canaliculus is the one Fig. 459.—Bowman's canaliculus knife. usually slit, the incision being made towards the conjunctival surface, so as to open a passage for the tears. Reunion is to be prevented by the daily introduction of a probe, by the application of nitrate of silver, or by 1 The canaliculus is sometimes plugged by a fungus, whicb may undergo calcifica- tion and form a dacryolite, or tear-stone. INFLAMMATION OF THE LACHRYMAL SAC. 787 excising a small portion of the mucous membrane. Jessop and Steavenson recommend electrolysis for this purpose. If the punctum be indistinguish- able the lachrymal sac may be opened beneath the tendo oculi, and the canaliculus slit from below upwards, as recommended by 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, introduced 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 commonly to be preferred for dilatation of the lachrymal passages, though bougies of the lamina- na digitata have been success- fully employed by several sur- geons. 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 in- troduction of a style through the slit canaliculus into the na- sal duct, the instrument being allowed to remain several days (Bowman), or of a canula of decalcified bone (thigh bone of a frog), which becomes incorpo- rated with the tissues; the in- ternal division of the strictured part by nicking the seat of ob- struction in several directions with a suitable knife (Stilling, Thomas); and the forcible dilatation or rupture of the stricture, as in Holt's method of treating stricture of the urethra (Herzenstein). The old plan of introducing a style through an external incision is now generally abandoned, except with refractory patients, or with children in whom fre- quent passage of the lachrymal probe is attended with difficulty. Inflammation of the Lachrymal Sac may be acute (Dacryo- 1 or chronic (Blennorrhcea, Mucocele). The former variety of the Fig. 460.—Introduction of probe into nasal duct by Bowman's method. (After Meyer.) 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 and antiseptic injections, especially pyoktanin (1-1000), introduced by means of a canula and syringe. In obstinate cases 788 DISEASES OF THE EYE. it may be necessary to excise the anterior wall of the sac (Ton Ammon, Bowman, Lawson, Monoyer), or to obliterate the sac itself by the u>e of caustic or the galvanic cautery, applied through an incision, which is best made, as advised by Agnew, of New York, through the conjunctiva. Sup- puration in the region of the lachrymal sac may, as pointed out by Pari- naud, be due to dental disease. Fistula Lacrymalis, or fistula of the lachrymal sac, is occasionallv congenital, but usually results from either acute or chronic inflammation 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 apparatus, 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 oedematous state of the eyelids (particularly the upper), chemosis of the conjunctiva, and protrusion of the eye, the displacement being usually somewhat downwards and inwards, as w7ell as forwards. Impairment of sight results from pressure on and stretching of the optic nerve. Fluctua- tion is finally developed, and pointing usually occurs below the inner por- tion of the supra-orbital ridge. The symptoms of chronic abscess are much less distinctive, the diagnosis from encephaloid or other soft tumor being often impossible without the aid of the exploring-needle. The treatment of either form of abscess consists in making an incision with a knife intro- duced flatwise at the point of greatest fluctuation, the subsequent manage- ment 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 Mracek, of Vienna, syphilitic periostitis is sometimes a manifestation of the' secondary, but usually of the later tertiary, period, and most fre- quently attacks the orbital margins, rarely the orbital walls behind Tenon's capsule. It may occur either as a gummatous or as a sclerosing or osteo- plastic periostitis. The treatment of these affections presents no feature? requiring special 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 Chapter XXVII.; in dealing with non- malignant growths, the eyeball should, if uninvolved, be, if possible, allowed to remain ; but in the case of cancerous tumors of the orbit, it must commonly be removed, to allow space for complete excision of the morbid growth. Lawson recommends that, after the removal of a malig- nant 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, Higgle and others. Aneurisms of the Orbit__The orbit may be the seat of ordinary aneurism, affecting the ophthalmic artery, of traumatic aneurism, or o diseases of the auricle. 789 aneurism by anastomosis. In either of the two first-named conditions 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 cav- ernous 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. Vas- cular protrusion without pulsation may result also from hypertrophy and hypersemia of the adipose tissue of the orbit, as in the peculiar affection known as Exophthalmic Goitre, or Graves's or Basedow's Disease, an affection which Bane" 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 592, 622.) Distention of the Frontal Sinus, by the accumulation of pent-up fluid, may, by forming a tumor at the upper and inner portion of the orbit, cause displacement of the eyeball, and entail great disfiguration on the patient. The treatment consists in evacuating the fluid by 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 drainage-tube. CHAPTER XXXVII. 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 operations 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 °f 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 incision, as in cases reported by Birkett and Gross. They may be associated with branchial fissure or congenital aural fistula, generally 790 diseases OF THE EAR. 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. Plastic operations for undue prominence of the ears, consist- ing in the removal of an oval disk of skin, and, if necessary, of a wedge of cartilage, from behind the auricle, have been successfully employed bv Dr. Monks. Acute Inflammation of the Auricle may be at times erysipela- tous, 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 applications are at first indi- cated, followed by painting with nitrate of silver or other astringents Vesicles or bullae may form, and go on to suppuration and the formation of crusts. Pain may be very severe in erysipelas 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 period 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 especially prone to 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 tym- panic cavity. Roosa recommends the warm douche as especially useful in subacute cases involving the meatus, but often water and soap are particu- larly 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 ointment, 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 Haematoma Auris. Traumatism is a frequent cause in the sane, but the cyst may occur without it, aud 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 i* more common in the insane, and its occurrence in others, without personal or family history of mental disease, is sometimes prodromal. It is most common on the left side. Recovery of the reason has taken place 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-Se^uard i? 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 sponta- 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, DISEASES OF THE EXTERNAL MEATUS. 791 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 of the External Meatus. In some cases it is possible to obtain a satisfactory view of the meatus by simply placing the patient in a good light and drawing the ear slightly backwards and upwards, while the tragus is pressed in the opposite direc- tion, so that the light passing by the observer's temple may fall into the 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. 461), and to press aside the hairs which line its outer portion ; the best instruments for general use are Wilde's, Toynbee's, and Gruber's. The speculum may be of silver or Fig. 461.—Vertical section of the external auditory canal, membrana tym- pani, and tympanic cavity, viewed from in front.—A. Upper osseous wall of the canal. K. 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 tubae. M. Glandular orifices in the skin of the cartilaginous canal. 0. Short process of the malleus. P. Eustachian tube. (Altered from Politzer.) 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 employed, such as Hassenstein's (which is provided with a tube containing a lens and a perforated mirror), or, for operating, 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. Artificial li.ifht is preferable to poor daylight, and is usually needed for satisfactory exploration. Direct sunlight is usually too dazzling and too uncertain ; it Fig. 462.—Toynbee's speculum. 792 DISEASES OF THE EAR. 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, and guided rather than pressed, with little at- tempt at dilatation. 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 37$j, aided, when necessary, by the gentle use of instruments under full illumination. Excoriated areas are often 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 absorb- ent 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, usually as- pergillus, causing often a marked inflammatory condition, with accumu- lation of dense white, or at times blackish, flakes of thickened cuticle. Pain, deafness, and a sense of fulness 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 depends principally upon this; it is most surely finished by vigorous mopping with hydrogen dioxide, drying, and dusting with boric acid. Burnett recom- mends insufflations of the salicylate of chinoline, 1 part to 16 of powdered boric acid. Specula and other instruments used should be thoroughly dis- infected, lest they should communicate the disease to other patients. Follicular Abscesses or Furuncles occur in the meatus, constitut- ing 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. Lbwenberg lays stress upon the parasitic character of furun- cles, and claims especially good results from antiseptic measures, both in controlling the lesion and preventing recurrence by auto-infection. The treatment consists in the use of hot irrigations, mopping with hydrogen dioxide, and maintaining pressure as firm as bearable by a conical plug of cotton. Pus is evacuated as soon as its presence is detected, and dilute citrine or other stimulating ointment is used to remove any indurations which may be left. Weber-Liel employs, as an abortive measure, inter- stitial 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 re- currence 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 divid- ing lines are generally arbitrary. If considered and treated as various phases of eczema, dry or moist, acute or chronic, they can generally be satisfactorily managed. Exudation may be rapid enough to cause an actual discharge of watery or purulent matter from the ear, but the great AURAL POLYPI. 793 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 tvmpanum or the accessory cavities, since all mucous surfaces are shut off bv 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 extremely7 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 and the gouty, being usually requisite, as well as a series of topical appli- cations as in chronic eczema. 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- panum. On the wrallsof the meatus, they may in rare instances arise from overgrowths of the papillae 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 explora- tion of the wall which forms the point of origin, aud 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 rupturing it. They generally consist of granulation tissue, but may often be included in the fibro-cellular variety of tumor (p. 529). 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 Fig. 463.—Wilde's snare. special symptoms, but are apt to give rise to hemorrhage, the presence of which in an otorrhcea often points to their presence. 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 polvpus is usually best effected by the " snare" of Sir W. Wilde (Fig. 463) or Blake's modification of the same, or by delicate forceps, of which good forms are 791 DISEASES OF THE EAR. exhibited in Figs. 464 and 465. Purves, of London, employs a sickle-shaped "polypus knife-hook." The wire employed in the snare should be very fine and annealed, or, as Ilinton recommends, the instrument may be armed with the gimp employed by anglers, instead of wire. The probe should be carefully 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 caustic applications, such as chromic acid, tincture of the chloride of iron (Politzer). or burnt alum—to prevent recurrence—astringent lotions or Fig. 464.—Forceps for aural polypus. Fig. 465.—Randall's aural forceps. powders being used at the same time. Politzer and MacBride recommend instillations of alcohol when removal is not permitted. Tumors 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 multiple, 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 application of tincture or ointment of iodine to the surface of the growth, and perhaps behind the ear, and by a perseverance in this plan the increase of the tumor may sometimes be arrested. At a later period little can be done beyond the prevention of the accumulation of wax, cuticle, or other matter behind the growth, by fre- quent syringing, though these tumors have been removed with the chisel (Politzer), forceps (Burnett), or snare (Cocks), and have been perforated with file (Bonnafont), trephine (Pritchard), or drill (Mathewson and Field). Cumberbatch has seen benefit from the application of nitric acid. BagroB 995599��99159911 DISEASES OF THE MEMBRANA TYMPANI. 795 employs the gouge and galvanic cautery. If suppuration is present, opera- tive 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 have been reported, but are generally onion-like epithelial masses, " cholesteatomata," which originate in the middle sac cavities and, growing bv addition of layers, absorb the bone about them and break through into the meatus, the lateral sinus, or the brain cavity. They should be scrupu- lously removed with probe, syringe, curette, and forceps, the mastoid being trephined if necessary. Malignant tumors of the meatus are rarely primary, being commonly extensions from growths in the tympanum. Diseases of 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 or persistence of the local manifestations, which may make the lesions appear indepen- dent; and these are sufficiently distinct to merit notice. Inflammation of the Drum-membrane, or Myringitis, may be acute or chronic, and its causes, besides 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 ; but any considerable loss of function is more often due to associated disease of the deeper structures. Inspection shows in the early7 stages a network of injected vessels upon the dull sur- face of the drumhead, 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, may7 give rise to ulcers: but the latter are rare. Resolution is usually prompt and complete in acute cases, but in chronic cases recovery is slower, and when these are neglected the excoriated or granulating surfaces which are pres- ent may give rise to considerable serous or purulent discharge, and the granulations may become polypi. Rupture of the drum-membrane may be caused by pneumatic pressure, as in explosions or by blows upon the ear, by wounds from penetrating bodies, generally introduced to re- lieve itching or to remove wax, or by violence to the whole head with or without fracture of the cranial bones charge (which, although copious, may not be of cerebro-spinal fluid), is the Fig. 466.—Enlarged representation of normal membrana tympani.—a. Short process of mal- leus, b. Posterior suspensory ligament, c. An- terior suspensory ligament. d. ShrapnelPs 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, to. Light spot or cone of light, n. Annulus tendinosus. Bleediner. followed by serous dis- 796 DISEASES OF THE EAR. most constant 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 regained unless the labyrinth has been injured. The treatment of inflammation of the tympanic mem- brane, in acute cases, is by protection, with depletion and cleansing when called for, and the use of moist or dry heat when the pain is not re- lieved by leeching. If the drum-membrane have been ruptured, the med- dlesome use of syringing or of fluid applications may seriously complicate and retard the cure. In chronic myringitis expectancy avails little, and the employment 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 McKeovvn, 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 drumhead may also improve the hearing by securingthetension 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 value. Calcareous deposits, 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 particularly with the power of hearing, and no treatment is likely to prove of much service. The pneumatic speculum of Siegle (Fig. 467) may be of considerable therapeutic as well as diag- nostic 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 principal value of inflation of the tympanum in such cases, can be very gently, yet thoroughly practised. The mobility of the apparatus may be increased with the result of improved hearing, lessened subjective noise, and a distinct sense of relief. Pressure of the finger upon the tragus, rapidly repeated (Hommel), or better still, alternate pressure and withdrawal of the linger, closing the meatus, forms a good substitute. Attention to the nares and pharynx 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. Fig. 467.—Siegle's pneumatic speculum. PERFORATION OF THE MEMBRANA TYMPANI. 797 Incision of the Membrana Tympani, or even excision of a portion or the whole of the membrane, with the malleus, is sometimes advised in the management of the various affections in which it is involved. 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 opening in the drumhead. 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 ingenuity7, but with little avail, and the eyelet of Politzer, and such means, are now rarely used. The simple excision of a flap is 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 operation 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 Kessel, Sexton, and others, with moderate reaction and occasional good results, but has generally been limited in its ap- plication to suppurative cases, with caries which was otherwise inaccessible. Perforation by acid (Simrock), actual cautery (Bon- nafont), or the galvanic cautery (Yoltolini and Purves) seems to have little advantage over inci- sion—the reaction is apt to be much greater, and the opening very slightly more persistent. In the same connection 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 membrane heals. Perforation of the Mem- brana Tympani may result from traumatic causes, from ulcer- ation of this structure itself, or, more commonly, as a conse- quence of intra-tympanic inflam- mation, the mucus or pus which accumulates within the cavity gradually makingitsway through the membrane, and being dis- charged externally. The open- ing is usually single; but, in rare cases, from two to five openings, or more, may be sim- ultaneously present. " One of these may be in the flaccid membrane. When multiple perforations occur, tubercular ulceration is the most frequent cause. The opening can com- monly 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 Fig. 468.—Politzer's method of inflating the tympanum. 798 DISEASES OF THE EAR. the Eustachiau tube be pervious, blow air through the meatus by making a forcible expiration (or, as suggested by7 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 swal- lows—the Eustachian tube being opened during this act, and the soft palate raised so as to shut off the naso-phary7nx 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 likelv to injure the nasal mucous membrane. Gruber has modified Politzer's method by7 directing the patient, instead of swallowing, to pronounce the syllable " huck" or " hck;" and with children success is most readily obtained by causing them to puff out the cheeks. If swallowing be employed, the larynx should be watched, and the inflation 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 side opposite 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 effect of pressure. The passage of air through a perforation will generally give rise to a sound, which may be 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 (Tangeman), or a piece of the lining membrane of an egg shell, or by inserting an artificial drumhead. As the main value of such treatment is merely to protect the tympanic cavity from external influences, it is well to determine that hearing will not be made worse, by closing temporarily the perforation before going further. A hole in the drumhead, far from being a death-blow to hearing, may greatly increase it. When there is reason to suspect loosening of the connections of the ossicula, great benefit may sometimes be derived from the adaptation of an artificial membrana tympani, which may consist simply of a plug of cot- Ik i^"^^ ton-wool dipped in glycerin (Years- O--------------»«J^ wtCl&mk ^)' an India-ru,l)0er disk or globe, ***ira^ wffiBjf as recommended by Toynbee (Fig. ^^■P^ 469), or any other body which will Fig. 469— Toynbee's artificial membrana exercise the requisite amount of tympani. pressure to restore tension, and yet not act as an irritating foreign body. Innumerable patented "artificial drums" are offered, with the most con- scienceless claims as to their value ; and medical men as well as the public support the charlatanry, supposing that a vibrating membrane is requisite. Few of them are as good as a cotton-pellet; and much harm is done by their indiscriminate employment. Considerable care is requisite in plac- ing the apparatus so as to secure the best result; and the adaptation of the appliance in each individual case may necessitate a series of experi- ments with its various forms. The cotton-pellet is usually the simplest and the best. DISEASES OF THE CAVITY OF THE TYMPANUM. 799 Diseases of the Cavity of the Tympanum. Inflammation of the Mucous Membrane of the Tympanum, or Otitis Media, is not infrequently present in its milder forms in cases of common " cold in the head and sore throat," giving rise to deep-seated pain in the ear, with buzzing noises and slight impairment of hearing; inflation of the tympanum is painful, and inspection shows the membrana tympani 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 intervals, giving rise ultimately to tissue-changes leading to permanent deafness. Sexton, of New York, lays much stress upon the fact that, in some cases, disease of the middle ear is dependent upon affec- tions 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 appli- cations (such as the hot (105°-l 15° F.) douche, or warm solutions of atropia or morphia), with leeching if necessary7, and counter-irritation over the region of the mastoid process during the attacks—followed by attention to the hygienic state of the patient, and to the condition of the nose and throat, during the intervals, so as to obviate recurrence. Hinton recom- mends that the tympanum should be inflated with warm vapor every even- ing 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 by7 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 seyerer symptoms ; yet the two affections seem quite distinct, and the catarrhal rarely passes into the suppurative form. Inspec- tion will generally show intense congestion of the tympanic membrane, and often of the adjacent walls of the meatus; and all landmarks maybe 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 usually7 so far involved as to render inflation of the tympanum, if at all possible, very difficult and painful; yet inflation after cleansing of the naso-pharynx may give great relief, either by establishing drainage through the normal outlet, or by rupturing the distended tympanic membrane, and thus relieving the painful pressure. If it fails, paracentesis of the tympanum may be done by a skilled hand, under full illumination, with a long-shanked needle, the operation 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 gen- erally the best position for the incision. The further treatment consists in local depletion, with the use of the hot douche, and perhaps warm ano- dyne 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, diaphoretics, 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 hot douching and dry heat will often obviate the need of paracentesis. 800 DISEASES OF THE EAR. The catarrhal form of otitis mediais 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 mav persist after the discharge has ceased; it. ma}7, on the other hand, contract or close prematurely, and give rise to retention of the secretion, cnllin"- for incision. Thorough cleansing is necessary, repeated as frequentlv as the amount of the discharge may demand, warm syringing with boric acid or other astringent solutions being probably the best means of secur- ing the object. The use of impalpably powdered boric acid, as recom- mended by Bezold, of Munich, has now been very generally adopted for the treatment of suppurating cases, after the subsidence of the most pain- ful stage ; and the " dry treatment" of this affection (including numerous modifications, rarely for the better) has established itself as the simplest and best for most cases. The accessible cavities are dried with absorbeut cotton, after a scrupulous cleansing either with the cotton-carrier or the Fig. 470.—Allen's cotton-carrier. 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 surpassed for effectiveness. The cleansing and insufflation must be repeated 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 powders, such as talc (Hinton) and iodoform (Rankin) are dan- gerous, and are less valuable in every7 respect; and even boric acid, in- soluble in mucus, is charged with clogging outflow7. 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 is 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, joins or constitutes 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 replaces or blends with the periosteum. Pain, tenderness, and swelling behind the auricle, forcing it out and forward, are usually marked in mastoid 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. Depletion, heat or cold, and rest in bed, may at times abort a threatened attack; but the most im- portant measure is to make a free and early incision down to the bone in a longitudinal direction, a quarter or a half of an inch behind the ear, and extending almost the whole length of the mastoid process (Wilde's incision). Marked relief may follow, even if no pus is evacuated; but in some cases it is necessary to open the mastoid cells and empty tbem or pus and granulations. In children, the thin, soft bone may be opened CHRONIC CATARRHAL INFLAMMATION OF TYMPANUM. 801 with a sharp spoon, but in the adult, the trephine, drill, or chisel is requi- site, the last being the best. The perforation is usually carried into the antrum ; and as the lateral sinus may be nearly in the field of operation, the surgeon must proceed cautiously, keep close behind the external meatus, and be ready to tampon. Carious bone should be curetted away, and any necrosed portions may be detached and removed ; yet, in view of the im- portant structures which might be injured, it is more common to await the spontaneous separation of the disorganized tissues, after establishing a free opening with drainage. Almost the entire temporal bone may be separated by exfoliation. The more complete the operation, the shorter the after-treatment. The form of mastoid abscess which bursts into the digastric fossa and burrows in the neck beneath the sterno-mastoid, has too often been misunderstood. The ear deserves careful study in relation to cervical and post-pharyngeal abscesses. Fatal Consequences of Inflammatory Affections of the Ear. —Inflammation attacking any of the deeper-seated structures of the ear may occasionally lead to a fatal result by implication of the brain or lateral sinus, the immediate cause of death being in the former case meningitis or cerebral abscess, and, in the latter, thrombosis of the lateral sinus, and perhaps of the jugular vein, giving rise to pyaemia, or to secondary pneu- monia, or even sloughing of the lung. Little can be done as a rule to avert the fatal issue when these lesions are actually present, but already quite a series of cases of cerebral abscess, secondary to otitis, have been successfully treated by trephining and evacuation, and the lateral sinus and jugular have been emptied of septic thrombi. The abscess is most frequently single, and in the spheno-temporal lobe, over the roof of the tym- panum; but may, especially7 in mastoid suppuration, be in the cerebellum. The point of election for trephining, when an exploration is made in the absence of localizing symptoms, is from one to one and a half inches behind, and from one to one and a half inches above, the upper wall of the auditory meatus. The mastoid should be trephined and a subdural ab- scess may be thus evacuated ; but intra-cranial explorations should be by an independent opening, and not through a purulent ear. 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 Eustachian tubes; and the dis- tinct hereditary character often observed in the affection is probably ex- plained by the inherited configuration of the nasal chambers. Pharyngeal involvement is generally present also, but the tendency is now to regard this as not causative, but as only another consequence of the nasal condi- tion. The semi-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 as 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 mucus. When attempts to inflate by the Valsalva and Politzer methods fail, catheterization may be required. This is effected by gently passing 802 DISEASES OF THE EAR. the Eustachian catheter (Fig. 472), 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 Fig. 471.—Application ol the auscultation tube. (Toynbee.) ■enter the orifice of the Eustachian tube ; or, it maybe introduced until its tip sinks on the velum, turned in and withdrawn until it engages the sep- tum, and then turned out and slightly up. Pomeroy, of New York, uses a " pharyngeal catheter," which is introduced through the mouth, as was Fig. 472.—Catheter for the Eustachian tube. 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 outweighmi; their probable value. The treatment of chronic catarrh of the tympanum should consist primarily in remedying as far as practicable the nasal aflec- tion, in rendering the Eustachian tube patulous, and restoring, if possible, the normal ventilation of the tympanic cavity. The treatment should be repeated at such intervals as to prevent the good effect of one sitting from being lost before the next, and may properly be interrupted for ten days or a fortnight, after some six weeks. 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 an( NERVOUS DEAFNESS. 803 gratifying. If, in the stage of sclerosis, with profound alteration of the mucous membrane, thickening of the joints of the ossicles, anchylosis of the stapes, and perhaps secondary degeneration of the internal ear, no treatment may succeed even in arresting the downward progress. Between these two extremes, all varieties of cases 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 otorrhoea of scarlet fever, etc., may prove the immediate cause of death. While it is not infrequently present in sub-acute and chronic catarrh, and while in some cases the curved surface-line of the fluid may be seen through the drum-membrane, Hinton's views have not found general confirmation. The exudation may become inspissated, and form bands and adhesions, as damaging to the hearing as organized new tissues; and calcareous degen- eration, or even organization of the deposits, has been thought to occur. The treatment consists in the removal, if possible, of the exudate. If it be in a fluid condition, it may7 often be evacuated through a patulous Eusta- chian tube, by simply placing the patient in such a position that the fluid will escape 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 hav- ing been first injected, if necessary ; but the method of incising the mem- brana tympani, and, if inflation fail to remove the secretion, syringing through the opening, either through the Eustachian catheter, or, as advo- cated by Hinton, 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 tympanum, when in approximately normal condition, by the use of the nasal douche or by nasal syringing, has given rise to severe purulent otitis; and this must be borne in mind in the use of any intra-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, th'e presence of mucus or other exudation in the tympanum, Hinton judiciously advises that in cases of cerebral irrita- tion 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 dissipate promptly what appears to be dangerous implication of the brain or meninges. Nervous Deafness.—The researches of modern aural surgeons have shown that most of the cases formerly classified under this head are really instances of some of the affections of the conducting media, which have already been described. Thus, the deafness in cases of anchylosis of the 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 employment of which are given by Hinton :— 1. In a normal state a tuning-fork is heard before the meatus after it lias ceased to be heard on the vertex. 2. When placed on the vertex, it is heard more plainly when the external meatus is closed. 3. Consequently, when one meatus alone is closed, the tuning-fork is heard most plainly in the closed ear. Hence, 4- In cases of one-sided deafness, if the tuning-fork, when placed on the vertex, is heard most plainly in the deaf, or more deaf, ear, the cause is seated in the con- 804 DISEASES OF THE EAR. ducting apparatus ; if it is heard loudest in the better ear, the cause is probably in some part of the nervous apparatus. 5. If, on closing the meatus, the tuning fork is heard decidedly louder, there is no considerahle 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 is the basis of " Rinne's test," which measures the relation of aerial to bone conduction and expresses the normally greater duration of the former as -f, 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 sound- ing 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-conduction means nerve lesion. Gelle* claims that rare- faction or condensation of the air in one auditory meatus reduces the hear- ing 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 generally accepted conclusion on the subject has yet been reached. True " nervous deafness" is rare, probably not furnishing more than five per cent, of the cases met with in practice ; and in but a part of these will it be found independent 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 as a functional affection, the result of anaemia and general nervous exhaustion. The deafness may7 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 gen- erally due to extravasation into the semicircular canals. Treatment can- not 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, anthel- mintics, or such other remedies should be given, as may seem to be indi- cated in each case. Politzer has obtained good results from the hypodermic use of a two-per-cent. solution of pilocarpine (rn, iv-x), and Hagen, of Leip- sic, from strychnine; and in cases of Meniere's disease large doses of qui- nine have been advantageously resorted to by Charcot Except perhaps in syphilis, recent lesions only prove as a rule amenable to treatment. Galvanism may be tried, but its usefulness is rarely very great. DISEASES OF THE NOSE. 805 Paralysis of the Tympanic Muscles may occur, but the recog- nition of the particular muscle involved is difficult, since their function in health is not certain. The stapedius is implicated in paralysis of the facial nerve, such as not unfrequently takes place, especially in otitis media with caries; and the tensor tympani generally is paralyzed with the palatal muscles. Roosa calls senile loss of hearing presbycusis, and considers it a loss of accommodation. If so, it may be due to a paretic condition 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 Eustachian tube. Tinnitus Aurium, or subjective noise in the ear, sometimes exists as an isolated symptom, and cannot be referred to any7 discoverable disease. It is usually of a hissing, ticking, or chirping character, though at times becoming a roar which the patient can hardly believe to be inaudible to others. It commonly7 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. Free inflation of the tympanic cavity with air or stimulating vapors, the use of the pneumatic speculum, electricity (especially the constant current), and internal medication,will each succeed in some cases; but a subjective noise, once heard, is rarely so completely lost again, that it cannot be heard when listened for in a still place. C. H. Burnett advises, in extreme cases, excision of the drumhead and ossicles ; relief has followed reduction of nasal hypertrophies ; Reyburn has obtained a cure by ligation of the occipital artery on the affected side ; and Seiss has had admirable results from freezing the mastoid with a spray of rhigo- lene. Michael and S. M. Burnett recommend inhalations of nitrite of amyl, and Woakes commends the internal use of hydrobromic acid ; nitroglycer- ine 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 XXXVIII. DISEASES OF THE FACE AND NECK. Diseases or the Nose. Lipoma (Acne Rosacea sive Hypertrophica) is a hypertrophied 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 involved. The treatment consists in excision, the only point in the opera- tion requiring any particular attention being not to lay open the nostril; the occurrence of this accident may be avoided by causing an assistant to distend the part with a forefinger, that he may warn the surgeon if the knife penetrate too deeply. There is usually a good deal of hemor- rhage which may be checked by the application of cold. If the wound is not too large, an attempt may be made to close it by stitches; or healing way be allowed to take place by granulation and cicatrization. To avoid 806 DISEASES OF THE FACE AND NECK. 1'iu. 473.—Acne rosacea, or lipoma. (From a patient in the Pennsylvania Hospital.) bleeding, Oilier recommends the employment of the galvanic cautery. Imperforate Nostril.— This is occasionally, though rarely, met with as a congenital deformity; if the obstruction be not too deeplv seated, it may be removed by in- cision and subsequent dilatationWith bougies. Epistaxis, Hemorrhage, from the Nostrils, is in many cases, par- ticularly when occurring in youii" persons, an effort of nature to re- lieve internal congestion, and may be looked upon under such circum- stances as rather salutary than oth- erwise. It is, however, even when not injurious, often annoying and inconvenient, and an attempt should therefore be made to prevent its oc- currence, in persons liable to it, by administerirrg laxatives to relieve visceral congestion, by attention to the menstrual function, etc. In most cases no further local treatment will be required 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 ac- tive measures must be adopted. The patient should, under these circum- stances, 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 tincture of iron, which may be applied to the mucous surface of the nostril by means of a camel's-hair brush. An in- genious nostril clamp has been devised by Caro for treating hemorrhage from the anterior 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 mm t (M>, Fig. 474.—Lipoma. (Liston.) THICKENING OF THE SCHNEIDERIAN MEMBRANE. 807 into the pharynx, the posterior nares must also be plugged—this beinc 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 liga- ture, is passed along the floor of the nostrils till it reaches the pharynx, when, the spring being protruded, the ligature may easily be brought out of the mouth and furnished with a plug of the required size. By with- drawing the instrument, the plug is now brought into position, the end of the ligature 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 Kiichenmeister 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 plugging the posterior nares appears to be not entirely free from risk, Cre'quy and Gelle* having recorded cases in which it was followed by suppuration of the middle ear. In a case of Verneuil's, in Fio. 475.—Plugging the nostrils with Bellocq's sound. (Fergusson.) which epistaxis appeared to be due to cirrhosis of the liver, all other means failing, a cure was effected by the application of a blister to the hepatic region. Chronic Inflammation with Thickening of the Sehneid- enan Membrane is not infrequent, especially among strumous children, though by no means confined to them. I have observed it in an adult, as the result of the mechanical congestion produced by constant vomiting (Hiring pregnancy. The portion of mucous membrane which lines the turbinated bones is that which is chiefly affected, appearing as a projecting "age, or mass, of a red color and velvety appearance, sometimes covered with muco-purulent secretion. Respiration is obstructed, particularly in wet weather, the tone of the voice being altered, and a constant disposi- mL??1--" c"nTtTrivanceS have beeD suSS«sted by Dr. Taaffe, Mr. Godrich, and Dr. ojornstrom, of Upsala. 808 DISEASES OF THE FACE AND NECK. tion to snuffling induced. Hypertrophy of the middle turbinated bone caused asthenopia and headache in a case recorded by Dr. Kibbe. The treatment consists in the application of astringents, frequent syringing with cold water, and (in a strumous patient) the administration of cod- liver oil, iodide of iron, etc. Xo operative treatment, except perhaps sca- rification, is, as a rule, admissible, though removal of the hypertrophied mass with a wire loop may occasionally be called for. Change of air is often beneficial. Rhinorrhoea or Ozama (the latter term referring to the fetid nature of the discharge) signifies a flow of muco-purulent matter from the nostrils, 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 appears 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 bivalve speculum,1 or the ingenious spring speculum devised by Wimmer, but the deeper portions of which can only be examined by the cautious introduction of a female catheter, Bellocq's sound, or Zaufal's speculum, 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 em- ployed in laryngoscopy will commonly answer every purpose, or two mirrors, as advised by Yoltolini, or the ingenious instrument devised by Simrock may7 be used instead; this apparatus is provided with a movable spatula by which the soft palate may be raised, so as not to obstruct the surgeon's view. White employs a palate-hook furnished with an attach- ment which is fixed over the upper lip, so as to hold the retractor in posi- tion The most important point in the local treatment of ozaena is to secure cleanliness, by the use of a solution of the permanganate of potas- sium, or other disinfectant lotion, which may be applied with a large syringe, or by means of Weber's or Thudichum's douche. This consists of a reservoir containing the disinfectant, which is placed a little above the level of the patient's bead, 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 communication between the nose and pharynx, and a continuous stream is made to flow by atmospheric pressure into one nostril and out by the other. The force of the stream can be regulated by varying the elevation of the reservoir. If one 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 alter- nated from one to the other. A posterior nasal syringe with long curved nozzle (Fig. 476), introduced by the mouth and made to inject fluids through the posterior nares, is preferred by many surgeons, and is proba- bly 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 1 H. Allen recommends a vulcanite speculum with an elliptical opening. NASAL POLYPI. 809 the Eustachian tube; a similar nozzle may be used with the ordinary douche, as recommended by Dr. George Thompson. Any ulcers that are detected should be touched with nitrate of silver, and to prevent the forma- tion of scabs, dilute citrine ointment may be applied at night by means of Fig. 476.—Posterior nasal syringe. a camel's-hair brush. Letzel recommends the use of iodoform as a snuff, in the proportion of one part to five of powdered 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 recom- mended by A H. Smith, or, as preferred by Bosworth, with glacial acetic acid or the galvanic cautery. The same surgeon, with Jarvis and F. L. Knight, advises, in some cases, removal of the protruding part with a wire ecraseur. Bucklin employs a small saw. Medicated nasalbougies, made with gelatine, have been employed with some success. If necrosis occur, the sequestra should be removed as soon as they have become loose, access to the part being facilitated, if necessary, by Rouge's method of turning up the nose and lip by an incision through the mouth. Adenoid Vegetations.—This name is given by Meyer, of Copen- hagen, to certain growths met with in the naso-pharyngeal 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 patient being unable to pronounce the nasal consonants m and n, and the voice being deficient in resonance; breathing through the nose is prevented, and the mouth is consequently kept open ; there is, moreover, a feeling of obstruction at the back of the throat, with a copious flow of mucus, and sometimes slight hemorrhage; the patient frequently is deaf, and often suffers from otorrhoea or annoying tinnitus. The growths themselves have a velvety appearance, and a deep red or sometimes yellowish hue. The diagnosis may7 be made by the aid of rhinoscopy, 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-forceps ; and the operation should be followed by spraying with saline or alkaline solutions. Polypi.—The term polypus has been applied to a variety of nasal tumors, which have in common merely their locality and their peduncu- lated character. 1. The ordinary Soft, Mucous, or Gelatinous Nasal Polypus belongs to the fibro-cellular variety of tumor (myxoma), and may spring from any part of the nasal cavity, except the septum, though its more usual point of origin is one of the turbinated bones; occasionally polypi 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 wThen 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 810 DISEASES OF THE FACE AND NECK. a disagreeable habit of snuffling; all the symptoms are aggravated in damp weather. As the polypi 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 thev 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 cases it is better to resort at once to an operation, which may consist in avulsion, in strangulation with the ligature, or in the use of the galvanic cautery ; before attempting removal by any of these methods, the position of the pedicle of the tumor must be ascertained by exploration Avith a probe. (1) Avulsion is effected with delicate but strong forceps 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 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 galvanic cautery. In some cases he removes also the portion of turbinated bone from which the poly7pus springs, and Banks 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. 477), and slipped around the tumor by the Fig. 477.—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 backward into the throat—when it should be instantly removed with forceps, lest by falling on the glottis it should cause suffocation. Griffin advises that after removal the part should be sprayed with witch-hazel or alcohol, twice daily, for at least a year. 1 Caro recommends interstitial injections of acetic acid, and Duplay and Barthi'lera; advise those of chloride of zinc, while Reginald Harrison practises puncture witli a needle or 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. 811 (3) Perhaps the neatest, as well as the most expeditious, way of re- moving nasal polypi, however, is by means of the platinum wire-loop ecraseur and galvanic cautery. The loop being adjusted around the base of the growth, is heated by connecting the instrument with the poles of the battery, when the mass is severed with a slight hissing noise; the ope- ration is both painless and bloodless. In some rare cases, in which the growth is very large, it is necessary, in order to expose the polypus suf- ficiently for the application of any means of removal, to lay open the cavity of the nose by an incision along the junction of the ala with the cheek. 2 The Hard or Firm Polypi of the nose belong to the class of fibrous tumors; they usually spring from the superior turbinated bone, or posterior part of the septum, project into the pharynx, and occasionally find their way into the antrum, through the pterygo-maxillary fissure, or even into the orbit. On the other hand, fibrous or fibro-nucleated tumors, originating in the antrum, or from the periosteum at the base of the skull (Naso- pharyngeal Polypi), may project into the nostril and be mistaken for intra- nasal tumors. Hence it may be, in some cases, an extremely difficult matter to decide whether a particular growth should be called a tumor of the antrum, a nasal, or a naso-pharyngeal, polypus. The fibrous polypus is usually single, very vascular, and is apt by 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. 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 complete removal possible, the surgeon may lay open the cavity of the nose, removing with cutting-pliers the nasal bone and the ascending process of the superior maxillary ; may turn down the nose over the mouth by means of a f|-shaped 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 Yon Bruns and MacCormac, and by myself in the case from which Fig. 478 is taken ; may cut through the hard and solt palate, as advised by Nelaton ; or, finally, may resort to pre- liminary excision of the upper jaw. Either of the last-named Fig. 478.—Fibrous polypus of nose, producing frog-face. Operations mav be employed in (From a patient in the University Hospital.) cases of true naso-pharyngeal polypus, the latter, which appears to have been first practised by Flaubert, in 1840, being probably the best procedure. ine operation is certainly justifiable, in view of the hopeless nature of the 812 DISEASES OF THE FACE AND NECK. affection which it is designed to remedy (these cases, according to Ne*lnton always proving fatal, either by hemorrhage, or by the obstruction to breathing and swallowing), but should not be too lightly undertaken, as it mayT 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 approach of adult life. The galvanic cautery has been successfully employed by Albertini. 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 ; Konig 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 ecraseur, and makes repeated applications of chromic acid to the remainder; Annandale raises the upper lip and nose, as in Rouge'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 operation which appears to have been suggested by7 Huguier in 1852 and 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, reviving Huguier's method, leaves the jaw attached by its palatal instead of it- nasal connections, and has thus operated twice successfully on the same individual. In another jcase, 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, however, proved entirely successful. Cooper Forster has further modified this operation by displacing the jaw in an outward direction. Burow has successfully operated by Langen- beck's method, but, on the other hand, fatal cases have occurred in the hands 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 neghboring bones, forming an elastic swelling; by their tendency to ulcerate and bleed; by the pain which attends their progress, and by7 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- 1 Weir has recorded a case treated by Nelaton'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. RHINOPLASTY. 813 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 incison 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 they must be removed by careful dissection. Thev 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 hsematoma or thrombus (the result of injury), of abscess, or of cystic 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 be treated by cutting away7 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. Schrbtter 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 265. 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 part of the septum only be destroyed, anew 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; the strip, with its end suitably pared, is then turned upwards, and aattched 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 place until firm union has occurred. The size of the newly formed nostrils must 814 DISEASES of the face and neck. 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 mav 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. Esmarch 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 checks. Konig employs 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. 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 neces- sary 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 employed 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, Hardie transplanted the ungual phalanx of a finger, keeping his patient's arm fastened up to her face for three months, and a similar pro- cedure is said to have been employed by Dr. Sabine. 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 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 &facetia merely, without any foundation in fact. RHINOPLASTY. 815 Fig. 479. -Rhinoplasty by Indian method. (Fergusson.) some cases it is possible to derive the columna from the forehead also. The operation, as usually performed, may be divided into three stages. (1) The first stage consists in the formation and attachment of the fron- tal 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. 479. 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 prolonged, 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 cut fairly down to the perios- teum, beginning at the root, which should be made long, so that its circu- lation 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 hope that osseous matter would be developed in the structure of the new nose.1 It does not appear, however, that such a result would be attended by any particular benefit, while the removal of the periosteum from the frontal bone exposes that part to the risk of necrosis. The flap, having been raised, is laid back upon a piece of wet lint, while the stump of the nose is pared and made ready for its reception. 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 pos- sible, without the use of ligatures), the flap is to be twisted upon its root and adjusted, being held in place by means of the interrupted suture, or, which is better, the "tongue and groove suture" employed by the late Prof. J. Pan- coast, the mechanism of which can be readily understood from the annexed diagram (Fig. 480). The flap should be supported 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 corre- sponding to each nostril. The extent of raw surface left upon the forehead may be dimin- ished by the use of harelip pins. The patient is then put to bed in a warm room, with a light dressing over the part to preserve its temperature. The Fig. 480.—Tongue and groove suture. 1 Konig goes still further, and includes with the flap a narrow strip of bone cut from the frontal bone with a chisel. 816 DISEASES OF THE FACE AND NECK. Fig. 481.—Result of rhinoplasty by Indian method. (From a patient in the University Hospital.) dressing should not be disturbed for several days, when it will usuallv be necessary to renew the plug, the sutures being allowed to remain until union has occurred. (2) The second stage of the operation consists in the formation of a columna, if this has not already been done in the previous part of the proceeding. The columna may be formed from the upper lip in the way directed at page 813. It is right to add that E. H. Bennett advises against the formation of a columna, finding that the contraction of the deep surface of the flap leaves none too large an orifice for the admis- sion of air, and that the over- hanging of the middle lobe pre- vents any deformity. My own limited experience confirms this opinion. (3) The third and last stage consists in the separation of the root of the frontal flap, which may be done after an interval of about a month. A narrow bis- toury being introduced beneath the twisted pedicle, is made to cut upwards, a wedge-shaped portion being removed so as to make a smooth bridge to the nose; or, as recommended by Fergusson, the root of the newly formed nose may itself be cut into a wedge and laid into an incision made for it in the forehead. The size of the nostrils, if a columna has been made, must be maintained by the patient's wearing, for some months after the operation, tubes of gutta-percha or silver. Rhinoplasty is usually a very successful procedure, though failure may ensue from sloughing of the flaps, or from a recurrence of the disease which caused the original deformity. Hemorrhage on the ninth day occurred in one of Liston's cases, and death even has followed the procedure in the hands of so distinguished an operator as Dieffenbach. The appearance after recovery may be seen by Fig. 481, from a patient upon whom I operated at the University Hospital. 3. Syme's Method. — Prof. Syme devised an ingenious opera- tion for the restoration of the nose, taking flaps of skin from the cheeks, as shown in the diagram, uniting them in the middle by sutures, and fixing their outer edges to raw sur- faces previously prepared at a suit- able distance from the nostrils. I have myself employed this method with a fairly satisfactory result. 4. Wood's Method—Mr. John Wood restored the nose by taking lateral flaps from the cheeks, and fig. 482,-Diagram of Syme's neoplastic uniting them over an inverted flap, operation. derived from the upper lip ana DISEASES OF THE CHEEKS. 817 elongated by splitting its mucous from its cutaneous surface, from the root of the flap to, but not through, its free border. 5. Ollier's Method consists in taking from the forehead a flap em- bracing the periosteum, and, having inverted this, covering it in with side flaps taken from the remnant of the nose. Operation for Depressed Nose—The nose may be flat and sunken from disease of its bones and cartilages, without external ulceration. Fergusson, modifying a proceeding of Dieffenbach's, remedied a deformity of this kind by separating the soft parts from the subjacent bones with a narrow7 knife, introduced within the nostril, and then bringing the whole organ forward by passing long steel-pointed silver needles across from cheek to cheek, and twisting them over a piece of perforated sole-leather. A columna was subsequently formed in the way already described. Operation for turned-up (tip-tilted) Nose, or Pug-Nose.—Dr. Hoe remedies this deformity by removing a sufficient portion of cartilage from below, local anaesthesia being secured by the use of cocaine. An external splint is adjusted after the operation, if necessary. Operation for Angular Deformities of Nose___Dr. Roe has suc- cessfully dealt with these cases by separating the soft parts subcutaneously from the bone, and cutting away the projecting portion with forceps. Diseases of the Frontal Sinuses. Distention of the Frontal Sinuses from an accumulation of the natural secretion of the part has already been referred to (see p. 789). These cavities may also be the seat of Abscess, or may give origin to Polypi, which subsequently descend into the nostrils.1 In either case the appli- cation of a trephine to the anterior wall of the sinus may be required. Diseases of the Cheeks. The cheeks may be the seat of Encysted Tumors, of Epitheliomatous or Cancerous Growths, of Rodent Ulcer, Lupus, Warts, Moles, etc. En- cysted Tumors may be removed by careful dissection, the operation being done from within the mouth if the cyst be nearer the mucous membrane than the skin. Cancer or epithelioma occurring in this situation, if it be recognized at an early pe- riod, may sometimes admit of removal by excision ; opera- tive interference is, however, rarely justifiable in advanced cases, and would be positively contra-indicated by the exist- ence of glandular implication. The treatment of rodent ulcer and lupus has already been considered (pp. 566, 568). If it be thought desirable to remove a wart or mole of doubtful nature from the face, ^ this may be conveniently done FlG- 483--Diagram of Burow's PIastic operation; the lur n„„!„: il • triangles a d b and etc are dissected off, the flaps a b c »J# excision, the ensuing gap and d e f loosened and the lines a d_a b and e f_. f "eing closed by what is Knapp has recorded a case of polypus of the frontal sinus in which there was no communication with the nostril, which remained unaffected. 52 818 DISEASES OF THE FACE AND NECK. known as Burow's operation. A triangle of skin embracing the growth having been dissected off, the base of the triangle is extended to three times its length, and a similar triangle denuded in a reversed position, as shown in the diagram. Two flaps (a b c and d ef) are thus marked out, which are to be dissected up and slid in opposite directions, the edges of the wound coming readily together, and a linear cicatrix resulting. Shrady has re- stored a cheek by transplanting a flap from the upper arm, first to the patient's opposite forefinger, and secondly to its permanent destination. Salivary Fistula usually results from accidental injury, but mav occur as a consequence of operations on the cheeks, of the opening of ab- scesses, etc. For the treatment of this affection see page 380. Diseases of the Lips. Contraction, or even Closure, of the Buccal Orifice is occa- sionally met with as a congenital affection, or may result from the cicatri- zation of a burn, etc. The deformity may be remedied by a plastic ope- ration, the details of such a procedure varying, of course, with each par- ticular case. As a rule, the skin and mucous membrane should be sep- arately divided, in the direction in which it is meant to enlarge the mouth, the cut surfaces being then pared and the mucous membrane everted, so as to form a new prolabium. Hypertrophy of the Lips may depend upon the existence of the scrofulous diathesis, or may be caused by the irritation produced by fissure? or ulcers, or, according to R. W. Taylor, by an affection such as asthma, or whooping-cough, which induces violent and long-continued coughing, or violent efforts in respiration. In some rare cases, hypertrophy exists without any apparent cause, and under such circumstances the surgeon may be called upon to retrench the pouting lips, which, however charming in poetry, may7 in real life, by the resulting deformity, occasion their owners no little annoyance. The operation consists in making two trans- verse incisions, so as to remove a sufficient slip from the thickness of the part, and then approximating the edges with delicate sutures. A similar operation may be employed to relieve the deformity7 known as double lip. Tumors of the Lips—Cystic tumors should be removed by careful dissection, mere excision of a part of the cyst wall not being sufficient in this locality. Erectile or vascular tumors of the lip may be treated by the application of caustic, by ligation, or by excision, according to the size of the growth and other circumstances of the case (see pages 592-596). Epithelioma__The lower lip is the favorite seat of epithelioma, though the disease occasionally attacks the upper lip. Epithelioma (which in this situation constitutes the affection commonly known as cancer of the lip) may begin either as a wart, or as an indurated fissure. It is much commoner in men than in women, rarely occurs before fifty years of age, and appears in many instances to be predisposed to by the use of a short pipe. This affection is to be diagnosticated from rodent ulcer, lupus, and labial chancre. Rodent ulcer is as rare in the lower as epithelioma is in the upper lip, while chancre may be distinguished by the early implication of the neighboring lymphatic glands, and by the effect of antisyphilitic treatment, which should always be tried in a doubtful case. The diagnosi- of epithelioma from lupus may occasionally be very difficult, and indeed a lupous ulcer may sometimes become the "seat of a true epitheliomatous formation. Lupus is, however, essentially a local disease, and does not EPITHELIOMA OF THE LIP. 819 involve the neighboring glands. The prognosis of epithelioma in this situation, if left to itself, is extremely unfavorable, death eventually ensu- ing from pain and exhaustion, or, if the disease extend to the neck, perhaps from hemorrhage. On the other hand, if submitted to early and thorough extirpation, the chances of permanent recovery are more favorable than in almost any other case of malignant disease. The treatment consists in free excision with the knife, which is in almost all cases preferable to the application of caustics. As in some instances an ordinary ulcer may be so irritated by the presence of a broken tooth, or by the accumulation of tartar, as to assume an epitheliomatous appearance, any such sources of irritation should be first removed, when, if non-malig- Fig. 484.—Epithelioma of the lip and neck. Fig. 485.—Result of operation in case repre- (From a patient in the University Hospital.) sented hy Fig. 484. nant, the ulcer will quickly heal under simple applications. Glandular implication does not necessarily7 forbid the excision of an epithelioma, pro- vided that the affected glands are so situated as to render their own removal possible (Figs. 484, 485). The operation must be modified according to the exigencies of each individual case; in most instances a simple V"snaPed incision will be suf- ficient, an assistant compressing the lip, and thus restraining the bleeding, while the surgeon transfixes the part from within, and cuts from below upwards, taking care to remove with the diseased part a wide margin of healthy tissue; the cut surfaces are then brought together with harelip pins, one of which serves to acupress the labial artery, while the accurate adjustment of the prolabium is secured by the introduction of a delicate silk suture. If a considerable extent of the margin of the lip be involved, it may be better simply to shave off the diseased portion, the mucous mem- brane being then brought forward, as advised by Serres, and stitched to the skin, so as to form a new prolabium. The result of such an operation is shown in Fig. 486, taken from the photograph of a patient in the Epis- copal Hospital. When a large portion of the lip has been removed, it may be necessary to close the gap by means of a cheiloplastic operation. 820 DISEASES OF THE FACE AND NECK. In all cases advantage may be obtained by freely dissecting the lip from its attachments to the jaw. Michel has lately revived a suggestion of Richerand's, that the mucous lining of the lip (which is seldom involved) should be spared, the growth being carefully dissected away from it. The plan is ingenious, but I confess seems to me less safe than the ordinary method. Cheiloplasty___Various op- erations for restoration of the lower lip have been practised, the most generally applicable being probably those recom- mended by Zeis, Malgaigne, Serres, Mutter, Buchanan, and Syme. The operation practised by Chopart consisted in the dis- section of a quadrilateral flap from beneath the chin, as far as the position of the hyoid bone, this flap being then brought forward and attached in the normal position of the lip, while the head was flexed on the chest to prevent tension. In Zeis's operation, which is a modification of Chopart's, the diseased structures are removed by means of a rectangular incision, and the tissues of the chin are then included between oblique cuts, dissected up, and brought forward in the form of an inverted /\ to supply the gap. Fig. 486.—Formation of prolabium by Serres's method. (From a patient in the Episcopal Hospital.) Figs. 487 and 488.—Serres's cheiloplastic operation, modified. (Erichsen.) In Malgaigne's and Serres's operation (Figs. 487, 488), as in the old Celsian method, the tissues of the cheek are utilized in forming the new lip, Figs. 489 and 490.—Cheiloplasty by Buchanan's method. (Erichsen.) while in Mutter's and Buchanan's methods, the flaps are derived from the chin. The diseased mass is first excised by an elliptical cut, from the centre CHEILOPLASTY. 821 of which1 two incisions are carried downwards and outwards, the outline of the flaps being completed by two more incisions, parallel and corre- sponding to the branches of the first. These flaps are then raised and brought°together in the median line by means of the twisted suture. Syme's method differs from the above in that the diseased structure is removed by means of a V-shaped incision, passing from the angles of the mouth to the apex of the chin, the flaps to supply the gap being taken from below the ramus of the jaw and curved at their lower angle, so that by a little stretching the whole wound may be accurately closed with su- tures, and union by adhesion thus obtained. In both methods, the new prolabium is formed by Serres's plan of uniting the mucous and cutaneous edges of the original wound of excision. The result of Syme's method is shown in the annexed illustra- tion (Fig. 491), from a patient of mine in the Episcopal Hospital. Restoration of a portion of the upper lip and of the angle of the mouth may be occasion- ally required to remedy the de- structive effect of lupus. In a case of this kind at the Episco- pal Hospital, I made a lozenge-shaped incision as seen in Fi<>- Fig. 492.—Diagram of operation for resto- ration of the upper lip and angle of the mouth. Fig. 493.—Result of operation for restoration of the upper lip and angle of the mouth. (From a patient in the Episcopal Hospital.) Figs. 494 and 495.—Restoration of upper lip. (Skdillot.) comes an important matter for consideration. Some surgeons have depre- cated early operations, and have even advised that all treatment should be postponed until adult life ; while others, going to the opposite extreme, have operated within a few hours of birth. Although it is impossible to give any positive rule upon this subject, it may be said, in general terms, that from six weeks to three months after birth is, in most instances, the period during which this operation should be by preference performed. If, how- ever, the deformity interfere with the nutrition of the child, by preventing suckling, or by allowing regurgitation of food, the surgeon should not hesi- 1 Under the name of preventive treatment of harelip, Tuckey recommends the adminis- tration to the mother, during pregnancy, of a mixture of the phosphates of calcium and sodium, carbonate of calcium, bicarbonate of magnesium, chloride of sodium, gelatin, and gum, aud reports several cases in support of his suggestion. HARELIP. 823 tate to operate at a much earlier period. The popular opinion that opera- tions in infants are apt to be followed by convulsions, though sanctioned bv 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 erly used if the patient be bey7ond the period of early infancy, but in children less than three or four months Old, it is, I think, better, On Fig. 497.-Cheek-compressor. (Fergusson.) the whole, to dispense with any anaesthetic. The child should be firmly wrapped in a sheet and held by an assistant, another fixing its head, while the surgeon stands behind the patient, or the surgeon may sit and hold the child's head between his own knees , The lip should be first freely separated from the upper jaw by dividing the fraenum and membranous adhesions ; a Xunneley's clip (Fig. 300) is then adjusted on either side so as to control the labial artery, while the surgeon, seizing with toothed forceps the extremity of one side of the fissure, transfixes the part near the summit of the gap with a small straight bistoury, and cuts downwards in a slightly curvilinear direction, concave inwards, so as to insure sufficient length to the cicatrix when the parts are brought together. The opposite side of the fissure is then pared in a simi- lar 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 prolabium at the base of the fissure. The cut surfaces are then accurately adjusted and held together with two or more harelip pins, the lowest of which is made to acupress the cut labial artery on either side. These pins should enter and leave the tissues at least a quarter of an inch from the lines of incision, and should embrace the whole thickness of the lip includ- ing its mucous lining. The more accurate adjustment of the prolabium may be effected by inserting an interrupted suture of fine silk through the mucous membrane, just behind the edge of the lip, and another may be placed superficially between the pins. In applying the twisted suture over the harelip pins, a separate thread should be employed for each ; the points of the pins being cut off, a piece of adhesive plaster 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 824 DISEASES OF THE FACE AND NECK. further lessened by the use of Dewar's or Hainsby's cheek compressor (Fig. 497), or by simply applying a long strip of adhesive plaster acros> the wound and around the head, as recommended by Coote. The pins mav commonly be removed on the fourth, and the interrupted sutures on the sixth day, but the parts should be supported with adhesive plaster for at least a week or ten days longer. The above description will suffice for what may be considered the sim- plest form of operation in a typical case of single harelip. Various modifications are required under different cir- cumstances ; thus, if. as often happens, the sides of the fissure be of different lengths, the red edge pared from the shorter side may be left attached at its base to the lower border of the lip, and fastened to the previously sloped border on the other side, as advised by Langenbeck and Holmes; or a flap may be taken from the longer, and attached to the base of the shorter tio^Th^tl^nlS^lrkX side- To obviate the notch which is aPl t0 '«' nssure. left at tne lower border of the cicatrix, Cle'mot's and Malgaigne's plan may be followed, the incisions being made as shown in the annexed cut, or N baton's method may be adopted ; this consists in surrounding the fissure with an inverted /^-shaped cut, and bringing down the flap, which is left attached at hoth sides, so as to convert the wound into one of a diamond v form. Many other very ingenious operations have been devised by Griraldes, Collis, Stokes, Wolff, Phelps, Golding-Bird, and other surgeons, but, while more complicated than those in common use, have not, as far as I am aware, been proved to possess any practical superiority. Butcher, Wheeler, and others operate with scissors instead of the knife, while the use of hare- lip pins has been abandoned by Mr. Erichsen in favor of the simple inter- rupted suture, as was likewise done by the late Mr. Collis; the latter sur- geon used horsehair as a material for his sutures, while the former gives the preference to fine silver wire. When the case is complicated with cleft palate, Wyeth separates a portion of the upper jaw on the shorter side, and displaces it forwards. Should the approximation of the cut surface- be hindered by the projection of the intermaxillary bone, this may be cut away, as advised by Fergusson, 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 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 happens, this interferes with the operation by its anterior pro- jection. If it be small, the intermaxillary bone may be cut away (and indeed Fergusson recommends that this 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 sometimes facili- tated by dividing the attachment of the projecting bone to the septum with cutting-forceps, as advised by Blandin and others, or by grooving its ba-e with ingenious forceps devised for the purpose by Butcher; in case thy intermaxillary portion should be found too large for the gap which it !•- CONGENITAL FISSURE OF THE LOWER LIP. 825 Fig. 499.—Double harelip; pro- jecting intermaxillary portion. (Holmes.) 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 di- viding the attachment of the projecting inter- maxillary bone to the nasal septum, there is often free hemorrhage, which may require the use of the actual cautery. Should it bethought necessary, the intermaxillary bone may be fast- ened by means of silver sutures to the adjoin- ing maxillae, as advised by Sims and White- bead. Primary union is usually obtained without difficulty in cases of harelip operation, but if it should fail (which may happen from too early withdrawal of the pins, or from a depressed state of health in the patient), the surgeon should not despair, but should re-approximate the parts in hope that union of the granulat- ing surfaces will occur ; in this way I have obtained a much more satisfactory result than might at first have been anticipated. If it be necessary to repeat the entire operation, an interval of at least a month should be allowed to elapse, in order that the parts may have time to return to a healthy condition. I have latterly divided the operation for double harelip into two stages, removing the submaxillary bone first, and postponing the closure of the gap until a subsequent occasion. The shock is thus diminished, and union of the freshened edges is more certainly obtained. After the operation for harelip, the child, if an infant, may be allowed immediately to take the breast, the action of sucking tending rather to keep the parts together than to separate them ; if already weaned, abun- dant nutriment in a fluid form should be supplied, and may be most con- veniently administered with a small spoon or dropping tube. 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 Diseases, where will be found an excellent account of the more complicated forms of the affection, and of the'special oper- ations required for each. Congenital Fissure of the lower lip is occasionally met with, as is the same deform- ity at the angle of the mouth, where it con- stitutes the affection known as Macrostoma, of which I have seen one case under the care of Dr. Harlan; these rare conditions require to be treated on precisely the same principles as those which have been laid down for the management of ordinary harelip. J. H. Morgan and F. Mason have called attention to the coexistence of macrostoma and the deformity of the ear which is marked by the presence of the so-called auricular appendages. As may be seen from the annexed cut (Fig. 500), the same peculiarity was noticed m the case of Dr. Harlan's patient. Fig. 500.—Macrostoma, or congen- ital fissure at the angle of the mouth. (From a patient under Dr. Harlan's care, at the Children's Hospital.) 826 DISEASES OF THE FACE AND NECK. Diseases of the Neck. Fig. 501.—Bronchocele (Greene.) Bronchocele or Goitre is a hypertrophied state of the thyroid gland, and may exist in an independent condition, or in connection with anaemia and protrusion of the eyeballs, as in the affection known as Graves's or Basedow's disease (Exophthalmic Goitre). Other varieties are recog- nized by systematic writers, such as the Fibrous Bronchocele, the Cystic Bronchocele* in which cysts are developed 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 upon the intrinsic vascularity of the growth itself. Bronchocele commonly appears as a soft, fluctuating, indolent tumor, occupying the situation of the thyroid gland, of which either lobe, or the isthmus, may be alone or chiefly involved, though in other cases the whole gland is equally implicated. The causes of bronchocele are somewhat obscure ; it prevails in cer- tain localities, as in the Tyrol and some parts of Eng- land, as an endemic affection, but is occasionally met with sporadically in all parts of the world, and as an acute affection has been observed as an epidemic. 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 appears to be traceable to the use of melted snow or of water impregnated with certain saline constitu- ents, for drinking purposes; but in other cases no such cause can be assigned. The use of a tightly fitting military stock, or other source of constriction about the neck, appears sometimes to have been an exciting cause of the affection. When of moderate size, bronchocele gives rise to no particular incon- venience, except by the deformity produced, and by a certain amount of dyspncea 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 congestion, organic disease of the air-passage, etc. When very large, as in a remark- able case under the care of Mr. Holmes, inflammation and suppuration 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. plunibi iodid., or the iodide of cadmium incorporated with lanolin (9j-3j), or. Wu'ch is particularly recommended by Mouat, the biniodide of mercury ointment (gr. xvj-3j). The internal administration of chloride of ammonium has been successfully resorted to by A. D. Stevens. Pressure sometime- forms a valuable adjunct to iodine inunction, but care must be taken not to irri- tate the skin, lest the disease should be thereby aggravated. Change 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. 827 residence would naturally be recommended in any7 case in which the affec- tion 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, galvano-puneture, 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. Galvano-puneture has twice succeeded in the hands of J. H. Lloyd. Oilier dissects off the integument and applies a layer of Canquoin's paste 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 supply of the diseased gland, is a dangerous mode of treat- ment, 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 by7 Meade and Mackenzie as a means of relieving the pressure on the air-passage, while, with the same object, Gibbs 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 lobes followed, and a cure was obtained. A similar operation was performed (unsuccessfully) by F. H. Hamilton in 1849. Where the enlargement is due to the presence of a tumor in the gland rather than to general hypertrophy, enucleation may be practised, cutting down in the median line till the growth is exposed, and then turning it out with the fingers. Cases successfully operated on in this way have been reported by Reverdin and Hache. Extirpation of the gland is an expe- dient fraught with considerable risk to life, and can only be justifiable in exceptional cases; when resorted to, care should be taken to plan the incis- ions so that the large vessels may, if possible, be encountered in an early stage of the proceeding, in order that, being secured once for all, the risk of subsequent bleeding may be less. Numerous successful operations upon this plan have been reported by7 Greene, Fenwick, Maury, Watson, Michel, Billroth, Kocher, Nelson, and other surgeons, Kocher's statistics giving 414 cases with 15 deaths, a mortality of but little over 18 per cent. In his own hands, the operation has been still more successful, his last series of 250 cases having given but 6 deaths, or 2.4 per cent. According to Kocher, Julliard, Reverdin, Burns, and Stokes, however, the operation is often—Semon says, in the proportion of one to three cases—followed by the development of a cretinoid condition with myxcedema, and from experi- ments on the lower animals, Zesas, Schiff, Horsley, Wagner, Sanquirico, and Canalis, conclude that complete thyroidectomy is not justifiable. Another risk of complete extirpation is the occurrence of tetany, which complicated 13 out of 37 cases recorded in Billroth's clinique, and in 8 of these proved fatal. Exophthalmic Goitre (Graves's or Basedow's disease), supposed by Filehne to depend upon a lesion of the restiform bodies, and observed by 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- 828 DISEASES OF THE FACE AND NECK. 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 reports a cure from galvanization of the sympathetic nerve in the neck. Digitalis and bromide of potassium have been successfully employed by Dr. Curtin. Gangrene of the thyroid gland has been observed by Gascoyen and other surgeons. Inflammation of the Parotid Gland may occur as an epidemic and probably contagious affection, when it constitutes the disease known as Parotitis or Mumps; or as the more serious condition denominated Parotid Bubo, which occurs 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 applicable to these cases is extirpation of the growth, and, if the tumor be of a non-malignant character, such an operation may be 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 hope 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 be 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 attempted with hope of bene- fit. Another point of impor- tance 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 superincum- bent tissues, and thus loosening the tumor, the surgeon should accomplisn the rest of the operation, as far as possible, bv pulling and tearing with nis fingers, aided with the handle of the knife, being chary of employing tne Fig. 502.—Tumor of parotid region. (Fergusson.) TUMORS OF THE NECK. 829 cutting edge in the deeper 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 bv 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 McClellan, 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 possible, 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 upper 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 are the cystic, fatty, fibrous, and glandular, though sarcomatous, carcinomatous, 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 extirpation 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 inter- ference. Eydrocele of the Neck is a name applied by Maunoir, Phillips, Syme, and other surgeons, to a cystic tumor, usually met with in the posterior inferior cervical triangle, and containing a fluid which may be of a limpid yellow color, or of a deep, grumous, chocolate hue. The treatment consists in the evacuation of the contents of the cyst, with a trocar and canula, fol- lowed by the subsequent injection of iodine, the establishment of a seton, or the conversion of the cyst into an abscess, by cutting away a portion of its anterior wall. A similar course may be adopted in the treatment of Gysls of the Parotid Region (unconnected with the gland itself), of Hygro- mataof the Hyoid Bursa, and of similar enlargements of the subcutaneous bursa sometimes found in front of the larynx, which constitute the " Super- laryngeal 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 chapter on that subject (see page 474). Congenital Tumor or Induration of the Sterno-mastoid Muscle is an obscure affection, which has been described by several surgeons, particu- 1 The operation is said to have been performed for the first time in this country by Dr. Richard Banks, of Georgia, in 1831. 830 DISEASES OF THE MOUTH, JAWS, AND THROAT. larly by Bryant, Holmes, T. Smith, H. 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. No treatment is required, as the induration subsides spontaneously in the course of a few weeks or months. According to D'Arcy Power, it is sometimes a cause of wry-neck. CHAPTER XXXIX. DISEASES OF THE MOUTH, JAWS, AND THROAT. Diseases of the Tongue. Glossitis, or Acute Inflammation of the Tongue, may occur from trau- matic causes, from the abuse of mercury, or as an idiopathic affection. The tongue rapidly swells, becomes cedematous, and protrudes from the mouth, preventing the patient from speaking or swallowing, and perhaps 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 patient 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. Tracheotomy may possibly be required to avert suffocation. Chronic Superficial Glossitis is the name given by Copland and Fairlie Clarke to an aflection 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 epithelioma. Clarke recommends the local use of nitrate of silver (gr. v to fjj) and glycerite of tannin, with the internal administration of iodide of potassium 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, but rapid recovery followed the use of borax gargles, with cataplasms, exter- nally, and the administration of quinia. Similar cases are described by Dolbeau under the name of acute ranula. 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 Gudneau de Mussy. Parella and 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 ULCERATION OF THE TONGUE. 831 very much swollen, with enlarged papillae, of a purple or brownish hue, and dry from exposure to the air. The saliva constantly dribbles from the mouth, and, in chronic cases, the alveolus and teeth of the lower jaw are displaced forwards by the pressure of the hypertrophied mass, which, ac- cording to Wegner and other modern pathologists, consists of a true lym- phangeioma. 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 V-pnaPecl piece from the tip of the organ, with the knife, galvanic cautery7, 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 septic poisoning 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 1 recoveries and 2 deaths. Gurdon Buck suggested that, as the thickness of the protruding portion was commonly more obnox- ious than its breadth, the flaps for excision should be made antero-pos- teriorly rather than from the sides of the organ. Ligation 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 widely7, according to the cause of the ulceration in each case. In most instances the diagnosis can be readily made by careful observation of concomitant symptoms ; the most difficult cases being, perhaps, those in which a chancre or tertiary syphilitic deposit is to be distinguished from an epithelioma (see pages 507, 513), or the latter from an ulcerated mass of tubercle. The Tuberculous Ulcer has been particularly studied by Tre*lat, who remarks that a chronic, intractable, superficial ulcer, with red, irregular borders, which occurs, without appreciable cause, and without enlargement of the neighboring lymphatic glands, on the tongue or in the mouth, is probably a tuberculous ulcer; and that the probability is increased if the patient be phthisical or tuberculous, or even predisposed to tuberculosis. The diagnosis, he adds, may be considered certain, if the surgeon can detect the presence of peculiar spots or patches, which are very slightly elevated, round, from half a line to two lines wide, of a yellowish, pus-like color, at first covered with epithelium, and exhibiting one or more follicular orifices —the epithelium disappearing in the course of a few days, and leaving an ulcerated surface. The only topical remedy which proved of benefit in M. Treat's case was the application of the actual cautery, but Verneuil has 832 DISEASES OF THE MOUTH, JAWS, AND THROAT. successfuliy employed chromic acid, which, according to Hybord, is a preferable remedy. Ichthyosis of the Tongue is the name given by Hulke to a chronic condition of this organ (characterized by the appearance of white or silvery patches), which may persist without change for years, but which ultimately leads to the development of epithelioma in the parts affected. According to R. W. Taylor, however, there are two varieties of ichthyosis; one in which the papillae are primarily involved, giving the tongue a warty ap- pearance, and the other beginning in the rete Malpighii. 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 H. Morris, Fairlie Clarke, Goodhart, Weir, and others, consists in excision, or, if this be not practicable, in removing sources of irritation, with attention to the digestive functions, and, as suggested by Fayrer, the administration of arsenic. Neuralgia of the Tongue has been treated by Mr. Lucas by cutting down upon and stretching the lingual nerve. Tongue-tie consists in a congenital shortening of the fraenum linguae, which prevents the tongue from being protruded beyond the line of the teeth. If present in an aggravated degree, this deformity may interfere with suckling, and, under any circumstances, the operation for its relief is so trifling that it may properly be done, if, as usually happens, the parents desire its performance. The operation consists simply in dividing the fraenum for about an eighth of an inch with blunt-pointed scissors, the cut being made towards the floor of the mouth, so as to avoid the ranine vessels, 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 performed, with a view of restoring the power of speech—a totally useless operation, since, as justly remarked by Holmes, the whole tongue itself may be ex- tirpated, and yet the power of speech remain. Tumors of the Tongue.— Cystic Tumors may occur in various parts of the tongue, but are most common beneath this organ, or in the floor of the mouth below the buccal mucous membrane, constituting in 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 majority7 of rauulae appear to be distinct cystic formations, analo- gous to those which are met with in other organs. Masses of adipocere were found in a ranula in a case recorded by Waren Tay, and numerous rice-like bodies in one described by J. G. Richardson True hydatids have been noticed in the tongue by Laugier, Molliere, and other 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 subse- quently allowed to heal by granulation. Prewitt insures the permanence of the opening by means of a plastic operation. Panas advises the in- jection 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 appear to be most accessible through an external incision. The risk of hemorrhage, however, in any attempt at complete extirpation h so great that it is, as a rule, better to" lay open the tumor from within, and TUMORS OF THE TONGUE. 833 turn out its contents, thus converting the cyst into an abscess, the healino- 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, bv excision, or by strangula- tion with the ecraseur, accord- ing to the size and situation of the growth. Busey reports •a case of papilloma of the tongue successfully treated bv the injection of acetic acid. Fatty, Glandular, and Fi- brous Tumors of the tongue may be treated Irv 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 deeply around and across the bleeding point by means of an ordinary naevus needle or one with a spiral extremity. Excision would appear to be a safer opera- tion than ligation, in cases of tumors involving the root of the tongue. Apart from the nSnf^T111^0^ swLelliri2 aQd *dema of the glottis, which attends the use oi the ligature m this situation, severe or even fatal cerebral compli- Hnnrwmay • develoPed as reflex phenomena (as in a case recorded by wew «W JDJUry r° fi?re? °f the glosso-pharyngeal nerve. If the tumor he1 , Ve7 fa!* back- and were Pedunculated, the ecraseur might PnlT I emPlo^ed> as ha* been successfully done bv Bigelow and fonte ',,,?•yPe:^K °f the ly™Ph*t™ follicles at the back of the ton ue (lingual'to nsil), a condition analogous to the adenoid vegetations flipifl an u P,har3rnx. may be conveniently treated, as advised by Uleitsmann, with the galvanic cautery. * mllThT fTi™ °fJhe Ton9ue are almost invariably of an epithelio- ZtZofTi J'ith°?8h tFUe lin^ual ™rcinomata, both of the scirrhous reawnt^^01! k*ds' are described by systematic writers. The only d seatd m ° u°.ffJr8 an^ prosPect of benefit consists i« removing the b ac omS'/;hM£' Whe? a portion on]y of the organ i« affected, may bv ZnF rv bj the aPP,,catioa of the galvanic cautery or the ecraseur, Prefect 1,&*ture8» a« i» cases of naevus, or by excision, which is the Preferable operation when the tip only is involved. H. Lee employs, in Fig. 503.—Ranula, between floor of mouth and mylo-hyoid muscles. (Feegusson.) 834 DISEASES OF THE MOUTH, JAWS. AND THROAT. addition to the ordinary ligature, one which is elastic, so as to prevent any risk of imperfect strangulation and consecpient absorption of septic material. The elastic ligature has also been employed by Despres, Delens, and other French surgeons. The tongue may usually be sufficiently ex- posed 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 Fi