NATIONAL LIBRAR NLM005545131 ( AN AMERICAN TEXT-BOOK OF SURGERY, PRACTITIONERS AND STUDENTS. BY CHARLES H. BURNETT, M. 1)., PHINEAS S. CONNER, M. D., FREDERIC S. DENNIS, M. D., WILLIAM W. KEEN, M. D., CHARLES B. NANCREDE, M. D., ROSWELL PARK, M.D., LEWIS S. PILCHER, M.D., NICHOLAS SENN, M.D., FRANCIS J. SHEPHERD, M. D., LEWIS A. STIMSON, M. D., WILLIAM THOMSON, M. D., J. COLLINS WARREN, M. I)., and J. WILLIAM WHITE, M. D. EDITED BY WILLIAM W. KEEN, M. D., LL.D., AND J. W ILL1AM WHITE, M. D., Ph.D. 6ENL' \/^0W>j PROFUSELY ILLUSTRATED. XJL/Rr"aqS PHILADELPHIA: W. B. SAUNDERS, 913 Walnut Street. 1892. wo cu Copyright, 1892, by W. B. SAUNDERS ELECTKOTVI'ED BY WKSTC'OTT 4 THOMSON, FHILADA. PRINTED BY EDWARD STERN & CO., t'HILADA. TO THE MEDICAL PROFESSION AND MEDICAL STUDENTS OF AMERICA BY THEIR CO-WORKERS AND FELLOW STUDENTS, xhk; .authors. LIST OF AUTHORS. CHARLES H. BURNETT, M. I)., Emeritus Professor of Otology, Philadelphia Polyclinic; Clinical Professor of Otology, Woman's Medical College of Pennsylvania; Aural Surgeon to the Presbyterian Hospital; and Consulting Aurist to the Pennsylvania Institution for the Deaf and Dumb, Philadelphia. PHINEAS S. CONNER, M. D., LL.D., Professor of Surgery, Medical College of Ohio and Dartmouth Medical College; Surgeon to the Cincinnati and Good Samaritan Hospitals. FREDERIC S. DENNIS, M. D., Professor of Principles and Practice of Surgery, Bellevue Hospital Medical College ; Attending Surgeon to the Bellevue and St, Vincent Hospitals; Consulting Surgeon to the Harlem Hospital and Montefiore Home, New York City. WILLIAM W. KEEN, M. D., LL.D., Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Jefferson Medical College Hospital and to the Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases; Consulting Surgeon to St. Agnes' Hospital and to the Woman's Hospital. CHARLES B. NANCREDE, M. D., Professor of Surgery and of Clinical Surgery, University of Michigan ; Surgeon to the University Hospital, Ann Arbor; Emeritus Professor of General and Orthopedic Surgery in the Philadelphia Polyclinic and School for Graduates in Medicine. ROSWELL PARK, M. D., Professor of Surgery, Medical Department of the University of Buffalo; Attending Sur- geon to the Buffalo General Hospital; Consulting Surgeon to the Fitch Accident Hospital. LEWIS S. PILCHER, M. D., Professor of Clinical Surgery in the New York Post-Graduate School and Hospital: Sur- geon to the Methodist Episcopal Hospital, Brooklyn. NICHOLAS SENN, M. D., Ph. D., Professor of Practice of Surgery and of Clinical Surgery, Eush Medical ('oil ego ; Professor of Surgery, Chicago Polyclinic ; Attending Surgeon to the Presbyterian Hospital; Surgeon-in- Chief to St. Joseph's Hospital. FRANCIS J. SHEPHERD, M. D., C. M., Professor of Anatomy and Lecturer on Operative Surgery, McGill University ; Surgeon to the Montreal General Hospital. LEWIS A. STIMSON, B. A., M. D., Professor of Surgery in the University of the City of New York; Attending Surgeon to the New York, Chambers Street, and Bellevue Hospitals. WILLIAM THOMSON, M. D., Professor of Ophthalmology, Jefferson Medical College; Ophthalmic Surgeon to the Jefferson College Hospital; Emeritus Surgeon, Wills Eye Hospital. J. COLLINS WARREN, M. D., Associate Professor of Surgery, Harvard University ; Surgeon to the Massachusetts Gen- eral Hospital. J. WILLIAM WHITE, M. D., Ph.D., Professor of Clinical Surgery, University of Pennsylvania; Surgeon to the University and German Hospitals: Consulting Surgeon to the Maternity and Samaritan Hospitals. PREFACE. The great advances which have been made in the Science and Art of Surgery within the last few years have created a need for new sources of reference, both for the student and the practitioner—a need which has been met to some extent abroad, but not so thoroughly in this country. For this reason the present Text-Book has been prepared by American authors who are teachers of surgery in leading medical schools and hospitals. Many of the most important subjects are considered from a new standpoint, and especial prominence has been given to Surgical Bacteriology, and to the most recent methods of treatment, particularly in relation to Asepsis and Antisepsis, and to the newer methods in those departments in which of late such notable progress has been made, as in cerebral, spinal, abdominal, and pelvic surgery, etc. The entire book has been submitted in proof-sheets to all of the authors for mutual criticism and revision. As a whole, the book may therefore be said to express upon important surgical topics the consensus of opinion of the surgeons who have joined in its preparation, although it must be under- stood that, while it thus represents in general the views of all the authors, each individual author is free from absolute responsibility for any particular statement. Minor differences of opinion necessarily exist, and are recognized in the text. The Editors assume the responsibility for the orthography, for the general plan of the book, and for the method of mutual criticism and of unsigned chapters. Very many of the illustrations are original, among them the bacterio- logical colored plates and the numerous half-tone plates, which are reproduced with great fidelity from photographs of patients or of specimens, and which it is believed add to the value of the work both artistically and surgically. A laro-e number of the wood-cuts and some of the colored plates have been taken from other authors, and are credited to them in the List of Illustrations; and the Editors desire to express their thanks, not only to the authors, but to the publishers of the various works, both American and foreign, from which these vii V11I PR KFACE. illustrations have been taken, for their uniform courtesy and liberality in aid- ing their work as far as possible. The Editors desire also especially to thank Dr. J. Chalmers DaCosta for preparing the index and for valuable aid in other ways, and Mr. Joseph McCreery for his very careful revision of the proof-sheets, and to express their appreciation of the unvarying courtesy and efficient co-operation of Mr. Saunders. William W. Keen, J. William White, Philadelphia, August 1, 1892. Editors. CONTENTS LIST OF ILLUSTRATIONS BOOK I. GENERAL S UR GER Y. CHAPTER I. Surgical Bacteriology.................... Plate I. Fig. 1. Staphylococcus Pyogenes Aureus and Albus (Original) . . Fig. 2. Streptococcus Pyogenes (Original)........... " II. Fig. 3. Bacilli of Tuberculosis in Sputum (Original)...... Fig. 4. Gonococcus (Original)................ Fig. 5. Bacillus Tetani (Original)............. " III. Fig. 6. Bacillus of Malignant CEdema (Original) ....... Fig. 7. Bacillus Anthracis (Original)............. " IV. Fig. 8. Giant Cells of Tuberculosis (Original)......... Fig. 9. " " (Original)......... PAGE 1 opposite p. P- P- P- P- P- P- p. 10 p. 10 CHAPTER II. Inflammation........... FIG. 1. Normal Vessels and Blood-stream (Lan- derer) ............. 2. Dilatation of Vessels in Inflammation (Landerer) ........... 3. Stasis of Blood and Diapedesis of White Corpuscles in Inflammation (Lan- derer) .............. 4. Stages of Migration of a Single White 10 Corpuscle through a Vein-wall (Ca- ton)...............13 5. Changes seen in the Leucocytes of a Frog during Ten Minutes (Original) ... 13 6. Blood-plaques, Red Corpuscles and White Corpuscles (Eberth and Schimmelbush) 14 7. Phagocyte destroying a Bacillus (Lan- derer) ..............16 CHAPTER III. The Process of Repair...........................25 Plate V. Wound healing by First Intention (third day) (Original)......opposite p. 26 8. Wound healing bv Granulation (Orig- I 10. Karyokinesis (Indirect Cell-division) inal) ...:.'........". 27 I (Ziegler)...........30 9. Repair showing Direct Cell-division 11. Carotid Artery of Horse, Two Months (Tillmanns^ .........29 after Ligature (Original).....33 CHAPTER IV. The Traumatic Fevers CHAPTER V. Suppuration and Absc 34 38 x COXTEXTS AXD LIST OF ILIA STRATIOXS. CHAPTER VI. PAGE Ulceration and Fistula.......................... 4(> CHAPTER VII. Gangrene.................................. ^9 Plate VI. Moist Gangrene from Laceration of Femoral Artery (by permission of the Surgeon-General U. S. A.) . ..........".....opposite p. 51 Fig. 12. Dry Gangrene (Original) ........................ 50 CHAPTER VIII. Thrombosis and Embolism ....................... 56 Fig. 13. A Thrombus in a Vessel (Billroth).................... 57 CHAPTER IX. Septicemia....................%............ 58 CHAPTER X. Pyemia................................... 61 CHAPTER XL Erysipelas................................. 63 CHAPTER XII. Tetanus CHAPTER XIII. Scurvy .................................. 69 CHAPTER XIV. Tuberculosis and Scrofula........................ 71 CHAPTER XV. Rhachitis................................. si CHAPTER XVI. Contusions and Wounds......................... s2 Fig. 13a. Actinomycosis (Albert).........................131 CHAPTER XVII. Syphilis...................................133 FIG. i FIG. 14. Flcerated Syphilitic Dactylitis (Orig- Syphilis (Cornil and Ranvier) . . L>1 inal).............180 16. Serrations in Normal Teeth (Cornil 15. Upper Median Incisors in Hereditary and Ranvier) .........lsl CHAPTER XVIII. Hereditary Syphilis............................17,i CHAPTER XIX. Tumors..................... .............iss Plate VII. Large Chondroma of Ilium (Original).............opposite i>. 193 " VIII. Large Sarcoma of Buttock (Original).............. »> p ii)s " IX. Fig. 1. Ulcerated Kpithelionui of Neck and Chin (Original) . . . " p. 207 Fig. 17. Fibro-cystic Tumor of Parotid , Ls. Sarcoma of Scalp (Original) .... 198 Region (Original).....191 19. Serous Cyst of Xeek (Original) . . '212 COXTEXTS AXD LIST OF ILLUSTRATIONS XI BOOK II. SPECIAL SURGERY CHAPTER I. Surgery of the Vascular System FIG. PAGE 20. Varicose Veins of the Legs and Left Thigh (Original)........218 21. Varicose Veins of the Abdomen (Gull and Bryant)..........219 22. Obliteration of Varicose Veins by Ligation (Gross)........220 23. Twisted Suture, occluding the Vein (Gross)............220 24. Na?vus (Original).........221 25. Cirsoid Aneurysm of the Temporal Artery (Bryant)........223 26. Tubulated or Fusiform Aneurysm (Original)...........224 27. Sacculated Aneurysm (Original) . . 224 28. Plan of Dissecting Aneurysm (Holmes) 225 29. Laminated Coagulum (Kev and Brv- ant) ........\ ... \ 226 30. Absorption of the Vertebrae and Ribs from Pressure by an Aneurysm (Original) . ........ .227 31. Sphygmographic Tracings of the Ra- dial Pulse of a Patient with Aneu- rysm of the Right Brachial Artery (Mahomed)..........229 32. Absorption and Perforation of the PAGE 214 Sternum from Pressure by an Aneurysm (Original)......230 33. Signorini's Tourniquet......233 34. Skey's Tourniquet........233 35. The Old Operation of Antyllus for Aneurysm (Original)......235 36. Anel's Operation for Aneurysm (Orig- inal) .......".....236 37. Hunter's Operation for Aneurysm (Original).........*. . 236 38. Brasdor's Operation (Holmes) . . . 237 39. AVardrop's Operation (Holmes) . . . 237 40. Traumatic Aneurysm (Original) . . 239 41. Plan of an Aneurysmal Varix (Orig- inal) . . ...........240 42. Varicose Aneurysm (Spence) .... 241 43. Application of Ligature to an Artery (Erichsen)...........24S 44. The Reef Knot.........248 45. Effects of Torsion on Femoral Artery (Bryant) ........ "248 46. Artery laid open to show Turning Up of Inner and Middle Coats from Torsion (Erichsen).......248 47. Modes of Applying Acupressure (Bry- ant) . . . .*.........*. 248 CHAPTER II. Surgery of the Osseous System.....................254 Plate X. Sequestrum of Entire Shaft of Femur; Involucrum riddled with Cloacae; the result of Acute Osteo-Myelitis (Original)...........opposite p. 261 XI. Fig. 1. Central Sequestrum and Osteosclerosis (Original) ..... " p. 264 Fig. 2. Tubercular Foci in lower Epiphysis of Femur (Original) . . " p. 264 XII. Fig. 1. Abscess in the Great Trochanter (Original) ........ " p. 2G7 48. Necrosis of Diaphysis following Acute Osteo-myelitis (Duplay and Reclus) 257 49. Arrest of Development of Ulna, Con- tinued Growth and Deformity of Radius (Poncet)......* . . 259 50. Superficial Sequestrum (Original) . . 261 51. Tubular Sequestrum (Original) . . . 261 52. Caries Sicca (Duplay and Reclus) . 263 53. Deformed Pelvis from Osteo-malacia (Oilier)............268 54. Exostoses of Various Dimensions (Pierret)...........269 55. Multiple Chondromata of Hand (Leo) 270 56. Osteo-sarcoma of Femur (Original) . 271 CHAPTER III. Fractures .......... ....................... Plate XII. Fig. 2. Impacted Fracture of Neck of Femur (Original).....opposite p. 57 {green-stick) Fracture (Stim- Partial son).............. 58. Transverse Fracture (Gurlt) .... 59. Longitudinal Fracture (Stimson) . . 60. Oblique Fracture (Stimson) .... 61. Toothed Fracture (Stimson) .... 62. V-shaped Fracture (Stimson) .... 63. Intercondyloid Fracture of the Hu- merus (Stimson)........276 274 27-j 275 275 276 276 64. Comminuted Gunshot Fracture {Med. and Surg. Hist. War Rebellion) . . 65. Comminuted Perforating Gunshot Fracture (Med. and Surg. Hist. War Rebellion).......... 66. Comminuted Fracture of Radius (Stimson)........... 67. Comminuted Fracture of Neck of Fe- mur (Stimson)......... 273 267 277 277 277 277 Xll CONTENTS AND LIST OF ILLUSTRATIONS. FIG. PAGE 68. Gunshot Fracture of the Humerus {Med. and Surg. Hist. IIV Rebellion) 278 69. Fracture of the Calcaneum, with crush- ing (Stimson).........279 70. Gooch's Flexible Wooden Splint (Stimson)...........285 71. Posterior Plaster-of-Paris Splint (Stim- son) .............286 72. Plaster-of-Paris Dressing (Esmarch) 286 73. Esmarch's Double Inclined Plane . . 287 74. Adhesive Plaster cut for Buck's ^Ex- tension (Stimson).......287 75. Plaster folded for Buck's Extension (Stimson)..........287 76. Adhesive Plaster applied for Exten- sion (Stimson)........288 77. Volkmann's Sliding Rest for Fractures of the Thigh..........288 78. Crisp's Splint..........288 79. Nathan R. Smith's Anterior Splint . 289 80. Hodgen's Splint........ . 289 81. Faulty Union after Fracture (Original) 293 82. "Four-tailed Bandage" for Fracture of Jaw (Stimson)........294 83. Sayre's Adhesive Plaster Dressing for Fracture of Clavicle, first piece (Stimson)...........298 84. The same, second piece (Stimson) . 298 85. Velpeau's Dressing for Fracture of Clavicle (Stimson).......298 86. Impacted Fracture of Humerus through the Tuberosities (R. W. Smith)............300 87. Separation of Upper Epiphysis of Hu- merus (Moore).........301 88. Fracture of Surgical Neck of Hume- rus (Stimson) .........302 FIG. PAGE 89. Fracture of Internal Condyle of Hu- merus (Gurlt) .........• 304 90. Fracture of Forearm, Angular Dis- placement and Union between the Bones (Stimson).......306 91. Recentlv-united Fracture of Lower End of Radius (R. W. Smith) . 307 92. Fracture of Lower End of Radius, displacement of broken fragment backward (Stimson)......307 93. Silver-Fork Deformity of Colles's Fracture (Original)......308 94. Fracture at Small Part of Neck of Femur (Stimson).......310 95. Fracture at Base of Neck of Femur, with splitting of great trochanter (Stimson)...........310 96. Impacted Fracture at Base of Cervix Femoris (Bigelow).......311 97. Bryant's Uio-femoral Triangle . . 312 98. Intercondyloid Fracture of Femur (Bryant)...........314 99. Hamilton's Dressing for Fracture of Patella............315 100. Agnew's Splint for Fractured Patella 316 : 101. Agnew's Splint Applied.....316 102. Malgaigne's Hooks.......316 103. Diagrams to Illustrate the Mechan- ism involved in Fracture of Lower End of Fibula (Treves) .... 319 104. The Usual Three Lines of Fracture in Pott's Fracture of the Ankle (Stimson)...........319 105. Pott's Fracture, showing Outward Displacement (Original) .... 320 106. Pott's Fracture, showing also Back- ward Displacement (Original) . 32f> CHAPTER IV. Diseases and Injuries of the Muscles, Tendons, and Bursse 321 107. Anderson's method of Lengthening a Tendon...........323 108. Synovial Sheaths of Flexor Tendons of Fingers (Original).....326 109. Chronic Teno-svnovitis of Extensor Tendons of Wrist (Original) . . 327 110. Melon-seed Bodies (Original) . . . 327 111. Czerny's Method of Tendon-suture . 331 112. Double Housemaid's Knee (Original) 333 CHAPTER V. Orthopedic Surgery...........................334 120. Genu Valgum (Bradford and Lovett) 339 121. Genu Varum (Bradford and Lovett) 340 122. Talipes Equinus (Albert).....341 123. Talipes Calcaneus (Albert) .... 341 124. Double Equino-varus (Original) . . 342 125. Pes Cavus (Albert).......344 126. Print of Normal Foot-sole (Albert) 345 127. Print of Flat Foot-sole (Albert) . . 345 128. Hallux Valgus (Bradford and Lov- ett) .............;.;4.3 129. Hammer-Toe (Anderson).....346 113. Torticollis (Original).......334 114. Dupuytren's Contraction (Keen) . . 336 The Same Hand after Operation (Keen) ..........336 Double Club-Hand (Original) . . . 337 Agnew's Operation for Webbed Fin- gers . . ...........338 Didav's Operation for Webbed Fin- gers (Walter Pye).......338 119. Transverse Section of Same (Walter Pye).............338 115. 116. 117. 118. CHAPTER Surgery of the Nerves......... 130. Neuromata in a Stump (Duplay and VI. 347 Reclus) ...........353 131, 132. Distribution of the Cutaneous Sensitive Nerves upon the Head (Seehgmuller) ........ 353 CONTENTS AND LIST OF ILLUSTRATIONS. XLU FI(i- PAGE 133. Distribution of the Cutaneous Sensi- tive Nerves to the Shoulder, Arm, and Hand (Henle).......359 134. Paralysis of Ulnar Nerve from Wound (Duchenne)......360 135, 136. Loss of Sensation on Anterior and Posterior Surfaces of Hand after Division of the Ulnar Nerve (Bowlby)...........360 FIG- PAI.K 137, 138. Areas of Anesthesia and Dyses- thesia on Palmar and Dorsal Sur- faces of Hand, after Section of Me- dian Nerve (Bowlby).....361 139. Musculo-spiral Paralysis after Frac- ture of Humerus (Erichsen) . . 362 140. Distribution of the Cutaneous Nerves of the Lower Extremity (Henle) . 363 141. Suture of a Nerve by Splitting the Ends (Beach).........365 CHAPTER VII. Surgery of Joints.............................372 142, 143. Position in Coxalgia (Albert) . 380 144. Common Site of Hip Abscess (Brad- ford and Lovett)........381 145. Intra-acetabular Luxation in Coxal- gia (Tillmanns)........381 146. Effects on Lumbar Spine of Flexing and Extending the Diseased Leg in Hip Disease (Albert) .... 382 147. Double Ankylosis from Hip-joint Disease (Original).......383 148. Result after Double Subcutaneous Osteotomy of the Femur in above case (Original)........384 149. Ankylosis and Contracture in Tu- berculosis of Knee-joint (Till- manns) ...........385 150. Subluxation in Knee-joint Disease (Schreiber)..........385 151. Ankylosis of Knee-joint (Marsh) . . 386 152. Advanced Tubercular Disease of the Elbow (Bradford and Lovett) . . 389 153. Osteo-arthritis of Elbow (Moullin) . 397 154. Angular Ankylosis of Knee (Brad- ford and Lovett)........405 155. Nodules of Fibro-cartilage in Joint (Howard Marsh).......406 CHAPTER VIII. Dislocations 156. Dislocation of Femur, with new ace- tabulum (Kronlein)......411 157. Diagram to show Effect of Position upon Apparent Length of Arm in Dislocation of Shoulder (Stimson) 412 158. Diagram to show Effect of Position of Limb upon Tension of a Liga- ment (Original)........413 159. Double Congenital Dislocation of Hip (Stimson)........416 160. Upward Dislocation of Acromial End of Right Clavicle (Original) 420 161. Adhesive Plaster Dressing for Up- ward Dislocation of Acromial End of Clavicle (Original).....420 162. Subcoracoid Dislocation of the Left Shoulder (Stimson)......422 163-165. Kocher's Method of Reduction of Dislocation of Shoulder by Manipulation (Ceppi) . • . 423, 424 166. Subglenoid Dislocation of Humerus (Original)..........424 ...................408 167. Subglenoid Dislocation of Humerus (Stimson)...........425 168. Supracoracoid Dislocation (Albert) 426 169. Dislocation of Elbow Backward (Stimson)...........429 170. Outward Dislocation of Elbow (Orig- inal) .............431 171. Complete Dislocation of Elbow (Hamilton)..........431 172. Deformity in Dislocation of the Wrist Backward and in Colles's Fracture (Stimson) ...... 434 173,174. Dislocation of Thumb (Farabeuf) 435 175. Dislocation of Hip Below and then Behind and Above the Obturator Internus (Stimson).......438 176. Recent Dorsal Dislocation of Hip (MacCormac).........438 177. Dorsal Dislocation of Femur (Stim- son) .............439 178. Diagram of Various Dislocations of Patella (Stimson).......443 CHAPTER IX. Diseases ami Injuries of the Lymphatics...............447 Plate IX. Fig. 2. Malignant Lymphoma (Hodgkin's Disease) (Original) . . . opposite p. 207 179. Lymphoedema of Leg (Original) 454 i 180. Lymphoedema in its Later Stage I (Original)..........455 CHAPTER X. Surgical Diseases of the Skin and its Appendages 456 CONTENTS AND LIST OF ILLUSTRATIONS. BOOK 111. RE GIONA L SI R GER Y. CHAPTER I. Diseases Plate XIII. XIV and Injuries of the Head 1 Fig. 1. Linear Fracture of Vault of Skull (Original)......opposite p. Fig. 2. Depressed Fracture of Vault of Skull (from within) (Orig- inal *......................• " p Fig. 3. Depressed Fracture of Vault of Skull (from without) (Orig- inal) ....................• • • " p. Fig. 1. Fracture of Base of Skull (Original).......... " p Fig. 2. Gunshot Fracture of Lower Jaw and Cranium (Original) . " p. PAGE 472 500 500 500 503 503 FIG. PAGE j FIG. 181. Skull showing the Points Named by Broca............474 182. View of Brain from Above (Ecker) 475 183. Outer Surface of Left Hemisphere (Ecker) . . .........476 184. Inner Surface of Right Hemisphere (Ecker 191. Hopkin's Rongeur Forceps .... 482 192. Horsley's Dural Separator .... 482 193. Keen's Double Brain-electrode . . 483 194. Keen's Rongeur Forceps.....487 195. Hemorrhage from Middle Meningeal Artery (Jacobson).......497 I<85. Chiene's Method of Fixing Position of Rolandic Fissure t Original) . 477 186. Horsley's Cyrtometer.......477 187. Wilson's Cyrtometer.......478 188. Head, Skull, and Cerebral Fissures (Adapted from Marsliall by Hare) 479 189. Motor Areas on Outer Surface of Brain (Horsley and Schafer) . . 480 190. Motor Areas on Median Surface of Brain (Horsley and Schafer) . . 481 476 ' 196. Perforating Gunshot Wound of Brain (Thompson and Keen].....507 197. Fluhrer's Aluminium Gravity Probe 508 198,199. Method of Determining the Point for Counter-trephining ( Bryant) . 509 200. Fungus Cerebri (Original) - . . - 510 201. Special Points for Trephining (Barker)...........520 202. Puncture of Lateral Ventricles (Keen)............523 CHAPTER II. Surgery of the Spine 536 Plate XV XVI XVII. Fracture of the Spine (Original) ... 537 Lateral Curvature of Spine (Scoliosis) (Original)........opposite p. Pott's Disease of the Spine (Spondylitis) (Original)....... " p. .............. " P- 203. Spina Bifida i Original) .... 204. Primary and Secondary Lateral Cur- vatures (Agnew) ........542 205. Torsion in Lateral Curvature (Brad- ford and Lovett)........542 206. Leather Jacket and Jury-mast i Sayre) • • >.........544 207. Manner of Picking Up an Object in Pott's Disease (Agnew).....547 208. Standing Position in Pott's Disease (Agnew).....,.....547 209. Psoas Abscess (Albert).....548 210. Extension in Recumbent Position (Reeves)...........549 211. Tripod for Suspension (Sayre) . . 55(i 212. Application of Plaster Jacket i Sayre, 213. Plaster Applied and Slit Up in order to prepare Plaster Cast..... 214. Fracture of Spine with Laceration of Cord i Shaw)........ 215. Fracture-dislocation of Seventh Cer- vical and First Dorsal Vertebrae iTliorburn).......... 216. Antero-lateral View of a Cervical Dislocation (Koenig)...... 217. Anterior View of same (Koenig) 21S. Complete Unilateral Dislocation of a Cervical Vertebra (Koenig) . . . 219. Luxation of the Fifth Cervical Ver- tebra (Blasius)........ 542 546 559 550 551 559 561 obo 565 566 566 CHAPTER III. Surgery of the Respiratory Organs ..................§§- 220. Deflection of the Nasal Septum 223. Roberts' Operation for Deviation of (Roberts)...........571 Septum............573 221. Jarvis's Punch .......572 224. Jarvis's Snare..........r-^ 222. Park's Nasal Saw (Original) ... 573 225. Raynor's Naso-pharyngeal Scissors ' 570 CONTENTS AND LIST OF ILLUSTRATIONS. xv 226. Bellocq's Canula.........580 227, 228. Mucous Polypi in the Nose jSajous)...........583 229. AYarrens Apparatus for Tagliacozzi's Method of Rhinoplasty .... 591 230. Indian Method of Rhinoplasty (Prince)...........591 231. Polyp of Larynx (Stoerek) .... 599 232. Papilloma of Larynx (Stoerek) . . 599 FIG. PAGE 233. Carcinoma of Larynx (Stoerek) . . 600 234. Park's Divided Trachea-Tube ... 607 235. Johnson's Modified Durham's Tra- chea-Tube .........608 236. Keen's Trachea-Tube.......608 237. O'Dwyer's Instruments......609 238. Park's Modified Gussenbauer's Arti- ficial Larynx.........613 CHAPTER IV. Diseases and Injuries of the Neck...................627 Plate XVIII. Goitre (Bronchocele) (Original)..............opposite p. 636 CHAPTER V Surgery of the Digestive Tract..... 239. Head of an Embryo (Quain) ... 639 240. Double Hare-lip (Koenig) .... 640 241. Hare-lip with Fissure of Lower Eye- lid (Kraske) ........" . 640 242. Hare-lip extending into Nose (Koe- nig) .............640 243. Hare-lip in a Negro (Original) . . 641 244. Simple Hare-lip with Equilateral Sides (Druitt).........641 245. Method of Clemont or Malgaigne (Nelaton)...........641 246. Method of Mirault (Nelaton) . . . 642 639 247. 248. 249. 250. 251. 252- 256. Deformity from Cicatrix following a Burn (Original)........645 Results of Operation in same (Orig- inal) .............645 Cancrum Oris (Albert).....646 Kocher's Incision for Removal of Tongue............655 AVhitehead's Gag (Koenig) ... 667 255. Operation for Cleft Palate (Ber- nard and Huette) .... 667, 668 Forceps for Removal of Foreign Body from Gullet (Fergusson) . 673 CHAPTER VI. Diseases and Injuries of the Abdomen................674 Plate XIX. Fig. 1. Inguinal Hernia (Original)..............opposite p. 784 Fig. 2. Femoral Hernia (Original)............. • p. 784 XX. Fig. 1. Large Scrotal Hernia (Original)............ p. 786 Large Labial Hernia (Original)............ " p. 786 257-259. Heinicke-Mikulicz Method of Pyloroplasty.......695,696 260. Gastroenterostomy (Rockwitz) . . 697 261. Oblique Division of Stomach and Duodenum in Pylorectomy (Bill- roth) ............. 262. Duodenum United to Greater Curva- ture of Stomach (Billroth) . . • 263. Lumbar Colostomy: Colon without Mesentery (Allingham).....707 264. Lumbar Colostomy: Colon with Marked Mesentery (Allingham) . 265. Decalcified-Bone Plate (Senn) . . 266. Ileo-colostomy (Senn)...... 267. Ileo-colostomy Completed (Senn) . 268, 269. Lateral Anastomosis with Abbe's Rings (Abbe).......713,714 270. Eye of Calyx-eyed Needle (Original) 714 271. Brokaw's Four-segment Ring . . . 714 272, 273. Intestinal Anastomosis without Rings (Abbe).........715 274. Lembert Suture.........717 699 700 707 710 711 712 275. Czerny-Lembert Suture...... 276. Intestinal Obstruction over a Band (Koenig) . . . _........ 277. Floating Liver (Original)..... 278. Rectum Opening into Bladder (Owen) 279. Section showing Feetal Bladder, Meckel's Diverticulum, etc. (Owen) 280. Imperforate Rectum (Holmes) . . 281. Rectal Veins seen from Without (Duret) ........... 282. Prolapsus Recti (Bryant)..... 283. Different Levels of Resection of Sa- crum (Maas)......... 284. Hernial Sac with Contained Bowel (Original).......... 285-287. Macewen's Operation for Hernia 288. Barker's Operation for Hernia . . 289-291. McBurney's Operation for Her- nia ............774, 292. Congenital Hernial Sac (Original) . 293, 294. Infantile Hernia (Original) . . 295. Funicular Hernia (Original) . . . 717 726 747 751 751 752 753 757 766 769 773 / to 783 784 784 CHAPTER VII. Surgery of the Genito-Urinary Tract '92 CONTENTS AND LIST OF ILLUSTRATIONS. Plate XXI. Fig. 1. Diverticulum of the Bladder (Original).........opposite p. 895 Fig. 2. Hypertrophy of the Median Lobe of the Prostate (Wat.-oni P- *$° XXII. Hvpertrophv of the Median and Lateral Lobes of the Prostate *( Watson)"........................ " p. 896 fk;. PAGE 296. Relations of Kidnev (Godlee and Thane).....".......792 297. Kidneys, Ureters, and Colon from Behind (Holden).......793 2(.K8. Operations upon the Kidney (Treves) 794 299. Surgical Kidney (Original) .... 799 300. Surgical Kidney Laid Open (Orig- inal) . . . .*.........799 301. Suprapubic and Rectal Routes in Retention of Urine (Holden) . . 812 302. Thompson's Searcher.......822 303. Curved Stone Forceps for Lithotomy 826 304. Straight Stone Forceps for Lithotomy 826 305. Lithotomy Staff.........'826 306. Catheter 'en Chemise......826 307. Lateral Lithotomy (Tillmanns) . . 827 308. Buckstone Browne's Tampon . . . 828 309. Lifting the Peritoneum by Rectal and A'esical Distention (Rotter) . 830 310. Petersen's Rectal Colpeurynter . . 831 311. Bigelow's Lithotrite .......832 312. Thompson's Lithotrite......833 313. Beak of Bigelow's Lithotrite ... 833 314. Bigelow's Evacuator.......S34 315. Leiter's Cystoscope (Tillmanns) . . 842 316. Thompson's Vesical Forceps . . . 844 | FIG. PAGE 317. Section of Bladder and Adjacent Structures (Owen).......845 318. Catheter Curves (Van Buren and Keyes)............846 319. Faulty Curves of Catheter (Van Buren and Keyes) .... ■ 846 320. Proper Curve of Catheter (Van Buren and Keves).......847 321, 322. Passing a Catheter (Albert) 847, 848 323. Filiform Whalebone Bougies . • - 848 324. Gouley's Tunnelled Catheter . . . 84s 325. Phimosis from (ionorrhea (Cullerier) 853 326. Paraphimosis (Cullerier) . . . . 854 327. Fasciae of Urethra, Prostate, and Blad- der (Macalister)........892 328. Vertical Section of Male Pelvis (Braune)...........895 329. \rertieal Section of Pelvis in Pros- tatic Hypertrophy (Koenig) . . 896 330. Hydrocele (Albert)".......908 331. Tapping a Hydrocele (Tillmanns) . 910 332. Duplay's Operation for Hypospadias ( Duplay and Reclus) ' .... 914 333. Transverse Section of Penis after same (Duplay and Reclus) . . . 914 CHAPTER VIII. Surgery of the Female Genito-Urinary Organs 334. Diagrammatic Sagittal Section of Fe- male Pelvis (Skene)...... 335. Relation of Ureters and Uterine Arteries to Cervix Uteri (Pozzi) . 336. Bimanual Palpation (Pozzi) .... 337. Line of Incision in Perineoplasty (Pozzi)............ 33s. Perineoplasty, the Vaginal Flap Raised (Pozzi)........ 339. Perineoplasty, condition after Sutur- ing (Pozzi).......... 340. Vesico-vaginal Fistula;, edges being pared (Simon) ........ 341. Shape of Flap in Anterior Elytror- rhaphy (Original)....... 342. Suturing the Wound" of Anterior Elytrorrhaphy (Original) .... 343. Hypertrophy of Cervix Uteri i Skene) 344. Diagram of the Pieces Removed in Amputation of Hypertrophied Cer- vix (Skene) .......... 345. Bilateral Laceration of Cervix Uteri (Original)......... 346. Fibro-myomata Uteri (Original) . . 347. Trendelenburg's Position by Ede- bohl's table.......... 348. Tamponade of Peritoneal Cavity after Hysterectomy (Pozzi) . . . 349. Lymphatic Vessels of Uterus (Pozzi) 918 350. Cancerof Both Lips of Uterus Skene i 351. Edebohl's Position .... 919 352. Hydrosalpinx (Hennig)..... 921 ) 353. Tubal Pregnancy: Rupture at end of Second Month (Bandl) . . . 927 | 354. Chronic Ovaritis with Multiple Cvsts | (Winckel)........'. . 927 i 355. The Cyst-regions of the Ovary (Sut- ton) ............. Incipient Cyst of Ovary \ Sutton i Human Ovary in Section (Sutton) . Paroophoritic Cyst (Doran) .... Ruptured Paroophoritic Cvst i Sut- ton)............. Papillary Cyst growing between the Layers of the Broad Ligament (Sutton)........... Papillomatous Cyst of the Broad Ligament (Original)....... Cyst of the Parovarium (Sutton i . Lateral A'iew of Abdomen in Ascites (Albert)........... Lateral View of Abdomen in Ovarian Cyst (Albert)......... 94S 365. Area of Dulness in Ovarian Cys- toma (Barnes) ......... 953 366. Area of Dulness in Ascites (BarnesI 918 957 958 959 964 96* 973 928 I 356. 357. 932 358. ' 359. 935 I 360. 935 936 ; 361. 937 362. 363. 938 943 364. 978 978 979 979 H8U 980 981 981 984 984 >),S.) 985 CHAPTER IX. Diseases and Injuries of the Breast 988 CONTENTS AND LIST OF ILLUSTRATIONS. xv 11 Plate XXIII. Fig. 1. Sarcoma of Breast (Original)............opposite p. 998 Fig. 2. Scirrhus of Breast (Original)............ " p. 998 XXIV. Fig. 1. Ulcerated Scirrhus of Breast (Original)....... " p. 1001 Fig. 2. Recurrent Scirrhus of Breast (Original)....... " p. 1001 FIG. PAGE 367. Fibroma of Breast (Agnew) . . . 996 368. Sarcoma of Breast (S. W. Gross) . 998 369. Retraction of the Nipple in Mam- mary Carcinoma (Bryant) . . . 1000 370. Atrophic Scirrhus of Breast (S. W. Gross)............1002 CHAPTER X. Surgery of the Eye......... 371. Glaucomatous Excavation of Optic Papilla (Fuchs).......1026 372. Operation for Blepharophimosis (DeWecker).........1031 373. Wharton Jones' Operation for Ectro- pion ............1032 374. Edges of AVound brought together inaY............1032 375. Pterygium (Meyer).......1034 376. Operation for Staphyloma Cornese (De Wecker) .........1034 377. Critchett's Operation for Staphy- loma............1035 378. Stump after Critchett's Operation for Staphyloma.......1035 379. Enucleation of Eyeball (Meyer) 1 1036 380. Silver Spatula (Swanzy).....1037 381. De Wecker's Forceps-scissors . . . 1037 382. Spring Speculum . .-......1037 383. Iris Forceps..........1038 384. Fixation Forceps........1038 385. Keratotome..........1038 1007 386. Blunt Hook..........1038 387, 388. Iridectomy (Juler).....1038 389. Linear Extraction (Swanzy) . . . 1039 390. Cataract Knife.........1040 391. Cvstitome...........1040 392. Capsule Forceps........1040 393. Horn Spoon..........1040 394. Wire Loop..........1040 395. Lid Elevator .......... 1040 396. Incision for Modified Peripheral Linear Extraction (Swanzy) . . 1041 397. Incision in Cataract Extraction (Juler)...........1041 398. Three-millimeter Flap Operation (Swanzy).........1042 399. Diagrams of Various Methods of Extraction (De Schweinitz) . . 1045 400. Bowman's Method of Capsulotomy (Swanzy)..........1045 401. Advancement of External Rectus (Swanzy)..........1047 CHAPTER XL Surgery of the Ear......... 402. Aspergillus Glaucus (Burnett) . . 1053 403. Insufflating Powder into the Ear (Burnett)..........1053 404. Politzer's Method of Inflating the Middle Ear.........1055 1048 405. Insertion of Eustachian Catheter (Burnett)..........1056 406. Fixation of Eustachian Catheter in Position (Burnett)......1057 407. Aural Polypus Snare (Burnett) . . 1058 BOOK IVY OPERATIVE SURGERY. CHAPTER I. General Principles ......... 408. Continued or Glover's Suture (Ber- nard and Huette).......1075 409. Interrupted Suture (Bernard and Huette)...........1075 410. Quilled Suture (Bernard and Huette)...........1076 1062 411. Twisted Suture (Bernard and Huette)...........1076 412. Button Suture (Bryant).....1076 413. Quilted Suture (Bernard and Huette)...........1076 CHAPTER II. Anesthesia . 1082 XV111 CONTENTS AND LIST OF ILLUSTRATIONS. CHAPTER III. Plastic Surgery PAGE 1092 CHAPTER IV. Ligation of Arteries...........................1099 Plate XXV. Surgical Anatomy of the Neck (Maclise)..........opposite p. 1101 XXVI. Surgical Anatomy of the Neck (Maclise).......... " p. 1103 XXVII. Surgical Anatomy of the Axilla (Maclise)........... " p. 1105 XXVIII. Surgical Anatomy of the Arm (Maclise).......... " p. 1107 XXIX. Surgical Anatomy of the Forearm (Maclise)......... " p. 1109 XXX. Surgical Anatomy of the Hand (Maclise).......... " p. 1111 XXXI. Surgical Anatomy of the Pelvis and Thigh (Maclise)..... " p. 1113 XXXII. Surgical Anatomy of the Leg (Maclise).......... " p. 1115 XXXIII. Surgical Anatomy of the Leg (Maclise)........... " p. 1117 414. Aneurysm Needle (MacCormac) . 1100 415. Aneurysm Needles (MacCormac) . 1100 416. Manner of Tightening Ligature (MacCormac)........1100 417. Incisions for Ligating Temporal, Facial, Lingual, Common Carot- id, Subclavian, Axillary, and In- ternal Mammary Arteries (Mac- Cormac) . . .........1101 418. Incisions for Ligating the Axillary, Brachial, Radial, and Ulnar Arteries (MacCormac) .... 1107 419. Position of Superficial Palmar Arch (MacCormac)......1109 420. Incisions for Ligating the Common and External Iliac Arteries (Mac- Cormac) . . .........1110 421. Incisions for Ligating the Gluteal, Sciatic, and Pudic Arteries (Mac- Cormac).............Ull Incisions for Ligating the Common and Superficial Femoral and the Posterior Tibial Arteries (Mac- Cormac) ...........1114 Incisions for Ligating the Anterior Tibial and DorsalisPedis Arteries (MacCormac)........1117 422. 423. CHAPTER V. Operations on Bones and Joints....................1118 424. A Curved and a Straightened Tibia (Treves, after Little).....1122 425. Macewen's Operation for Genu Val- gum (Treves)........1122 426. Osteotomy for Faulty Ankylosis of Hip (Treves) ........1124 427, 428. Excision of Upper Jaw (Treves) . . ..........1125 429. Saw Incisions in the Maxillae (Treves)...........1126 430. Extirpation of the Scapula (Till- manns) ...........1127 431. Excision of Shoulder (Treves) . . 1128 432, 433. Excision of Elbow (Treves) . 1129 434. Excision of Elbow (Treves, after Farabeuf)..........1130 435. Excision of Wrist (Treves) . . . 1131 436. Various Excisions of Hand (Treves) 1131 437. Excjsion of Hip-joint (Tillmanns) 1132 438, 439. Excision of Hip (Treves) . . 1132 440. Resection of Knee (MacCormac) . 1133 441. Excision of Knee (Treves, after Farabeuf)..........1134 442. Excision of Knee (Treves) . . . 1134 443. Resection of Ankle-joint (Till- manns) ...........1135 444, 445. Excision of Ankle and Astrag- alus (Treves).........1135 446. Osteoplastic Resection of Foot (Treves)...........1136 447. Foot and Shoe after same (Treves) 1136 448. Excision of First Metatarsal Bone (Treves)...........1137 CHAPTER VI. 456 457 Amputations............. 449. Petit's Tourniquet (MacCormac) . 1139 450. Circular Amputation (Esmarch) . 1141 451. Flap Amputation by Transfixion (SeMillot)....... . . . 1142 | 458 452. Mixed Method of Amputation (Es- march) ...........1143 453. Amputation of Phalanx (Treves) . 1145 454. Amputation of Thumb (Treves) . 1145 455. Amputation of Forearm (Bryant) . 1146 | 1137 1147 Amputation of Arm (Bryant) . . Larrey's Amputation at the Shoul- der-joint (Treves).......1147 Removal of the Wrhole Upper Ex- tremity (Treves).......H48 459. Amputation of Toes (Treves) . . . 1148 460. Lisfranc's Amputation (Treves) . . 1149 461, 462. Coupde Main in Lisfranc's Am- putation (Guenn) .... 1149,1150 CONTENTS AXD LIST OF ILLUSTRATIONS. xix FIG. PAGE 463. Chopart's Amputation (Treves) . 1150 464. Syme's Amputation (Treves) . . . 1150 465. Pirogoff's Amputation (Wyeth) . 1151 466. S£dillot's Method of Amputating (Wyeth) ..........1151 467. Bilate'ral Flap Method of Stephen . Smith............1152 FIG. PAGE 468. Amputation of Thigh (Bryant) . 1152 469, 470. Wyeth's Method of Amputa- tion at Hip-joint.......1154 471. Liston's Amputation at Hip-joint (Wyeth) ..........1155 CHAPTER VII. Minor Surgery...............................1159 Plate XXXIV. Bandages (Original)..................opposite p. 1160 XXXV. Bandages (Original).................. " p. 1162 XXXVI. Bandages (Original).................. " p. 1164 XXXVII. Bandages (Original).................. " p. 1166 472. Aveling's Apparatus for Immediate 473. Aspirator and Injector.....1170 Transfusion.........1170 LIST OF PLATES. I. Fig. 1. Staphylococcus Pyogenes Aureus and Albus (Original) . . opposite page 5 Fig. 2. Streptococcus Pyogenes (Original)........... " " 5 II. Fte. 3. Bacilli of Tuberculosis in Sputum (Original)....... " " 7 Fig. 4. Gonococcus (Original)................ " " 7 Fia. 5. Bacillus Tetani (Original)............... " " 7 III. Fig, 6. Bacillus of Malignant CEdema (Original)........ " " 9 Fig. 7. Bacillus Anthracis (Original)............. " " 9 IV. Fig. 8. Giant Cells of Tuberculosis (Original)......... " "10 Fig. 9. Giant Cells of Tuberculosis (Original)......... " "10 V. Wound healing by First Intention (third day) (Original)..... " "26 VI. Moist Gangrene from Laceration of Femoral Artery (by permission of the Surgeon-General U. S. A.).............. " " 51 VII. Large Chondroma of Ilium (Original)............. " " 193 VIII. Large Sarcoma of Buttock (Original)............. " "198 IX. Fig. 1. Ulcerated Epithelioma of Neck and Chin (Original) ... " " 207 Fig. 2. Malignant Lymphoma (Hodgkin's Disease) (Original) . . " " 207 X. Sequestrum of Entire Shaft of Femur; Involucrum riddled with Cloaca?; the result of Acute Osteo-Myelitis (Original) .... " " 261 XI. Fig. 1. Central Sequestrum and Osteo-sclerosis (Original) .... " " 264 Fig. 2. Tubercular Foci in lower Epiphysis of Femur (Original) . " " 264 XII. Fig. 1. Abscess in the Great Trochanter (Original)....... " "267 Fig. 2. Impacted Fracture of Neck of Femur (Original)..... " " 267 XIII. Fig. 1. Linear Fracture of Vault of Skull (Original) ...... " " 500 Fig. 2. Depressed Fracture of Vault of Skull (from within) (Orig- inal) ....................... " "500 Fig. 3. Depressed Fracture of Vault of Skull (from without) (Orig- inal) .................... • . . " "500 XIV. Fig. 1. Fracture of Base of Skull (Original).......... " "503 Fig. 2. Gunshot Fracture of Lower Jaw and Cranium (Original) . " " 503 XV. Lateral Curvature of Spine (Scoliosis) (Original)........ " " 542 XVI. Pott's Disease of the Spine (Spondylitis) (Original)....... " "546 XVII. Fracture of the Spine (Original)............... " "559 XVIII. Goitre (Bronchocele) (Original)............... " "636 XIX. Fig. 1. Inguinal Hernia (Original).............. " "784 Fig. 2. Femoral Hernia (Original) .... ......... " "784 XX. Fig. 1. Large Scrotal Hernia (Original)............ " "786 Large Labial Hernia (Original)........... " " 786 XXI. Fig. 1. Diverticulum of the Bladder (Original)......... " " Si*o Fig. 2. Hypertrophy of the Median Lobe of the Prostate (Watson) " " 89o XXII. Hypertrophy of the Median and Lateral Lobes of the Prostate (Watson) ........................ " "896 XXIII. Fig. 1. Sarcoma of Breast (Original)............. " "998 Fig. 2. Scirrhus of Breast (Original)............. " " <)98 XXIV. Fig. 1. Ulcerated Scirrhus of Breast (Original)......... " " 1001 Fig. 2. Recurrent Scirrhus of Breast (Original)........ " " 1001 XXV. Surgical Anatomy of the Neck (Maclise)........... " " H01 XXVI. Surgical Anatomy of the Neck (Maclise)........... " " H03 XXVII. Surgical Anatomy of the Axilla (Maclise) ........... " " HQ5 XXVIII. Surgical Anatomy of the Arm (Maclise)............ " " HOT XXIX. Surgical Anatomy of the Forearm (Maclise).......... " " H09 XXX. Surgical Anatomy of the Hand (Maclise)........... » " HH XXXI. Surgical Anatomy of the Pelvis and Thigh (Maclise)...... " "1113 XXXII. Surgical Anatomy of the Leg (Maclise)............ « "1115 XXXIII. Surgical Anatomy of the Leg (Maclise)............ '< "HIT XXXIV. Bandages (Original)..................... « « 1160 XXXV. Bandages (Original)..................... « "116° XXXVI. Bandages (Original)..................... « <• 1164 XXXVII. Bandages (Original)..................... « « 116o- xx AN AMERICAN TEXT-BOOK OF SURGERY. BOOK I. GENERAL SURGERY. CHAPTER I. SURGICAL BACTERIOLOGY. Bacteria or micro-organisms, or microbes, as they are variously called, belong to the lowest order of the vegetable kingdom, and are closely allied to the algae. They derive their name from ftaxzyptov, a rod, which some of them resemble in shape. The developed organism is, in form, a cell, consisting of a membrane enclosing a protoplasm. This protoplasm can be strongly stained by aniline dyes. The membrane, with difficulty separated from the contents, consists of a substance closely allied to cellulose. It is not usually visible, but when treated in water its outer layer may swell and form a gelatinous envelope or capsule. During the process of division this holds the organisms together, and as they multiply may form the zooglea or glue-like mass in which they are sometimes grouped. Many bacterial growths are highly colored, being red, yellow, or blue; according to some observers the coloring matter is in the protoplasm; according to others, it lies in granules which have been exuded—both theories are true. Many forms of bacteria possess no movement whatever, as is the case with the micrococci and the anthrax and tubercle bacilli. The great majority are at times capable of motion. The principal forms of bacteria are the micrococcus or globular form (xoxxo^, a berry), the bacillus or staff shape (bacillus, a little rod or staff), and spirillum or spiral shape. The micrococci, when developing rapidly, are seen often in the stage of division, and, being grouped in "pairs," are called diplococci. When arranged in rows or "chains" they are called streptococci (ozpeTtzot;, a chain); when bunched together in "grape-like" masses they are called staphylococci (ozayukij, a bunch of grapes.) These forms undergo no essential changes, although under differing condi- tions they may have an altered appearance. They multiply by fission, the process being more readily observed in the cocci than in the bacilli. A 1 2 AN AMERICAN TENT-BOOK OF SURGERY. number of the bacilli and a few spirilla undergo germination, spore-formation taking place within the cell before it is finally destroyed. There may be only one spore to each cell, the spore thus formed possessing an extremely dense enveloping membrane, which protects it from external influences until it can find conditions favorable for future growth. The cell is usually distended either in the middle or at one end by the spore, and when the latter has reached its full development the cell-membrane undergoes a gelatinous softening, the cell breaks up, and the spore is free. When the spore begins to develop into a bacillus it loses its tough envelope, and is then much more readily destroyed. Bacteria are to be found everywhere, even occasionally in the interio: of the healthy living tissues. They exist in the air, the soil, the water, in our clothing, on the surface of our bodies, and on the mucous membrane of the intestinal and respiration tracts. They grow best in alkaline or neutral media. They multiply under favorable conditions with great rapidity: according to Cohn, a bacillus divides into two in the space of an hour, into four at the end of a second hour, and so on. In twenty-four hours the number derived from a single bacillus will amount to sixteen and a half millions. It is chiefly in dead organic substances that they find a favorable soil, and it is through them that the process of decom- position is carried on. Those concerned in this process are called saprophytic or saprogenic. A certain number grow in the living body, causing by their presence morbid conditions, and are known as the pathogenic or disease- producing bacteria. Those which produce pus are known as pyogenic bacteria. Pasteur divided bacteria into aerobic, or those which live best in the pres- ence of oxygen, and anaerobic, or those which live without oxygen. The greater portion of the bacteria are aerobic. Some are so sensitive that a slight diminution in the amount of oxygen is sufficient to prevent their development. These are called the obligate aerobic bacteria. Others, however, can grow well in media rich in oxygen, but are also able to grow where there is no oxy- gen. These are called the facultative aerobic bacteria. Most of the pathogenic bacteria belong to this variety, the oxygen of the body not being found in large quantities and being soon consumed by the micro-organisms in their growth. It is rare that we find a strictly anaerobic pathogenic form. An example of this variety is the bacillus of tetanus. The presence of sunlight is unfavorable to the growth of bacteria. During the process of decomposition very powerful poisons known as pto- maines (nzcofxa, a dead body) are developed in the presence of saprophytic bacteria. They resemble alkaloids in their physiological action, and when absorbed into the body may produce more or less marked constitutional dis- turbance. The sepsin of Bergmann and the cadaverin and putrescin of Brieger are examples of these chemical substances. Leucoma'ines are also alkaloidal substances produced by the action of bacteria upon albuminoid material (keuxos), but only during the life of the animal furnishing such material. A ptomaine may thus, under certain circumstances, be met with as a leucomaine (providing it be capable of production either before or after death), but the contrary never. To this class probably belono- the "toxines." Some of these substances appear to have an inhibitory influence upon the micro-organisms, and it is in virtue of this action that manv of the artificial cultures of bacteria after a period of growth cease to develop'. It is not yet fully settled how the bacteria act upon the living tissues of the body: by some it is supposed that the symptoms of infectious disease are pro- duced by the chemical substances which they elaborate as a sort of specific excretion; others believe that the phenomena of disease are produced bv the changes brought about in the tissues by the organisms during their growth .S* UR GICA L BA CTERIOL O G Y. 3 and that it is not necessary to assume the development of a particular virus. Such action of the micro-organisms will produce locally what is known as irritation or inflammation. The chemical substances produced are, moreover, diffused throughout the body, and in virtue of a ferment-like action greatly increase the tissue-metamorphosis and act also upon the thermic centres, producing fever or "constitutional disturbance." Occasionally we have an absorption of ptomaines alone, which may be introduced in large amounts, producing grave disturbances. Such a condition is known as septic intoxication or toxic infection, as distinguished from septic infection of bacteria. The effect of the virus of certain diseases upon the tissues of the body is often such as to afford a protection against future attacks. This is thought by Pasteur to be due to the exhaustion of a supposed chemical substance neces- sary for the growth of the micro-organisms. According to Fraenkel, certain products of bacterial action are left behind after the first invasion, and prevent a return of the same kind of organism. Metschnikoff has advanced the theory that the leucocytes, seen in such large numbers in inflammatory processes, possess the power to attack and destroy the invading bacteria, taking them up into their protoplasm. He gives these amoeboid cells the name of phagocytes. The general weight of opinion seems to be that predisposition to disease means chiefly that the tissues of the body offer a soil the chemical composition of which is favorable to the growth of bacteria, and that immu- nity is possessed by those tissues which furnish a soil unfavorable for their development. The chemical constitution of the liquor sanguinis is therefore an important element in the solution of this question. Pfeffer has recently called attention to the faculty possessed by all motile bacteria of moving toward or away from certain substances which attract or repel them, and has given to it the name of chemiotaxis. The leucocytes and various others cells possess the same property, and their phagocytic action is but a part of the general power which they have of incorporating into them- selves and then removing foreign dead or offending material. Further investi- gation in this direction may explain immunity in some instances. The question of the direct transmission of microbic disease from parent to offspring is one not susceptible of easy demonstration. There are two routes through which hereditary disease may be communicated: through the placenta during intra-uterine life, or during the act of conception through the semen as a vehicle. Placental infection has been observed in small-pox, erysipelas, typhoid, and intermittent fever. Glanders has been transmitted in this way from mare to foal, and the bacilli of anthrax, glanders, and malig- nant oedema have been shown by experiment to pass through the placenta to the foetus. The tubercle bacillus has been found in the seminal fluid of consump- tives not suffering from tuberculosis of the genital organs. Tubercular lesions have been found in the human foetus at varying periods of intra-uterine life. There is therefore no doubt that this disease may be transmitted from parent to child: it is merely at the present time a question of the frequency and method of transmission of the disease (Baumgarten). It is also well known that syphilis may be acquired through both the semen and placenta, although the fact that no specific organism has as yet been discovered renders it impos- sible to furnish the bacteriological proofs. Most bacteria grow best at a temperature varying from 86° to 104° F. The saprophytic or putrefactive organisms prefer a temperature of about 75° F., or the ordinary house temperature. The pathogenic bacteria grow best at a temperature of from 95° to 104° F. Subjecting solutions containing bacteria to freezing temperatures does not generally kill the micro-organisms. They 4 AN AMERICAN TENT-BOOK OF SURG ELY. all lose the power of movement and reproduction at this temperature, but may preserve the power to resume their activity at a higher temperature. Cohn has reduced the temperature of liquids containing bacteria as low as —186° F. without destroying their vitality. Cold is therefore an agent which can- not be employed to destroy these organisms. Experiments show that organ- isms containing spores, like the bacilli of anthrax, are much more difficult to kill than the micrococci, which do not contain spores. If dry heat is used as a means of sterilization, it is necessary to expose the latter to a temperature of 212° F. for an hour and a half in order to destroy them. Bacilli containing spores, however, must be subjected to a temperature of 284° F. for three hours before they are rendered incapable of further growth. The dry heat, moreover, does not always penetrate easily to the centre of arti- cles subjected to this process, and most materials, and particularly instruments, are permanently injured by such high temperatures. The fact that boiling water will kill all kinds of organisms and spores in a few minutes suggested the application of hot steam for the purpose of disinfec- tion. Experiments showed that moist heat had in fact a much greater germicidal value than dry heat. In Koch's sterilizer all kinds of bacteria are destroyed in half an hour when subjected to a temperature of 212° F., even in those cases where the organisms were surrounded by voluminous dressings and materials of different kinds. Most of the ordinary pyogenic bacteria are micrococci, and therefore produce no spores. They are not tenacious of life, but are easily destroyed by heat. The bacilli of anthrax, malignant oedema, and tetanus, spore-bearing surgical bacteria, can practically be left out of consideration in the sterilization of surgical instruments. The following experiment shows how readily the ordinary surgical bacteria can be destroyed: Agar-agar tubes planted with a mixed growth of cocci were exposed to the action of steam in the Arnold sterilizer, and one tube was removed at the end of five minutes, a second tube at the end of ten minutes, and so on. A second series of tubes was inoculated from the first tube removed, and all of them remained sterile. No further growth occurred in the original tubes, showing that the micrococci were destroyed by the action of the steam for the minimum length of time, five minutes. (A. K. Stone.) The Arnold sterilizer, which is cheap and convenient and is in common use in this country at present, furnishes a rapid and easy method of generating steam, and when in action can prepare a set of instruments for a suro-ical operation in five minutes' time. The short period during which the instru- ments are exposed to the heat renders them much less liable to injury, which is almost certain to follow longer exposure, and which has rendered unpopular this mode of sterilization among many surgeons. The most powerful of bactericidal drugs is corrosive sublimate. A solution of 1 : 1,000,000 exercises a marked retarding influence upon the develop- ment of bacteria. A solution of 1 : 20,000 kills the spores of bacilli in ten minutes, and a solution of the strength of 1 : 1000, according to Koch, destroys the most powerful organism in a few minutes, without any previous preparation of the object to be disinfected. Aqueous solutions of carbolic acid in the strength of 1 : 100, destroy in two minutes sporeless anthrax bacilli, and in the strength of 1 : 30 is sufficient for all ordinary surgical purposes, as it retards the development of the spores and kills the mature oro-anisms. But solu- tions in oil have not the least influence upon the life of micro-oro-anisms. Boric acid and salicylic acid have been regarded as useful antiseptic drugs but their germicidal power is now known to be almost nil. Iodoform is not a germicide, but markedly retards the growth of bacteria; used as a powder, it PLATE I. •:.;k •• /•76\ /. [Camera Lucida. Zeiss aprochromatic objective 2. o mm. ocular 6.] Staphylococcus pyogenes aureus and albus. a. pus cell with nuclei, b. free nuclei. FIG. 2. [Same power as jig: 1.] Streptococcus pyogenes in pus. a. pus cell with nuclei, b. free nuclei. SURGICAL BACTERIOLOGY. o has a tendency to stop serous oozing, a condition favorable to bacterial growth. When moistened it liberates iodine, which has a certain antiseptic value. It does not procure asepsis of material, instruments, or wounds. The microscopical study of bacteria has been greatly facilitated by the use of the Abbe" condenser, which is placed beneath the object-glass and throws a cone of rays with a very broad base, thus giving powerful-illumination of the section and making it possible to use higher powers which would otherwise cut off the light. By this means the section is flooded with light and the structure of the tissues is made quite transparent. If now we use aniline dyes, which stain the micro-organisms, and wash the sections afterward in alcohol or acetic acid, the coloring matter will be in great part removed from the tissues, and the bacteria alone will retain the dye. In this way the bacteria are readily dis- tinguished from other objects, when examined with suitable lenses. For this purpose immersion lenses alone are reliable. Furthermore, contrast-stains can be often advantageously employed, by means of which the tissues are given a decidedly different though paler hue. Fragments of tissue which it is desired to examine for bacteria should be cut in pieces half an inch square and placed immediately in absolute alcohol. This should be changed once or twice, and in two days the specimen is ready for cutting. The sections are placed for five to fifteen minutes in dilute solutions of fuchsin or gentian-violet. They are then decolorized in acidulated water, and afterward washed in water; after alcohol has been used to remove the water from the specimen it is mounted in Canada balsam. It is often necessary to examine the urine or the sputa for tubercle bacilli, for the purposes of diagnosis. The urine, which should be collected in con- siderable quantity, is allowed to deposit a compact sediment. A small portion of this sediment is spread upon a thin cover-glass held by a pair of forceps. It is best to let this become nearly or completely dry, and then to pass the cover-glass three times gently through the flame of an alcohol lamp in order to better fix upon the glass the material it is proposed to examine. If the sediment is light, a second or even a third drop is added, and each time evaporated to dryness. The cover-glass is now placed in the following solution, (Ziehl), which has been slightly warmed, for from five to ten minutes:l Fuchsin, 1 gram; Carbolic acid solution (5 %), 80 c.c.; Alcohol (95 %), 20 c.c. It is then decolorized by placing it in a 5 per cent, solution of strong sul- phuric acid, which removes the fuchsin from all but the bacilli. The length of time necessary for the bleaching process must be determined by experiment. The cover-glass is next washed thoroughly with distilled water, and is then placed in a strong watery solution of methyl-blue for about five minutes. The glass is finally washed in distilled water, dried thoroughly, and mounted in Canada balsam upon a glass slide. The bacilli appear under the micro- scope as minute red rods scattered about upon a blue background. The same 1 Koch-Ehrlich Stain for the Bacillus of Tuberculosis.—1. Sections or cover-glass preparations are left in aniline water fuchsin (or gentian-violet) solution for twenty-four hours in the cold. 2. Transfer to a solution of nitric acid (1 part to 3 of water if sections, 1 part to 4 of water if cover-glasses) for two to three seconds (just long enough to pass them through). 3. Then transfer to 60 per cent, alcohol for a moment, to complete the decolorization. 4. Wash in water. 5. A contrast-stain may be made with a watery solution of methylene-blue [it fuchsin be the first stain) or vesuvin (if gentian-violet be first used). 6. AVash thoroughly in water, dry, and mount, if cover-glasses. Dehydrate, clear in oil of cedar, and mount, if sections. 6 AN AMERICAN TENT-BOOK OF SURGERY. method of staining is applicable to the detection of the tubercle bacillus in the sputa of phthisical patients. A drop of the sputum is selected from one of the tough yellow clumps floating in the sputum and placed upon the cover-glass; a second cover-glass is then placed on top of it, and the sputum is pressed out into a thin layer. The glasses are then separated and dried, and furnish two specimens for the coloring process. Bacteria are not usually found in the healthy tissues of the body, although occasionally they may be concealed in certain structures which show no symp- toms of disease, and first make themselves manifest after the infliction of an injury or during the course of some inflammatory process. Cocci and spores may remain latent in cicatrices for a considerable length of time, awaiting a suitable opportunity for development. It is not uncommon to discover the presence of tubercle bacilli in individuals apparently healthy. An injury or a slight bruise under such circumstances would offer an opportunity for their development either as a local or a general tuberculosis. Micrococci are often found tem- porarily in the blood of individuals whose vital powers are enfeebled. They may disappear quite rapidly—even in a few hours—without having given rise to any well-defined pathological process. Bacteria are found in all kinds of true inflammations. The term "sim- ple inflammation" is intended to designate that variety in which no micro- organisms are found. This form of inflammation is a more limited one than was formerly supposed, and is confined chiefly to those processes which follow injury and are concerned in repair if bacteria are excluded (Senn). The forms of bacteria most frequently met with in surgical diseases are those which produce suppuration. These organisms are known as the pus microbes or pyogenic cocci. The Pus microbes consist of several varieties, but the most common form is the staphylococcus pyogenes aureus (PI. I, Fig. 1), so called from the grouping of the cocci in clusters. Its shape is globular, and it meas- ures from 0.7 to 0.87 micromillimeters in diameter. It multiplies by division, but the line of fission is difficult to see. It is a very durable organism, and requires several minutes' boiling or steaming to destroy its power of growth. It is readily stained by all the coloring agents. It grows well at the ordinary house temperature, but is more active when growing at a temperature nearer that of the body. It does not need a large amount of oxygen for its growth. When cultivated in the test-tube upon beef gelatin it forms at first a yellowish-white layer, which later changes to an orange color; hence the last part of its name —aureus. If thrust deeply into the gelatin, the upper surface softens as the growth forms, and becomes liquefied in virtue of peptonizing action exerted by the organism. It has a peculiar odor of sour paste. The aureus is found abun- dantly outside of the human body. It can be obtained from dirty dish-water, the soil, or the air, particularly in foul hospital wards, but its most common seat is the superficial layers of the skin, particularly of the axillse and other moist parts, and also under the ends of the finger-nails. It is also found in the mucus of the pharynx and digestive tract. Other forms of the pyogenic cocci, but less frequently seen than the aureus are the staphylococcus pyogenes albus and the staphylococcus pyogenes citreus. The Streptococcus pyogenes (PI. I, Fig. 2), is an important variety of the pus cocci. The arrangement of the organism is in chains or rows six to ten being usually attached together. These cocci measure about one micro- millimeter in diameter. On culture-media the growth reaches its development in four or five days, and has at first a transparent whitish look, but later a TLATE II. % V x -*/ FIG. 3. [Camera Lucida. Zeiss aprochromatic objective 2. o mm. ocular 6.\ Bacilli of tuberculosis in sputum. T We. . \ ^ — * \ X /•YC. 4. [Same power as jig. 3.] Gonococcus from gonorrheal pus. FIG. 5. [Same power as jig. 3.] Bacillus tetani. Cover glass prepara- tion from culture by Kitasato. SURGICAL BACTERIOLOGY. 7 brownish color. The streptococci are found under normal conditions in the saliva, secretions of the nostrils, vagina, and urethra. The Bacillus pyocyaneus is an organism Avhich is found in green or blue pus. It is a small, thin rod with distinctly rounded ends, and unites in chains of five or six links. It has a very active motion. The pigment is deposited from the bacilli when in contact with oxygen, and is then seen principally on the exposed edges of dressings. The substance thus found is termed pyocyanine. The pyogenic cocci are found in all acute abscesses. The staphylococci are found in circumscribed abscesses, as boils, carbuncles, suppurating glands, em- pyema, osteomyelitis, etc. The streptococci are more frequently seen in the spreading inflammations, as phlegmonous cellulitis, erysipelas, ulcerative endo- carditis, and metastatic abscesses such as are seen in pyemia. In order that suppuration should take place it is not simply necessary that the pyogenic cocci should be introduced into the living tissues. It is found that other conditions are of equal importance. Cheyne has shown by experi- ment that the number of bacteria injected is an important factor. The dose must be sufficiently large. It is owing, probably, to this fact that many cases of imperfect asepsis in surgical operations often heal well. Doses of less than 18,000,000 of the Proteus vulgaris when injected into the muscular tissue of a rabbit seldom cause any result, and it requires as large a number as 250,000,000 to produce a circumscribed abscess. But the state of the tissues in which the organisms are arrested is also a matter of great importance. Tissues which have been damaged by injury or inflammation are not so resistant to the action of bacteria as when in a state of health. A healthy peritoneum may receive and absorb a large number of bacteria, but if damaged during a laparotomy, so that a considerable portion of its secreting surface has been destroyed and at the same time considerable oozing of blood and serum has taken place from the injured surfaces, a soil favorable for the growth of the organisms is provided and a septic peritonitis may result. Tense sutures are more likely to be followed by " stitch abscesses " than where the sutured margins of the wound come easily together. The question has arisen, Can suppuration take place without the presence of bacteria ? Steinhaus has shown that calomel, and also nitrate of silver, when injected into the tissues can produce pus in certain animals. Even the chemical substances formed by the pyogenic cocci, when separated from them and injected, can produce non-bacterial pus. But, as Senn remarks, the matter remains practically where it was before, as clinically we do not meet with examples of acute suppuration without the introduction of the pyogenic cocci into the system. Foreign bodies or mechanical irritation cannot produce pus without the aid of bacteria. The pus-producing power of the cocci lies in their ability to liquefy the fibrinous exudation of inflammation. The pyogenic cocci are not usually found in cold abscesses. It was sup- posed that this form of abscess was produced by the tubercle bacillus only, but Ernst and others have found the aureus and albus in several cases of psoas abscess. It is possible that the failure to obtain cultures from this kind of pus is due to the dying out of the organism owing to the age of the abscess. The Streptococcus erysipelatis resembles closely in all respects the streptococcus pyogenes, and the weight of evidence is at present strongly in favor of their identity. In all cases it is the cause of the disease, and direct proof has been given of its power by inoculation of open wounds in the human subject. The Gonococcus (PI. II, Fig. 4) is the specific organism which pro- duces gonorrhea. It measures 1.25 micromillimeters in diameter, and is S ^.V AMERICAN TEXT-BOOK OF SURGERY. usually arranged as a diplococcus. One of the most striking peculiarities which distinguishes it from nearly all other forms of micrococci is its ability to penetrate cells and multiply rapidly within them. In this way it may be read- ily recognized under the microscope. It is difficult to cultivate, as it will only grow on blood-serum and when isolated from other cocci. The gonococci are stained well with methyl-blue, and may be prepared for examination by the cover-glass method mentioned previously. The organisms grow more readily on those mucous membranes which possess a cylinder epithelium or one closely allied to it, as the membranes of the male and female urethra, the uterus, and the conjunctiva. It does not penetrate below the epithelial layer, the more deep-seated suppuration, such as bubo, being due to the presence of the pyo- genic cocci. The Tetanus bacillus (PI. II, Fig. 5) is a large, slender rod with somewhat rounded ends. Spore-formation takes place at the end of the bacillus, and, as it enlarges the cell considerably, gives it the so-called drumstick shape. It is mov- able, belongs to the strictly anaerobic organisms, and rapidly dies when exposed to the air. It is readily colored by methyl-blue and fuchsin. It can be culti- vated in cultures of gelatin mixed with grape-sugar, and grows well at the bottom of the inoculation puncture, whence it sends out innumerable little pro- longations, giving the growth the appearance of the fir tree. It is difficult to separate from other organisms, but several American and foreign bacteriolo- gists have succeeded in obtaining pure cultm*es. The spores are found in garden soil, in masonry, in decomposing liquids, and in manure. Hence the frequency of the disease in those employed about stables. It is quite frequently met with in the dust of the streets, but owing to its anaerobic nature is not easily inoculated into the living tissues. Brieger has obtained from cultures a number of toxines, to one of which he has given the name tetanin, and inasmuch as the same group of symptoms are obtained experimentally by the toxines as by the bacilli, and as the latter are hard to find in the blood and internal organs in individuals who have died of tetanus, it has been thought probable that the symptoms of the disease are produced, in a great measure, by this substance. The Tubercle Bacillus (PI. II, Fig. 3).—This organism was first seen under the microscope by Baumgarten, but Koch cultivated and fully identified the organism with the disease in 1882. The bacilli are small, thin rods, two to four micromillimeters in length—that is, about one-half the diameter of a red blood-corpuscle. The rod is slightly bent in the middle and its ends some- what rounded. The longest rods are usually seen in phthisical sputa. They are usually single, occasionally being found in pairs or arranged in the form of the letter V. They do not possess the power of motion. The bacillus possesses great powers of resistance to destructive agencies, the organisms in tuberculous sputa being destroyed only after twenty minutes' boiling. The expectoration can be kept for months and even years in a dried state without destruction of - the bacilli. They are stained by the ordinary aniline dyes with far greater dif- ficulty than any other bacteria, and, in common with the bacilli of leprosv, which they closely resemble, do not yield to bleaching fluids like all other bacteria. The bacilli are found between the leucocytes in the tubercles, in the epithelioid cell, and also in large numbers in the giant cell, being generally seen at its periphery. The organism is very difficult to cultivate, and grows well only on a hardened blood-serum or a combination of the ordinary nutrient media with glycerin, for which latter agent it appears to have a special predilection. When cultivated on agar the first signs of the growth appear at the end of fourteen davs, and one to two weeks more pass before full development has taken place. It appears then as thick scales of a dull grayish-white color, which are very dry 'PLATE III. \ \ ...... ..^.. l& .Jf^ /*YC. 6. [Cawzera Lucida. Zeiss aprochromatic objective 2. o mm. ocular 6.] Bacillus of Malignant Oedema. Cover glass preparation from spjeen of white mouse. *-'^ "' >/ ./ ' ,1/ 1 :^'«*»"•■ \ I: : "V \ \ / —/ \ \ : . ^ ■•''™.>:.-;i;, 'v. ,,lVtfSI..f :•/> \ f/G. 7. [Same power as jig. 6.\ Bacillus Anthracis. Cover glass preparation from spleen of white mouse. SURGICAL BACTERIOLOGY. 9 and brittle. The material for culture is usually obtained by inoculating a guinea-pig with tuberculous sputum. Cover-glass preparations "show the bacilli growing in S-shaped or scroll-like masses. The tubercle bacilli are true parasitic organisms, as they are unable to grow outside of the living tissues of man and animals. Inoculation may take place through the skin, following slight bruises or cuts. The organism is very re- sistant to the action of the digestive fluids, and animals fed experimentally with tubercle bacilli have developed general tuberculosis. It is probable, therefore, that they can penetrate the mucoac membrane, and may be carried into the system with the food. H. C. Ernst has shown that six drops of the milk from a tuberculous cow, injected subcutaneously into a guinea-pig, may develop a tuberculosis. The milk of tuberculous cows is therefore a very dan- gerous article of food. The breathing of infected air is the most frequent mode of acquiring the disease. The frequency of pulmonary tuberculosis is sugges- tive of this mode of infection. Cornet has shown that the dust of infected localities is dangerous. The organisms are distributed through the air when in a dry state, and are found in the dust of hotels or hospitals occupied by consumptives, and in factories and prisons. The tuberculous sputa should not be allowed to dry, being harmless when kept moist. All tuberculous patients therefore should expectorate into a cup containing an antiseptic solution. Bacillus of Malignant CEdema (PI. Ill, Fig. 6).—This bacillus was first described by Pasteur, but its present name was given to it by Koch. It is occasionally found in traumatic gangrene. It is a saprophytic organism, and is found in decomposing substances and in rich garden soil. The bacilli have an active motion and contain large spores. The cultivation is attended with the evolution of gas, and when the bacilli are inoculated into animals they produce a gangrenous oedema as in man. The pseudo-oedema bacillus is also sometimes found in this form of gangrene, as well as the streptococcus. In noma, a gangrenous inflammation of the mouth and female genitals in young children, Lingard has found long bacilli, and Ranke has found strepto- cocci. No specific organism for traumatic gangrene has yet been found. It is probable that the ptomaines play an important part in the process. No bacte- rial examinations have been made of hospital gangrene, as, thanks to antisepsis. it is now almost an historical disease only. Studies made as early as lt the flow qt blood is greatly increased and a greater amount of blood is observed in the part. The lumen of the artery is greater than before, and the column of red corpuscles is much broader and fills a comparatively greater portion of the lumen of the vessel. The capillaries are now quite distinctly seen, and are crowded with blood-corpuscles. They appear to be considerably larger than they were before. The flow of blood is also more rapid in the veins, and it is of a brighter and more arterial color. This condition of the circulation is known as hyperemia (Fig. 2), and is presently succeeded by a slowing of the current, which soon becomes much more F'G- 3- sluggish than in the normal state. This is first noticed in the capilla- ries, and soon after in the veins. The pulsation, however, continues in the aiteries. As a result of this diminution of speed the column of blood-corpuscles becomes broader, and almost completely fills the in- terior of the vessels. In the veins a great accumulation of white cor- puscles takes place on the interior of the walls. Being of a lower specific gravity than the red cor- puscles, the leucocytes are not forced onward with the same mo- mentum, and are dropped, as it were, here and there on the vessel- wall. Finally they are so greatly increased in numbers that the entire wall of the vessel appears to be lined with leucocytes. The white corpuscles also accumulate in the capillaries, but not to the same extent. In the arterioles these corpuscles cling more readily to the wall during the diastole, but they are soon swept away again into the blood- current. Another step in the process, beginning concurrently with the slowing of the blood-stream, is the emigration of the leucocytes from the interior of the veins (diapedesis) (Figs. 8 and 4). Many leucocytes, by a change of shape, send out little prolongations of protoplasm into the substance of the wall, and slight protuberances are soon seen projecting from its outer surface. These enlarge, and we now see the corpuscles presenting an hour-glass appearance. The por- tions within the vessel soon follow those without, and the leucocytes escape from all contact with the vessel. Many corpuscle* appear to follow one another through the same point in the wall. Whether there are actual holes (stomata) between the endothelial cells of the vessel through which the leucocytes escape or not is still a disputed question. The annvboid movements of'the leuco- cytes are effected by a power of those cells to change their shape. Processes (pseudopodia) are thrown out from the protoplasm of the cell, which now becomes elongated or flask-shaped. As the protoplasmic mass 'resumes its more or le-s globular form, the main portion follows the protruded mass, and Pta»i> of Blood and Diapedesis of White Corpuscles in Inflammation: a, artery; b, vein ; c, capillary. INF LA MM A TION. 13 a change in the position of the cell results. The white corpuscle is a minute mass of granular, or, according to some authors, reticulated, protoplasm, con- Ym. 4. 10-30. PM. 10-1-0. H-15. 11-40. 12-20. Stages of the Migration of a Single White Blood-corpuscle through the Wall of a Vein in Two Hours and Ten Minutes (mesentery of the frog). taining one or more nuclei, and without any limiting membrane. The cells which accumulate in large numbers outside the walls of the blood-vessels in Fig. 5. Changes seen in the Leucocyte of a Frog during Ten Minutes. inflammation have the same appearance. Migration takes place to a limited extent also from the capillary vessels, but no such process is observed in the walls of the arteries. A considerable quantity of liquor sanguinis also escapes from the blood-ves- sels into the meshes of the surrounding tissues, where it coagulates and encloses many of the leucocytes. When the inflammation has been severe the increased determination of blood to the part—or congestion, as it is usually called—is much greater; many red corpuscles may be forced through the vessel walls, 14 AX AMERICAN TEXT-BOOK OF SURGERY. and we then find among the leucocytes occasionally a few red corpuscles. There is a considerable increase FlQ- 6-_____________ i>, the number of white corpuscles in the blood, and those organs in which leuco- cytes abound, as the spleen and lymphatic glands, are frequently enlarged at this a, blood-plaques or third corpuscle^ 6, red corpuscles; c, white time The tyrd corpmcle of the blood (Fig. 6, a), or blood-plaque, is also frequently seen in increased numbers in the blood in inflammatory processes. This is a colorless protoplasmic disk 1.5 to 3.5 micro- millimeters in diameter, numbering about one to every twenty red corpuscles (Osier). They are not visible in the circulating blood, but are found in masses as component parts of a clot. They are supposed by some to be connected with the formation of red blood-corpuscles, and are seen in large numbers at the crises of fevers and after the healing of acute abscesses. When caustic is applied to a minute spot in the centre of the frog's tongue, we may observe all these different changes in the circulation under the micro- scope at the same time. At some distance from the point of irritation the circulation is normal; nearer are seen the dilated vessels, with slowing of the blood-current; next comes a zone in which a free emigration of leucocytes has taken place. As we approach the centre the circulation becomes still" slower, and when we finally reach the spot where the reagent has acted directly upon the vessels, the blood no longer flows through them : this is the condition known as stasis. The slowing of the blood-current was regarded by Cohn- heim as characteristic of inflammation. Recklinghausen, however, does not consider this a necessary part of inflammation. There is probably consider- able variation in the rapidity of the current, which depends upon the amount of swelling, or destruction of tissues, or other causes which may mechanically impede the circulation of blood in the vessels. The slowing of the current seen in laboratory experiments is, according to Recklinghausen, due princi- pally to mechanical conditions. When blood is drawn by venesection in inflammation or fever, coagulation takes place less rapidly, and on the surface of the clot a buffy coat (crusta phlo- gistica) is formed. This is due to the presence of numbers of leucocytes which contain a large amount of paraglobulin and fibrin ferment. These substances, uniting with the fibrinogen found in the blood-plasma, produce the fibrin of the blood-clot. The old theory of a fibrinous crasis is thus explained. The changes seen in the circulation account for two of the cardinal symp- toms—viz. heat and redness. The rapid return of color seen after pressing the finger on an inflamed surface indicates the increased amount of blood. The copious bleeding from incisions in an inflamed tissue shows the increased determination of blood to the part and the distention of even the smallest capillaries. The bright scarlet redness is also an indication of the active hyperemia which exists in acute inflammation. In the more chronic forms, or in those in which the congestion is very intense and the flow of blood is consequently not so rapid, there is a bluish tinge to the reddened surface. If the color cannot be entirely pressed away with the finger, this is due either to decomposition of the coloring matter of the blood, which leaves'a yellowish tinge behind, or, if a reddish tint remains, it is caused by the presence of red blood-corpuscles which have been forced out of the vessels bv the inten- sity of the pressure. This " hemorrhagic" form of inflammation has often IXFLAMMA TIOX. 15 a much deeper and more irregular coloring than is usually seen in acute inflammation. Redness is entirely absent in bloodless parts, as in the cor- nea, but in this case we find a hyperemia of the vessels of the conjunctiva, and later an actual development of vascular loops in the direction of the inflamed spot. It was at one time supposed that the increased warmth of the part was due to a local production of heat. It is now known that the local rise of temperature is due to the greater amount of blood which flows through the vessels. One of the most constant symptoms of inflammation is the swelling. This is rarely absent, and is seen even in non-vascular parts. The increased amount of blood in the vessels of the part does not add materially to its size. We must seek for an explanation of this phenomenon in the altered condition of the tissues of the part. On making an incision into an inflamed spot we find the meshes of tissue distended with an abundant exudation, which, as we have seen, escapes through the Avails of the dilated blood-vessels. The tissues are saturated with this material often to such an extent that it may be difficult for the surgeon to recognize the difference between muscles, fascia?, and vessels. The exudation consists not only of leucocytes, but, in addition, of a certain amount of fluid which closely resembles the liquor sanguinis, and from which fibrin is formed giving a certain firmness to the part. The tissues are also crowded with leucocytes. The increased number of cells in the part was at one time attributed to the division or "proliferation" of the pre-existing cells of the inflamed tissues, but Cohnheim maintained that the new cells were the escaped white blood-corpuscles, and that the so-called fixed connective-tissue cells played no part in the process, being incapable of proliferation. This doctrine he illus- trated by experiments upon the cornea. The opacity produced by an artificial inflammation was found to be due to the presence of numberless leucocytes, while the corneal corpuscles were found to be unchanged. Subsequent obser- vations have, however, shown that the fixed cells of the cornea also undergo proliferation and take part in the process. Cohnheim thought that the immense number of cells found in an inflamed part were all derived from the white cor- puscles, and that by subsequent proliferation they were increased in number and formed what is known as granulation-tissue, Avhich he assumed played a prominent part in the healing process. It is a well-known fact, however, at the present time, that the fixed connective-tissue corpuscles and other cells in tissues of the body are capable of division. According to the latest views on the origin of the granulation-tissue, the round cells with single nuclei are mostly formed by the proliferation of connective-tissue and other fixed-tissue cells. Later, many of these cells, as also the leucocytes, become polynuclear cells, and as such are incapable of taking any further active part in the process. Accord- ing to Ziegler, the polynuclear leucocytes appear to be taken up and destroyed by the proliferating connective-tissue cells, the leucocytes apparently serv- ing simply as nutriment for these cells. The process of multiplication by cell-division is now much better understood than formerly, and the mode of indirect division (karyokinesis, p. 30) in which the nucleus plays a prominent part is the one most frequently observed. The meshes of the tissue are distended with coagulated lymph, and the connective-tissue fibres are swollen and softer than usual, and here and there terminate suddenly, as if broken off, giving them a club-shaped appearance. In the organs affected we find the epithelial cells altered in appearance, being in the condition known as that of " cloudy swelling;" that is, their protoplasm is granular and more opaque, and containing frequently fatty granules. Dur- ing the development of the inflammatory process the leucocytes are seen infil- 16 AX AMERICAN TEXT-BOOK OF SURGERY. Fig. 7. A Phagocyte destroying a Bacillus. trating the tissue betAveen the pre-existing cells, arranged in toavs or irregular masses or scattered about singly. They are more numerous in the immediate neighborhood of the small veins and capillaries. At the height of the inflam- mation the part may be completely filled Avith small round cells, many of them leucocytes and many of them derived from the cells of the inflamed part. Various views are held as to the function of the leucocytes. Cohnheim regarded them as the active agents in the process of repair. By others they have been regarded as the scaven- gers Avhich appropriate to themselves the broken-doAvn materials Avhich result from inflammation, and thus aid in the process of absorption. Fragments of dirt or blood-clots or carmine granules, Avhen used experi- mentally, are found in the proto- plasm of these cells. Metschnikoff has advanced the theory known as phagocytosis, according to Avhich the cells of the inflamed part, in virtue of their ability to consume foreign sub- stances, attack and destroy the invading bacteria (Fig. 7). These cells are called phagocytes (ifdyto, to eat, and xuzo^. a cell). If they are able to destroy the bacteria, the system is protected from the invading organisms. The leucocytes are called micro-phagocytes (or microphages), and the larger cells developed from the fixed connective-tissue cells are called the macro-phagocytes (or macrophages). The latter may consume the smaller cells after their struggle Avith the bacteria, and thus assist in the process of absorption. A large number of experiments were performed by Metschnikoff in support of this theory. Other writers have, however, shoAvn that the leucocytes may be the vehicles by Avhich the bacteria are conveyed to distant portions of the body, and that they are therefore capable of spreading infection. The doctrine has not been generally accepted as an explanation of the immunity Avhich certain animals or individuals possess against the attacks of certain diseases. The rich cell-infiltration of an inflamed part may, however, exert a protective influence in other Avays. The lymph-spaces of inflamed tissue are usually crowded Avith leucocytes, and absorption of chemical or bacterial poison is thus prevented. The mechanical protection Avhich the gran- ulating surface of a wound affords is in striking contrast to the rapidity with Avhich a freshly-exposed tissue will absorb a virus. Returning to the microscopical changes to be seen in inflamed tissues, we find that Avhen granulation-tissue has formed the intercellular substance is not so easily seen as before, and the part appears to be composed almost exclusively of cells. It is, hoAvever, rich in blood-vessels, as can be easily demonstrated by special methods of preparation. Much of the intercellular substance and many of the fibers have disappeared, and a granular intercellular substance has taken their place. This condition exists usually in the more indurated portions of the inflamed part, and gives rise to the characteristic "cake-like" hardening so often felt. In the surrounding softer and more pulpy structures Ave find a large amount of coagulated fibrin and serum, which latter substance may at times be excessive in quantity, and then produces a condition that is known as inflammatory adema. Such collections of the fluid products of inflamma- tory transudations are most marked in loose connective tissues, as in the eyelids and the prepuce. When an cedematous sAvellin^ of this character takes place in the mucous membrane of the larynx fatal complications niav arise. IXFLAMMA TION. 17 When mucous membranes are inflamed the exudation usually shows itself in the form of an increased and altered secretion on its surface, in certain con- ditions even assuming the consistence of a false membrane. When serous surfaces are inflamed the transudation will take the form of an effusion into the serous cavity involved, as in the pleura or the cavity of the knee-joint. The cells which are a part of the exudation may, however, form a membrane on the Avails of these cavities, and give rise to adhesions which interfere with the motion of the two surfaces upon each other. The next symptom of inflammation is pain, which is due to the pressure or tension produced by the SAvelling upon the terminal branches of the nerves; it may also be due to exalted sensibility from hyperemia, and to the chemical irritation of ptomaines. It is most severe in the early stages of the inflammation, before the tissues have had an opportunity to accom- modate themselves to the pressure exerted by the exudation. It will vary greatly with the anatomical nature of the part. In bone, where the tis- sues yield less rapidly than elseAvhere, it Avill be very severe, and even in the chronic forms of inflammation the pain will be of a boring character, Avhich is proverbially hard to bear. The throbbing pain is due to the pulsation of the hyperemic vessels of the part, and the peculiar lancinating pain Avhich pus causes in its efforts to escape is characteristic of an abscess Avhich is about to discharge. Pain may, however, be entirely wanting. This is the case in nerveless tissues, and also in severe inflammations which rapidly destroy the vitality of a part. The fifth symptom of inflammation, disturbance of function, will show itself in various ways, according to the part affected: an inflamed muscle will become rigid and contracted; an inflamed gland will cease to give forth its natural secretion. The special senses may also be impaired, or even perma- nently affected, by the inflammatory process. Inflammation does not begin spontaneously. Old writers recognized an idiopathic form of inflammation, but the term, if intended to mean more than non-traumatic, should be discarded. Inflammation is due to some cause which acts in an injurious or destructive manner upon the tissues, such as heat, cold, chemical action, injury or trauma, the temporary removal of blood from a part, as in laboratory experiments or in frost-bite, and, finally, infection, or the action of micro-organisms and their products upon the tissues. There is a tendency at the present time to ascribe all inflammation to the action of bacteria. According to Senn, inflammation proper should be made to embrace patho- logical conditions which are caused by the action of micro-organisms or ptomaines upon the histological elements of the blood and fixed tissue-cells. Hueter also believed in the universal agency of bacteria in inflammation, and regarded it as an epidemic and contagious disease existing everywhere. All other forms of inflammation would, according to this view, be regarded as the phenomena accompanying the process of repair. The question of the action of the nerves in inflammation, at one time dis- carded, has been recently revived by Lister. It is claimed that the most striking clinical example of this type of inflammation is the so-called urethral fever Avhich folloAvs the use of the catheter. The inflammation of the genito- urinary tract thus brought about, and the accompanying chill and fever, are supposed to be due to a reflex action of the nerves of the part. Doubtless many of these cases may be ascribed to a septic infection by the instrument or to injury of already infected organs. The value of counter-irritation as a method of treatment is brought fonvard to shoAV the probability of an abnormal action of the nerves. The so-called trophic action of the nerves in inflam- 18 AX AMERICAX TEXT-BOOK OF SURGERY. mation Avas at one time regarded with favor. Division of the vagus nerve in animals was found to be followed by pneumonia. These cases are, however, now explained satisfactorily by bacterial infection following removal of the protective nerve influence of the part. The list of inflammations to be ascribed to the action of the bacteria and their products is no doubt constantly enlarging, but Ave are not yet in a position to discard all other supposed inflammatory agencies. Cohnheim believed that all these agencies acted upon the Avails of the blood-vessels and produced a molecular change in them by means of Avhich the phenomena of inflammation were produced. Yirchow advanced the " abstrac- tion " theory, in which the cells of the tissues played a prominent part. Lan- derer does not think Ave ought to separate the capillaries from the tissues in which they lie in considering the seat of inflammation. When the cause of inflammation acts upon the tissues they become relaxed, the equilibrium between blood and tissues is disturbed, and Ave have a leakage or exudation into the inflamed part. Most traumatic inflammations take their origin in the tissues, as these are acted upon directly by the inflammation-producing agent. Other inflammations, as the more deep-seated forms, are produced by an agent acting through the blood-vessels or the lymph-channels. In this way those types of inflammation knoAvn as parenchymatous or interstitial are produced. From a study of the pathology of this affection we are justified in assuming, therefore, that the phenomena of inflammation are evidences of injury to the nutrition of the part, Avhile the consequent flushing of the part Avith increased blood-supply, by preventing mural implantation of bacteria, and exudation, assist in the removal of injurious substances, and leave the tissues in a condi- tion favorable to a return to the normal state. There are several varieties of inflammation to be considered. For- merly the terms traumatic and idiopathic Avere used to designate respectively inflammation caused by injury and that which arises spontaneously; but Ave hear little of the idiopathic form at the present time. Inflammation may be simple or infective. The simple inflammations are limited in extent, and tend to recovery as soon as the inflammatory agent ceases to act. The infective inflammations are caused by bacteria, and have a tendency to spread. Inflammations are said to be sthenic or asthenic according to the severity of the symptoms. The sthenic type is seen in a young and vigorous subject Avhen affected with acute inflammation. The asthenic forms occur chiefly in old and feeble individuals. In the parenchymatous inflammations the part attacked is the specific cells of an organ or its parenchyma. These cells undergo a "cloudy SAvelling," and later proliferation may occur, or even destruction of the cells may result. An inflammation is called 'interstitial when the connective- tissue stroma Avhich supports the parenchyma appears to be the part principally affected. We see then a cellular infiltration in the stroma of the organ. There is no essential difference in these two types, as the connective tissue is usually increased in direct proportion to the destruction of the parenchyma. When an inflammation affects the walls of a serous cavity, we may have considerable accumulation of fluid. The term serous inflammation is then used to denote the type which produces a collection of fluid in the joints or the pleural cavity. The amount of serum discharged from a wound may at times be very large, and drainage-tubes are often employed to conduct away the fluid Adhesive or fibrinous inflammations are seen best in the peritoneal cavity when two surfaces of peritoneum are quickly united by the process The rapidity with which this membrane may become united to itself exceeds that IXFLAMMA TIOX. 19 of any other in the body. In a feAv hours the adhesion will already have formed, and the peritoneal cavity may in this way be protected from the intru- sion of poisonous substances such as pus or feces. The same result may be obtained in the interior of joints or the pleural cavity. The motion of the parts will stretch these neAV adhesions, which may thus be draAvn out into bands of considerable length. When extensive adhesions occur between the opposing surfaces of a joint or in the folds of its capsule, anchylosis or great impairment of motion will result. When bacteria are present, particularly the pyogenic cocci, these organisms exert a solvent action upon the exudation, and fibrin does not form; the tendency is therefore to a liquefaction of the tissues, and suppuration takes place. This Ave call suppurative inflammation, or, less correctly, phlegmonous inflammation. Hemorrhagic inflammations occur Avhen the red blood-corpuscles are present in unusual numbers in the exudation-fluid. This condition is found in very intense forms of inflammation, Avhen the congestion has been extreme and large numbers of corpuscles are forced through the Avails of the vessels by the unusual pressure. Black measles and hemorrhagic small-pox are familiar types, as are also some of those extremely septic forms of inflammation Avhich the surgeon meets Avith. Small hemorrhages may occur in the inflammations of the aged and feeble or those affected with cardiac disease, or in scorbutic patients. The presence of blood in a serous exudation is suggestive of intense congestion of a part, as in strangulated hernia, or of the existence of malignant disease. When a false membrane forms upon the surface of an inflamed mucous membrane the inflammation is called croupous. The exudation-cells and newly-formed cells of the part are caught in a fine reticulum of fibrin Avhich forms on the surface and prevents their escape in the mucous discharges. There is more or less destruction of the epithelial cells Avhich, Avhen intact, exert a preventive influence against the formation of such a membrane. This form of inflammation is due to the presence of bacteria, Avhich, as they invade the tissues more deeply, produce a sort of coagulation-necrosis of the more super- ficial layers of the tissues, and form Avhat is knoAvn as a diphtheritic membrane. The principal distinction between a croupous membrane and a diphtheritic membrane lies in their anatomical situation. The former is on the surface of the mucous membrane, the latter is situated in the mucous membrane itself. There is probably no important etiological difference betAveen the tAvo pro- cesses. Coagulation-necrosis is caused by arrested nutrition or by the action of chemical or thermal agencies. The changes seen in the dead tissues are due partly to a coagulation of lymph Avhich flows into the part, and partly to a change in the cells of the part, the nuclei of Avhich lose their poAver to be stained by dyes. The cells and intercellular substance become subsequently transformed into a more or less homogeneous tissue. Gangrenous inflammations belong to the most malignant types. Death of a part may occur either from the virulence of the poison Avhich invades it or from the great distention of the tissues by SAvelling, and a consequent stasis of the blood-current. The anatomical character of the tissues affected will serve as an important factor. In bone, Avhich is unyielding, we frequently see death or necrosis of the tissue in acute inflammation. The non-bacterial forms of inflammation have no tendency to spread. In simple inflammation the disease is confined to the part originally affected. In the infective inflammations Ave find the tissues involved for a considerable 20 AX A ME RICA X TEXT-BOOK OF SURGERY. distance from the original starting-point. In mucous membranes the inflam- mation has a tendency to spread along the surface rather than to deeper parts, and the same is true of inflammation of the skin. In the phlegmonous types of inflammation the process will involve deeper parts, and the subcutaneous connective tissue may become the seat of abscesses. Dense fascise and bone may resist the invasion of the inflammatory process, but the softer tissue of the interior of bones is a frequent seat of infective inflammations. Not only will the part attacked feel the influence of the inflammatory agent, but the Avhole system may be affected, and we then have what is known as constitutional disturbance—i. e. fever. The nature and extent of the febrile process depends upon the materials which are taken up and absorbed from the inflamed area. In chronic inflammations the symptoms are much less marked. The swell- ing is only moderate in amount, and there is very little increase of temperature. There will be some pain, of a neuralgic or boring character according to the locality of the part, but it Avill not be continuous, as in the acute form. Micro- scopically Ave find an abundant connective-tissue groAvth, containing a large amount of fibers, but comparatively feAv cells. Many degenerative changes are seen in such tissues: the fibers are often transformed into a gelatinous trans- parent tissue, and they appear to have been absorbed or destroyed. The num- ber of leucocytes in such forms of inflammation is probably small, and the new cells found in the tissue are probably derived chiefly from the fixed cells of the part. We find degenerative changes in their nuclei and protoplasm, and also evidences of proliferation of the cells going on at the same time. Here and there Ave see clusters of granulation-cells Avith epithelioid and giant cells. In other cases a dense fibrous tissue is formed, or, in bone, bony growths Avhich lead to an hypertrophy of the part. The causes of this form of inflammation are malnutrition of the part and a continuous action of the inflammatory agent. Loss of nerve-supply by section of the nerve or injury to the spinal cord so diminishes the vitality of the tissues that the slightest injuries give rise to inflammation. Repeated slight injuries Avill also produce a chronic inflam- matory process. The most frequent causes are the chronic forms of bacterial disease, such as syphilis or tuberculosis. The results of such inflammation may lead to adhesion in joints or thickening and deformity of bones. A class of swellings knoAvn as the granulomata are produced by the bacterial growths. Chronically inflamed parts are often much discolored and pigmented, and slight injuries may lead to ulceration Avhich heals with difficulty. Subacute inflammation is a term used to denote a type intermediate, in regard to the severity of its symptoms, betAveen acute and chronic. Inflammation may terminate by resolution, suppuration, gangrene, or tissue- production. Resolution implies that the various symptoms gradually subside, and the part will return to its normal condition Avithout any appreciable altera- tion of its tissues. The granulation-tissue Avhich has formed will gradually disappear by absorption of the leucocytes and effused lymph. Many of the leucocytes return into the circulation through the lymphatic vessels and the capillaries and veins; others are broken down and disintegrated. The same fate meets also the proliferated cells of the part. New fibres are formed in the place of those Avhich have been destroyed during the inflammatory process, and the injury done to the tissues is thus repaired. With the absorption of the products of inflammation the inflammatory agents also disappear. When suppuration takes place there is °a loss of substance, and after the pus has been discharged a more extensive process of repair is needed to produce a healing of the Avound and the formation of the cicatrix. IXFLAMMA TIOX. 21 Very severe forms of inflammation will lead to gangrene. The dead tissue is gradually separated from the living, to Avhich it is attached, by the formation of a line of demarcation—that is, by suppuration—and Avhen the slough has separated healing by granulation takes place. As absorption takes place, the red blood-corpuscles found in the exudation are broken up and part with their coloring matter, AA7hich remains behind and frequently produces pigmentation. Many of the cellular elements undergo fatty degeneration, Avhich may occasion- ally occur on so extensive a scale that the material is not all absorbed, but remains behind as masses of cheesy degeneration. In some cases lime-salts are eventually deposited in the unabsorbed material, and calcareous concre- tions are formed. Treatment.—The principal method of treating inflammation a generation ago Avas the so-called antiphlogistic treatment. This Avas based on the theory that inflammation Avas an inflammable condition of the part, Avhich, like a fire, must be subdued by appropriate measures. It did not take into account the causes of the process, Avhich are now so much better understood. This method consisted in the use of emetics, venesection, cupping and leeching, and the administration of drugs, like mercury, Avhich Avere supposed to have an anti- phlogistic tendency. This method has given place to antiseptic treatment. Some of the older measures are, hoAvever, still retained, and may occasionally be used to advantage in relieving some of the symptoms of inflammation, thus, without removing the cause, favoring a return to the normal condition. Local Treatment.— Venesection is an operation rarely seen at the present time, and may be said to have been Avholly abandoned as a surgical therapeutic measure. The local abstraction of blood under certain conditions may, hoAvever, be used to advantage. Nancrede has attempted to formulate these conditions. He has shoAvn by study of the microscopical changes in the web of the frog that removal of blood from the venous side of the circulation produces an increase in rapidity Avith a lessened force in the circulation of the part, .and favors an absorption of the exudation. The use of drugs, like ergot, which constrict the arterioles he regards as harmful at this stage, as tending to produce stasis; but such remedies might be given Avith advantage during the preliminary stage of hyperemia. In cases of extreme congestion, Avhere there is danger of death of the part from a general stasis, the use of leeches is of value, as also frequently in less severe forms, Avhen the removal of pressure brings Avith it great relief to pain and assists in bringing about that natural termination of inflammation—reso- lution. As the majority of surgical inflammations are of a septic nature, the anti- septic treatment will be the more rational method to pursue in most cases. This method will be described in its appropriate place, as also the aseptic treatment, Avhich may be regarded as the prophylactic treatment of surgical inflammation. (Jounter-irritation Avas another of the Aveapons of the antiphlogistic system, but, although much less used at the present time than formerly, has not been Avholly discarded. It is a remedy of more value in chronic inflamma- tions than in those of an acute type, and may act, possibly, through the nerves of the part by a reflex process, and thus produce a change in its nutrition and promote absorption. The actual cautery is still occasionally used in deep- seated inflammation of the joints. It should be lightly applied at a Avhite heat over a considerable extent of skin near the inflamed part, and should act only on the superficial layers of the skin. Repeated blistering is also of benefit in producing absorption in an enlarged gland or a "Aveeping sineAV," or 22 AX AMERICAX TEXT-BOOK OF SURGERY. of an exudation Avhich is sIoav to disappear. Iodine may be used for the same purpose, but probably acts in virtue only of its poAver to produce a local irrita- tion on the surface, and not from any special sorbefacient quality possessed by the drug itself. Compression is a valuable agent in the treatment of both the early and the late stages of inflammation. In the acute stage it restrains the tendency to exces- sive swelling of the part and the collection of serous or bloody discharges between the lips of a Avound. It must be applied, however, with great care during this period, as sloughing or even gangrene may be the result of tight bandages on a part Avhen the circulation is enfeebled by injury. In the later stages com- pression may be employed with great advantage, and is one of the most val- uable agents which the surgeon possesses to promote absorption and resolution. It is most useful in chronic inflammation. The beneficial effect of pressure upon a varicose ulcer by plaster or a rubber bandage is an admirable illustra- tion of this power, as is also the effect produced upon the serous effusion in a knee-joint by elastic bandages made of rubber or flannel. A most efficient means of obtaining compression of the knee-joint is with compressed sponge: two coarse sponges may be flattened over-night under a heavy piece of furni- ture ; one is put on either side of the joint, which is placed on a posterior splint; a long cotton bandage is now firmly applied, after Avhich a stream of water is alloAved to trickle into the sponges. This dressing may be left on for one or two days, sufficient moisture being supplied to keep the bandages tight. Cold and heat are used for the purpose of reducing the hyperemia and to relieve pain. Cold may be applied either by evaporating lotions or by the use of ice. Evaporating lotions can be used on exposed parts, but must be changed very frequently to have the desired effect. They are less used than formerly. Ice may be applied in thin rubber bags. Cold can also be applied by the "ice-coil," by means of which a current of ice-water is allowed to Aoav through a coil of rubber or metal tubing over the part. Care must be taken to avoid freezing the superficial layers of the skin if a prolonged use of the remedy is intended. The ice-bag is comforting in cases of rapid swelling folloAving injury, to a tender and swollen knee-joint, or to an inflamed throat. It is dangerous in cases of extreme congestion, as in strangulated hernia. Heat may be applied in the form of fomentations, hot-water bags, or the hot douche. It acts, doubtless, in various Avays. A hot fomentation Avhen first used produces a powerful counter-irritation ; later, it acts through the circulation, relieving stasis and favoring an absorption of exudation. If the heat be main- tained at a high point by frequent application of the hot douche, a constriction of the blood-vessels takes place, and congestion is thus diminished. The flax- seed poultice is now discarded in the treatment of Avounds, but may still be used with advantage when no AA-ound exists. The antiseptic poultice, now used for Avounds in certain cases, is practically a hot fomentation to Avhich some anti- septic agent has been added. Incisions are often of great value in certain types of inflammation, even when suppuration has not taken place. In cases of intense congestion of the inflamed part, Avhen the integuments are thick and brawny, one or more incis- ions are followed by a free gush of blood and serum Avhich greatly relieves the tension of the part and wards off not only threatening deep-seated suppuration, but also gangrene of the parts. The incision should be made completely through the skin and cellular tissue, but should not be over two inches in leno-th in most cases. Early interference of this kind is imperatively needed in the rapidly spreading forms of inflammation such as occur often in the hand and forearm, which may not only ruin a hand, but endanger a life. IXFLA MM A T10X. 23 Elevation of the inflamed part, combined with rest by splints, etc., is of the utmost importance in controlling the progress of an inflammation. Other remedies Avill be of little use if the congestion is favored by allowing the limb to be dependent, and if motion is permitted to interfere Avith the natural tend- encies toward resolution and repair. Physiological rest of injured as well as of internal organs is also indicated, to enable the disturbed function to be restored. The importance of absolute rest after injuries to the brain has long been recognized. A chronic cystitis may be cured by cystotomy Avhen all other remedies have failed. Parenchymatous injections Avere proposed at one time to arrest the prog- ress of bacterial infection. Hueter employed 3 per cent, solution of carbolic acid in this way around the area of erysipelatous inflammation. This method, in general, has not met Avith favor. It is possible, however, that the hypo- dermatic syringe may have a future in surgical diseases which is not yet apparent. The results of inflammation Avhich remain in the shape of stiffened joints, contracted or enfeebled muscles, and thickened integuments can best be dealt Avith by massage, Avhich not only favors absorption, but is a powerful restora- tive of the physiological action of the part. Constitutional Treatment.—It is essential to remember that local treatment, whatever its nature may be, is not the only method to be employed to restore the patient to health. The careful surgeon will always pay due attention to the general condition of the patient. The presence of organic disease elsewhere must not be alloAved to pass undiscovered. Stimulants may be used during the progress of the fever to sustain strength. Alcohol can be used freely in all cases Avhere there is an abnormal consumption of tissue, Avhether the result of acute febrile disturbance or of chronic wasting disease. Here alcohol becomes a food, and one of the most valuable kind. Patients Avho cannot bear the usual doses of alcohol often experience benefit from minute quantities. Dram doses of Avhiskey are often Avell borne, and are of service in such cases. In the " typhoidal" state which accompanies profound septic infection astonishingly large quantities Avill be assimilated even by patients unaccustomed to its use. Flushing of the face is an indication that the dose should be diminished in quantity. Champagne is a good substitute for whiskey or brandy Avhere the stomach is sensitive. Beer and ale are useful during convalescence or in chronic types of inflammation. The use of antipyretics has little permanent influence on the pyrexia, and does not appear to give that relief to symptoms which is obtained by it in so-called medical diseases. A much more reliable method of controlling the constitutional disturbance is careful attention to the local conditions of the wound or inflamed part. A large variety of medicines have been used in former times on account of their supposed virtues in arresting or shortening the inflammatory process. Among these may be mentioned quinine and mercury. Quinine is still much used, on account of its tonic action even during the febrile state. Its employment in large doses of 20 grains or more is confined chiefly to malarial regions, Avhere perhaps there is a tendency to use it to excess. In doses of 5 grains it may be given, three times a day, in any form of fever in which a tonic effect is desired. It is still used largely in erysipelas. Mercury Avas formerly used internally in every form of inflammatory process, on the theory that it had a powerful antiphlogistic action. ^ It Avas supposed to dissolve the fibrinous exudation. Much of its reputation was probably due to the effect it had upon unrecognized forms of syphilis. Calo- 24 AX AMERICAN TEXT-BOOK OF SURGERY. mel, in which form it was usually administered, has noAV given place to corro- sive sublimate, Avhich as an antiseptic takes the highest rank. Calomel may also have exerted a beneficial effect in virtue of its cathartic action. Purgatives Avere used freely as part of the antiphlogistic system of treat- ment, and are still valuable in certain forms of inflammation. They are part of the routine treatment of head injuries, and, if administered promptly in coma folloAving these injuries or in apoplexy, are supposed to remove sources of irritation and to leave the system in a condition unfavorable to meningeal or cerebral inflammation. Six grains of calomel placed upon the tongue is an easy means of acting upon the boAvels under these circumstances. The dose may be folloAved in two hours by an aloes enema (one dram of poAvdered aloes to a pint of hot soapsuds). Such a mode of treatment is supposed to exert a " derivative " action, by means of Avhich irritation is removed from the brain and its coverings to distant parts of the economy. The tendency to hyperemia is in this Avay diminished. The treatment of peritonitis by purga- tives, particularly after laparotomy, has lately come into vogue. It seems to be based upon the power of the cathartic to remove gas, and consequently to relieve the tympanites, and by its production of Avatery stools also to relieve the engorgement of the intestinal vessels, and eliminate germs or ptomaines by causing the emptier vessels to absorb the peritoneal exudates. A Seidlitz poAvder or a dose of Epsom salts will often promptly remove alarming symptoms. Smaller doses of salts, repeated every hour or half hour, may be substituted for the single larger dose. Diaphoretics, although but little used in surgery, may occasionally be found of value, owing to their antipyretic action. Water can almost always be given freely if taken in small quantities from time to time. SAveet spirits of nitre in dram doses, Avhen largely diluted in Avater, will favor diaphoresis, and at the same time is useful as a sedative and also as a diuretic. The importance of diuretics in inflammation of the bladder need not be insisted upon here. Their value will be discussed in another chapter. Emetics have long since been discarded as a means of controlling inflam- mation, though they are useful Avhen the stomach is overloaded. They Avere formerly used in connection with venesection. Anodynes are of the greatest value in the treatment of inflammation. They relieve the most disagreeable symptom of inflammation—namely, pain— and also the malaise and nervous disturbance Avhich are the accompaniments of fever. First among these is opium, which not only relieves pain, but con- tracts the peripheral vessels. The crude drug is rarely given except in a sup- pository. Morphine is on the Avhole the most useful of its derivatives. The subcutaneous injection of morphine should be reserved for the more acute forms of pain. It is well to avoid the habit of giving the alkaloid in this Avay too freely, as it is a powerful remedy, acting Avith double the poAver of the same dose Avhen given by the mouth, and is sometimes folloAved by symptoms of col- lapse or opium narcosis. The liquor lnorphinte sulphatis (gr."j to |j) can be given by the mouth in teaspoonful doses, and repeated every hour or half hour until pain is relieved. If it is desired to avoid the disagreeable effects of mor- phine upon the stomach, it can be given by suppository. This is an exceed- ingly convenient way of administering opium for pain in any part of the body. The relief from pain brings with it rest—a most important element in the treat- ment. The production of obstinate vomiting by even the smallest dose of opium or its derivatives is of occasional occurrence. It is usually a personal idiosyncrasy. In important cases its possible existence should not be lost sight of. The nervous disturbance will be also relieved by this druo-, but Ave must THE PROCESS OF REPAIR. 25 rely more upon chloral, the bromides, sulphonal, or other hypnotics for the relief of this symptom and to obtain sleep. The diet is of the greatest importance in all forms of inflammation. The fallacy that low diet is necessary under these circumstances is noAV Avell exposed. The stomach should be supplied Avith food of the most nutritious character, but in a form that can be easily digested. Milk is the most valuable of all liquid forms of food. It may be given pure, mixed with lime-Avater, peptonized, or sterilized, or it may be taken in the form of gruel. Alcohol may be given with it. A very digestible combination is \vine-whey. Clear beef-tea has but little nourishing poAver. Meat-broths are, hoAvever, nutritious and digestible articles of diet for the sick. Pure beef-juice is a most reliable form of concen- trated and digestible nourishment. When food cannot be taken by the stomach, enemata may be given by the rectum. These may consist of beef-broths, Avith or Avithout brandy. Some of the various peptonized forms of meat may be found useful for this purpose. A few drops of laudanum may be given Avith the enema Avhen there is any difficulty in retaining it. After the inflammation and fever subside the solid forms of food may be used more freely. Light wines or beer can be used if any alcohol be needed at this period. Tonics are noAV indicated, as iron, quinine, calisaya-bark, and the phosphites. They improve the appetite and favor the local process of repair and the return of the system to a normal condition. CHAPTER III. THE PROCESS OF REPAIE. It was formerly supposed that inflammation Avas necessary for the healing of a wound, but from the present point of vieAV the processes of inflammation and repair are regarded as distinct from one another. Lender the condition of asepsis Ave are noAV able to see wounds heal Avithout the usual phenomena of inflammation. The symptoms of inflammation are brought about by the dis- turbed functions of tissues Avhich have been damaged. Repair, on the other hand, is the result of an active process by means of Avhich the cells of the part are enabled to replace tissues AA'hich have been destroyed. Healing of a Avound is said to take place either by first intention or by second intention. In healing by first intention, or primary union, repair takes place without suppuration. When an incision is made through the skin and superficial tissues, the edges of the Avound separate from one another according to the elasticity of the different structures Avhich have been divided: the AA^ound is said to gape. The bleeding of the smaller vessels soon ceases spontaneously, owing to' the con- traction of their lumen and to the retraction of the arterioles into their sheaths, where they are soon obstructed by the formation of a clot. The largest vessels are controlled by pressure, torsion, or ligature. When the blood has been washed or wiped aAvay the edges of the wound are carefully adjusted by means of sutures. If such a Avound has been kept perfectly aseptic—that is, if no bacteria have been alloAved to gain access to it—we shall see but little change in the appearance of its edges during the healing process. There ■will be a slight swelling of the lips of the Avound, and the tissues in the immediate neighborhood of the linear incision and around the stitch holes will be some- 26 AX AMERICAX TEXT-BOOK OF SURGERY. what firmer than in the natural state. This is due to the disturbance in the circulation owing to division of the vessels, and to the injury done to the tissues. There is no redness, as hyperemia is usually absent, but a moderate amount of exudation occurs, which" results in the formation of fibrin, by means of Avhich the surfaces brought in contact are temporarily glued together. In large wounds the amount of exudation may be considerable, and, unless it be conducted off by a drainage-tube, may accumulate in spaces which have not been accurately brought in contact, and thus separate the opposing surfaces. In order to avoid this either buried sutures or pressure must be employed to keep the raw surfaces of the wound in contact, or a drainage-tube must be inserted to conduct off the exudation, and thus allow the ra\v surfaces to adhere. It was at one time thought that the edges of a Avound might unite by Avhat Avas called immediate union—that is, by an adhesion of the microscopical structures of the part, Avithout any reparative effort. It is now known that such a union is merely the temporary adhesion of fibers to fibers by means of fibrin, Avhich is preliminary to final union by the formation of neAv tissue. In all large Avounds, no matter how careful the adjustment of the parts has been, there are ahvays places Avhere the Avails have not come accurately in contact. If Ave examine under the microscope a wound healing by first inten- tion, Ave find these small spaces occupied by blood-corpuscles and masses of coagulated fibrin. There will also be found some fragments of bruised and injured tissue, and here and there small portions of tissue which have under- gone a necrosis owing to the impairment of their blood-supply. At the end of the first twenty-four hours there will be an accumulation of leucocytes along the line of the wound. The number of these cells is usually small, "but when inflammation is present to any extent they may accumulate in sufficient numbers to obscure the pre-existing elements of the tissue. At this period the vessels are not seen near the margins of the Avound, but Thiersch has shoAvn by injection preparations that a system of plasma-canals exists, which com- municate directly with the adjacent vessels, and that many of the red blood- corpuscles and masses of fibrin, apparently extravasated in the tissues, lie in these spaces, which thus are able to provide nutriment to the part until neAv blood-vessels are formed. As the process of repair proceeds the number of cellular elements of the part—indifferent cells, as they are called—increases perceptibly (PI. V). As the cells increase the fibers of the old tissue become more obscure, and many of them, and of other elements which have undergone retrograde changes, disappear, and the cells seem soon to be supported in a neAv granular or fibril- lated or reticulated intercellular substance, and the so-called granulation or embryonic tissue is formed. At first this is composed of round cells; in the course of a few days, however, a large number of spindle-shaped cells are found mingled with these, and other large cells with one or more nuclei, which are called epithelioid cells. A high-power microscope .will show, in fact, the greatest variety of shapes at this time. Later the spindle-shaped cells become more numerous, and the new tissue begins to present a fibrous appearance. The origin of the cells of the granulation-tissue is a subject about which there has been much dispute. According to Cohnheim, these cells are the emigrated leucocytes, which are able by proliferation to produce other cells like°them- selves. and are the active agents in the formation of the new tissue. The view that the fixed cells of the connective tissue and the parenchyma cells of organs are able to proliferate and form new cells during the process of repair has been gradually regaining its lost position, and the very latest views are as follows • 'PLATE V. ;». it *■■"■■*%r^- -.9.: - 3.- ~y.J« *= •A* .i- —* 5 6 ^^ Left margin of wound healing by first intention on the 3d day. a. epidermic layer showing cells undergoing karyokinesis. b. leucocytes accumulating on the edge of the wound, c. blood clot filling dead space — commencing "organization." d. vein from which leucocytes are emigrating. THE PROCESS OF REPAIR. 07 Granulation-tissue contains many leucocytes, but they take no active part in the healing process, serving simply as food for the other cells as soon as they have reached a certain stage in their career, known as the polynuclear sta^e, a point beyond Avhich they are unable to develop. The cells coming from the proliferating tissue-cells are the constructors of the new tissue, and they have in early life amoeboid movements (Ziegler). It is not possible to distinguish the two kinds of cells in granulation-tissue, and Avhen cells of either kind become polynuclear they are no longer able to take an active part in the growth of tissue (GraAvitz). It is proposed by Marchand to call the leucocytes found in granulation-tissue " exudation-cells," and the proliferating connective- tissue cells the "formative cells." Soon after the first day of the healing Fig. 8. AVound healing by Granulation. a, papillary layer; 6, cutis vera ; c, adipose layer; d, granulation-tissue, containing newly-formed vascular loops. process new vessels begin to form in loops which develop from the pre-exist- ing vessels. On the surface of a capillary loop a mass of granular protoplasm is seen, Avhich gradually increases in size and groAvs to an elongated mass of solid nucleated protoplasm Avhich projects toward the edge of the wound. These prolongations either become attached to the wall of another vessel, or unite Avith similar outgroAvth's from other vessels or Avith the cells of the sur- rounding tissue. Later, the central portion of these newly-formed structures melts away, and they become holloAv and establish a communication with the vessels from Avhich they spring. The Avail of the new vessel is at first homo- geneous, but later becomes nucleated and lined Avith endothelium. In this Avay a mass of capillary loops form on either side of the Avound, eventually becoming united and forming an exceedingly rich capillary network in the neAv tissue. As cicatrization completes itself many of the spindle cells and round cells dis- appear. Some undergo granular degeneration and are absorbed ; others wander into the adjacent lymph-spaces, and are taken up again into the circulation; many, after reacKing a certain stage of development, are destroyed by the more active cells in the reparative process. As the cells vanish new fibers make their appearance, and the Avound becomes thus firmly united. In the mean time, on the surface a clot or crust of broken-doAvn blood-corpuscles, epithelial scales, and exudation-material has formed, underneath Avhich new epithelium develops from the deeper layers of the rete mucosum Avhich covers in the sur- face of the wound. When from loss of tissue or other cause it has not been possible to close a wound, and the lips are separated Avidely from one another, union can only take place by the process of healing by granulation, or second intention (Fig. 8). If Ave watch such a Avound Avith the naked eye Ave shall observe, in the course of an hour, that a film has formed upon the surface ; the wound has become glazed by the deposition of a thin layer of coagulated fibrin. This layer, at first trans- parent, soon becomes stained Avith masses of coagulated blood and fragments of 28 AX AMERICAX TEXT-BOOK OF SURGERY. fibers torn from their surroundings and lying upon the surface. I his layer is also soon occupied by numbers of emigrated leucocytes. In tlnsAvay the wound is covered over so that the structures beneath can no longer be recognized. The discharge which flows from the wound is at first of a reddish hue, and consists chiefly of bloody serum in which are floating fragments of broken-down tissue. This gradually changes to a grayish color, and is found to contain more white corpuscles and fewer red corpuscles as time goes on. In a feAv days the dirty layer covering the surface of the wound is washed away by the discharge, Avhich has noAV assumed the yelloAvish-white or creamy color of pus. and the wound is said, in surgical parlance, to clean off. As the debris is swept away we find underneath a surface of bright and irregular-shaped nodules Avhich are called granulations. The time Avhich granulations take to form may vary from two or three days to a Aveek, according to the health of the individual or the nature of the tissue involved. Microscopically, the tissue consists chiefly of small round cells mingled Avith epithelioid or larger cells, such as are seen in the so-called granulation-tissue, the origin of which has already been described. The cell-groAvth concentrates itself chiefly around the capillary loops which develop from the adjacent blood-vessels, and forms little wart-like elevations on the surface, and gives to the granulations their velvety appearance. The cavity of the wound is gradually obliterated, partly by the growth of the granulations and partly by cicatricial contraction by which the edges of the wound are approximated. In the mean time the epidermic cells by prolifera- tion begin to cover in the margins of the open surface of the wound, and a thin bluish-Avhite border indicates the presence of a fresh epithelial cell-growth. New formation of epithelial cells cannot occur in the center of the wound unless some fragment of epithelial structure, such as a portion of a papilla, sweat-ducts, or hair-follicles, may have remained, from which such an outgroAvth could take place; hence cicatrization always progresses from the circumference toward the centre. Occasionally the groAvth of granulations is so exuberant that they project above the surface of the skin, and the epithelium may then be unable to cover in all the surface. This "proud flesh," as it is popularly called, must be removed Avith the knife or caustic before the healing process can be completed. In the mean time the granulations undergo the series of changes which have already been described, and the spindle cells thus formed by a change of their protoplasm into fibers become fibrous tissue. Many of them disappear altogether, as do also great numbers of the neAv blood-vessels, and an abundant formation of fibers interwoven in various directions takes their place. This tissue possesses great contractile poAver, and it is as the result of this contractility that so many of the delicate vessels disappear and the scar eventually becomes paler than the surrounding parts. In extensive sears this contraction gives rise to great deformities, particularly when the wound is situated in regions Avhere tAvo adjacent portions of the body may be thus bound together by a dense scar. Examples of this may be seen after burns on the neck or at the flexures of the joints. Granulations are not always firm and red : occasionally thev are pale and flabby, Avhich appearance is due to an oedematous condition. These are often seen in tubercular processes. Erethistic granulations bleed easily and are excessively painful. They appear to be caused by some mechanical disturbance of the Avound. The surface of the wound will sometimes be found covered with a membrane which has a diphtheritic appearance, and is caused bv imper- fect development of the capillary vessels or is due to their obstruction bv inflammation. A coagulation-necrosis of the upper layers of the granulation is thus produced. THE PROCESS OF REPAIR. 29 The healing of subcutaneous wounds does not differ essentially from the process already described. Repair, hoAvever, usually takes place Avithout suppuration. In this case Ave find the seat of the Avound occupied by a blood- clot, sometimes of considerable size. As repair progresses the extravasated blood is gradually absorbed, and granulations push out from the surroundino- connective tissue and ramify in the clot, Avhich furnishes a favorable culture soil for the neAv cell-groAvth. The amount of inflammation Avhich will accom- pany this process depends upon the degree of trauma which has taken place or upon bacterial infection. In the case of infection by sloughing of the integu- ments or of intravascular infection, suppuration will take place and an abscess will form. The same mode of healing under a blood-clot occurs Avhen an open sterile wound has been filled Avith an aseptic blood-clot Avhich is alloAvecl to remain. The layer of clot Avhich covers the surface becomes hard and dry, and gradually loses its dark color. As the clot shrinks the epithelial margins follow close upon its edges, while the connective tissue-growth beneath has been substituting itself for the fibrin and blood-corpuscles A\hich are gradually absorbed. When the wound has healed the remains of the surface clot break up and come aAvay with the dressings, and a firm cicatrix is disclosed. If infection of the Avound has taken place, the clot Avill break down and be swept Fig. 9. jpi — d i£S' Repair showing Direct Cell-division. a, blood-vessel; 6, proliferating cells; c, vascular buds about to form new vessels; d, flbrillated connective tissue forming from new cells. away with pus Avhich forms, and the wound will then heal by granulation. This method of healing by organization of the blood-clot, as it has been called, is the one which usually occurs in ruptures of the internal organs, as the liver or kidnevs. 30 AX AMERICAX TEXT-BOOK OF SURGERY. The formation of fibrillar connective tissue is accomplished by the prolifera- tion of the fixed cells of the connective tissue. (Jell-division takes place either directly or indirectly. Direct cell-division (Fig. !>) is simply a segmentation of the nucleus followed by a division of the whole cell, and was thought to be the ordinary mode of cell-growth, but the indirect method is the one which usually occurs. This latter is knoAvn as karyokinesis (Fig. 10.) When such a mode of cell-division is about to take place, the delicate reticulum of fiber of which the nucleus is composed when in the quiescent state—and which is called chromatine substance, from its capacity to take staining fluids—becomes con- Fig. 10. Karyokinesis, or Indirect Cell-division. a, cell with nucleus in quiescent state. The nucleus contains nucleoli and a network of threads; 6, forma- tion of coarse chromatine threads in nucleus: c, disappearance of nucleolus and membrane of nucleus ; arrangement of threads in loops forming the 'rosette "; d, angles of loops directed toward the poles of the cell, which are formed of achromatic threads; e, beginning division of the cell- this is followed by a gradual return of the nucleus to the quiescent state (a). verted into a skein of contorted filaments, which gradually assumes the shape of a rosette, and subsequently a star. Meanwhile the wall of the nucleus has dis- appeared. In a later or equatorial stage of the process the star-shaped mass of filaments separate into two groups, which dispose themselves around the two poles of the nucleus, leaving a clear space in the plane of the equator. When the nucleus has thus divided the filaments return to their former quiescent state. The protoplasm is contracted along the line of equatorial division, and the division of the cells becomes complete (Quain). The new cells, or fibroblasts, as they are called, become elongated by the formation of prolongations from their extremi- ties, and, as shown above, develop fibrilla? by a differentiation of their proto- plasm. Examples of wounds of bloodless tissues are seen in the cornea and in car- tilage. When the cornea is divided and the wound gapes, it is filled in at first partly by a coagulum of fibrin, and partly by a growth of epithelial cells. At the end of a few days the corneal corpuscles begin to proliferate and push aside THE PROCESS OF REPAIR. 31 the elements which occupy the cleft, and thus permanently close the wound. In cartilage, owing to the poor supply of nutriment, the cells appear to take but a feeble part in the process of repair. Incised wounds of joint-cartilage are found many Aveeks after the injury filled Avith a clot of fibrin, which eventually is replaced by connective tissue. The cartilage-cells near the Avound become polynucleated, and the intercellular substance becomes fibrillated, but this is probably only a retrograde metamorphosis. Xeiv epidermis is formed by proliferation of the epithelial cells. New epithelial cells possess amoeboid movements, and may wander a short distance from the margin of the Avound. The deep layers of the rete mucosum furnish cells Avhich multiply rapidly, and it is this layer of the skin which is utilized by Reverdin in transplanting small grafts to the granulations. The success of the Thiersch method, Avhich consists in the transplantation of portions of skin several inches in length to the freshly-cut surface of open Avounds, is due to this fact. The grafts are cut Avith the razor and are exceedingly thin, so that only the most superficial portions of the skin are rehioved. Regeneration of striped muscular fiber occurs to some extent in slight injuries. The cicatrix following a Avound in the muscle is, hoAvever, usually composed of connective tissue, and the fragments of the muscle are thus united by a tendin- ous mass. At first an increase in the size and number of the muscular nuclei are seen. Some observers have noticed karyokinetic changes in these nuclei. These new cells or sarcoblasts assume a spindle shape and are arranged in rows, and at the end of the third Aveek begin to show striations. Each spindle cell elongates, and finally forms a muscular fiber. Regeneration of muscular fiber has been observed in myocarditis, and has also been produced experimentally in animals. Attempts to graft the muscle of a dog into a wound of the biceps following extirpation of a tumor did not succeed. Large loss of substance of muscle, hoA\ever, may not be followed by much impairment of motion. Regeneration of nerve-tissue is sufficiently perfect to unite the ends of divided nerves which have been sutured, and to restore even the continuity of nerves Avhich have been resected in their trunks for the cure of pain. Views differ as to the histological changes which occur during the process of repair. GroAvth appears to be more active from the central end, although it may take place from the peripheral end also. The axis-cylinders become elongated and divide into several fibers, which later are covered by the medul- lary sheaths. According to another vieAv, the axis-cylinders may be formed by a growth of spindle cells, neuroblasts, Avhich takes place from both ends of the divided nerve and unites the tAvo fragments. Around these cylinders medullary substance is deposited later, and neAv sheaths are thus produced. The completion of the process takes several months. When the ends of the nerve are separated by a distance of over one inch in length, repair can rarely take place spontaneously. The ends of the nerves have then a club-shaped enlargement, due chiefly to a growth of the neurilemma, and many of the fibers become degenerated. Suturing of the ends of a divided nerve, Avith restora- tion of function, has been accomplished over a year after the injury. When a tendon is divided the tAvo ends are separated from one another in the tendon sheath, and a Aoav of blood fills the intervening space Avith clot. A groAvth of cells takes place from the sheath and surrounding tissue, and granulations force their Avay into the clot, Avhich is absorbed. The neAv tissue gradually assumes the appearance of a fibrous tissue running parallel Avith the fibers of the tendon. The tendon does not at first appear to take any part in the process of repair; later it is difficult to distinguish between the old and the 32 AX AMERICAX TEXT-BOOK OF SURGERY. new fibers. The new tissue appears to be derived chiefly from the connective tissue. AVhen a bone is broken the new tissue which unites the fragments is usually bone. A true regeneration of bone, therefore, does take place. The tissue which first forms around and between the ends of the bone is of a temporary character, and is called the provisional callus ; that formed from the periosteum is called the external callus; and that from the medullary tissue, the internal callus. The intermediate callus lies betAveen the ends of the bone, and is at first, in part, a growth from both of these regions; but it is here that the per- manent cicatrix is finally developed from the bone-forming tissue. The size of the callus will depend upon the amount of traumatism and the amount of displacement and of motion during the process of repair. Later the provisional callus is absorbed, and cicatrization is sometimes so perfect that it is difficult to detect the precise seat of an old fracture. In groAving bone the cells which are most active in the process of development are found in the deeper layers of the periosteum. Here an active cell-groAvth takes place, and medullary spaces containing the bone-forming cells or osteoblasts are developed. A growth of bone also occurs in the deeper layers of the cartilage. Bone-salts are deposited betAveen the cartilage-cells, and the spaces occupied by them are converted into medullary spaces, and the medullary cells, and probably also cartilage-cells, become converted into osteoblasts. The osteoblasts form neAv bone by a change of their protoplasm into a finely fibrillated or homogeneous material, which by a deposit of lime-salts is transformed into bony lamella. Absorption of bony substance is accomplished by giant cells, noAV known as osteoclasts, Avhich are derived from the protoplasm of the various kinds of cells Avhich come in contact Avith bony tissues (Tillmans). These cells are said to form carbonic dioxide, which dissolves the lime-salts. The ossification of the internal callus is accomplished by the osteoblasts, which develop an osteoid tissue Avhich subsequently, by deposit of lime-salts, becomes true bone; or the bone-formation may be preceded by the development of cartilage from these formative cells. In the second Aveek an osteophyte growth is already seen on the surface of the bone, and by the end of the third Aveek the periosteal callus usually consists of firm, spongy bone. A similar formation of bony tissue occurs in the medullary cavity in the development of the internal callus. The amount of this groAvth, hoAvever, varies greatly in different cases. Formation of cartilage also occurs here near the seat of fracture, but is not so constant or extensive as in the periosteal callus. The provisional callus becomes converted into a permanent cicatrix by a condensa- tion of its tissue. An absorption of its more superficial and deeper portions also takes place—a process which is brought about mainly by the action of the osteoclasts. The medullary cavity of the bone, sometimes completely broken in its continuity by an overlapping of the fragments, is eventually more or less completely restored. The healing of arteries after ligature is not unlike that of bone in the sequence of events. AVe have here also a provisional growth which forms around the ligature and encloses the tAvo ends of the vessel; as in the bone, the size of the •"callus,"' as it may be called, will depend upon the amount of traumatism. In the interior of the vessel a thrombus forms, Avhich in purely aseptic operations is exceedingly small, and it has been maintained bv some observers to be absent altogether under these conditions. The proximal thrombus is usually larger than the distal one. The external growth or -callus" is composed of granulation-tissue, and as the Avails about the lio-ature are infiltrated with leucocytes, the ligature loosens its hold upon the vessel, THE PROCESS OF REPAIR. 33 and the two ends retract and separate slightly from one another, but are still The ends of the vessel now open Fig. 11. - -a held enclosed in the external callus slightly, and admit a groAvth of granu- lation-tissue Avhich infiltrates the thrombus. Subsequently this granu- lation-tissue is absorbed, and as it disappears it becomes apparent that a growth has taken place from the walls of the vessel Avhich forms the permanent cicatrix. In the interior a formation of neAv tissue has taken the place of the thrombus, which noAV has disappeared. If the thrombus has been a large one, there will be a con- siderable growth of connective tissue filled Avith vascular spaces. A neAv groAvth of endothelium covers this tissue and lines the new vessels con- tained in it. In aseptic wounds the amount of connective-tissue groAvth is small, and we then find, when the process is completed, a crescent-shaped cicatrix at the end of the cul-de-sac formed by the ligatured vessel. The surface of this cicatrix is covered Avith a rnew endothelium; beloAv this is a new layer of muscular cells which have developed from the media, and externally is a connective tissue-groAvth from the adventitia (Warren). The two ends of the vessel are now united by a ligamentous bond. The usual method of ligature is to apply a single thread around the vessel with sufficient force to rupture the internal coats. Unless this is done there is a possibility that the lumen of the vessel may not be obliterated. According to Senn, however, two ligatures can be applied near one another, Avithout sufficient force to rupture the coats, with speedy obliteration of the vessel. In amputation stumps the ligatured artery does not terminate abruptly in a cul-de-sac at the point of ligature, but is partially obliterated for some distance from the ligature by a growth from the intima and other coats of the vessel. This compensatory endarteritis adapts the vessel to the greatly diminished blood-supply needed for the stump. After ligature in continuity the branches given off above and below the ligature become enlarged, and, anastomosing with one another, establish a collateral circulation. Carotid Artery of Horse, Two Months after Ligature. o, thrombus ; 6, callus ; c, arterial wall; d, liga- ture sinus. 3 31 ^A AMERICAN TEXT-BOOK OF SURGERY. CHAPTER IV. THE TRAUMATIC FEVERS. During the process of healing there is more or less constitutional disturb- ance Avhich depends upon the nature of the changes going on in the Avound. The disturbance Avhich accompanies these changes in the absence of suppuration is termed primary ivound fever, and that which occurs during sup- puration is called secondary wound fever. Primary wound fever is composed of two varieties: these are aseptic fever, and traumatic or surgical fever. 1. Aseptic Fever.—In wounds that heal aseptically inflammation is absent, and only slight febrile disturbance is therefore to be expected. Nevertheless, a rise of temperature often occurs after aseptic operations, and lasts for several days. The normal temperature of the body is 98.4° F., or 37° C. During this form of fever the temperature may rise to 102° F., and not return to normal for two or three days. It has been shown by experiment that a large number of chemical sub- stances Avhen introduced into the circulation will produce a rise of temperature. Among them is the fluid obtained from defibrinated blood, Avhich contains a substance knoAvn as fibrin-ferment. When injected into animals this ferment produces extensive coagulation of blood in the vessels, and death. Other sub- stances, as pepsin and even Avater, will produce, AAhen injected, febrile disturb- ance. During the healing of a large Avound there is necessarily a breaking down of minute portions of tissue and blood-clot, Avhich, Avith effused serum, are absorbed in greater or less quantity. These chemical substances are but slightly altered from their normal condition, but when absorbed appear to have what is known as a pyrogenous or fever-producing action. Beyond the rise of temperature there are but fe\v symptoms in this form of feATer. The patients thus affected do not suffer from delirium or malaise, and are not conscious of feeling ill. They are able to sit up in bed or to move about the room. This aseptic fever is seen in simple fractures and wounds in Avhich no drainage-tubes have been inserted, or in very large wounds which are heal- ing by first intention. 2. Traumatic or Surgical Fever.—Before the introduction of antiseptic treatment all Avounds healed Avith more or less inflammation, even Avhen suppuration did not occur, and this Avas supposed to be a part of the pro- cess of repair. The amount of constitutional disturbance Avas considerable, and was called surgical or traumatic fever. Examples of this type are seen to-day in Avounds that have not been treated antiseptically, particularly those Avhich are due to injuries and have been exposed to septic "infection. The presence of bacteria in the secretions of such Avounds gives rise to a fermentative process during which ptomaines are developed. These chemical substances differ greatly from the natural fluids of the body, and are of varying degrees of virulence. It is probable that the fever is produced by their introduction into the circulation rather than by the presence of bacteria. Very few bacteria are found in the blood during this type of fever and if present, are rapidly eliminated; and, moreover, as soon as a free dis- charge occurs from the Avound, and the chemical substances are no longer pent up and absorbed, the temperature falls. Such a change would not occur had THE TRAUMATIC FEVERS. 35 the fever been caused by the presence of bacteria which multiply after their introduction into the system. In this form of fever the constitutional symptoms correspond pretty accu- rately with the condition of the wound and the amount of inflammation : there is a sharp rise of temperature a day or tAvo after the operation or injury; the skin is hot and dry, the pulse rapid, and the tongue coated. The subjective symptoms are also Avell marked: the patient suffers greatly from heat and thirst and restlessness, and there may be some delirium ; the urine is scanty and high- colored. On the evening of the second day the thermometer will indicate a temperature of 102° F. or more. The next morning there will be a slight drop in the temperature, Avhich Avill rise in the evening, probably higher than it did the evening before. On the third or fourth day the Avound usually cleans off, suppuration is established, granulations spring up, the chemical substances Avhich have been the cause of the fever are no longer absorbed, and the tem- perature falls. Surgical fever usually lasts about a week. With the fall of the temperature the other symptoms disappear. The skin becomes cool and moist, the urine flows freely, the tongue becomes clean, and the patient's con- dition as to comfort is greatly improved. The presence of a high temperature alone does not necessarily indicate a disturbance in the healing process, but if Avith the pyrexia the other symptoms of fever are present, and the fever curve remains high, it becomes the duty of the surgeon to examine into the condition of the wound, and satisfy himself as to the presence or absence of bacterial infection. If on removing the dressings the lips of the wound are found red, swollen, and tender, inflammation is pres- ent, and has usually been caused either by too great tension or, more commonly, by the presence of micro-organisms. The septic inflammation may be due to the infection of retained secretions or to the groAvth of bacteria along the track of one of the sutures, and the consequent development of a stitch abscess. A free evacuation of all infected areas must be secured. The infected stitches should be removed, drainage-tubes should be inserted, or the Avound laid open and moist antiseptic dressings applied. The amount of interference necessary must be decided in each case by the surgeon. Little constitutional treatment is indicated in these cases beyond the administration of nervous sedatives or opium for the relief of insomnia and pain. Good nursing usually suffices to make the patient comfortable. Secondary wound fever is a term applied to that form of fever which occurs after the establishment of suppuration, and is especially marked if the pus do not escape freely. If at the end of a feAv days after the beginning of the healing process the temperature does not fall, but remains high or begins to rise again in a second curve, it is highly probable that pus has formed in the Avound. This form of fever is sometimes called suppurative fever. It is due to the absorption of a chemical poison, the result of the action of the pyogenic cocci. The micrococci themselves appear not to play a leading role, for they are not ahvays seen in the blood or tissues, and the fever curve drops as soon as the pus is evacuted. There is no progressive infection of the system after the virus has been absorbed, as in pyemia. When suppuration takes place in a Avound the constitutional disturbance is usually marked. The fever may be ushered in by a chill, but more frequently a sharp rise of temper- ature alone indicates the beginning of the process. If the abscess is confined to the limits of the Avound, abundant opportunity can be obtained for the escape of pus, but if the surrounding connective tissue has become infected, the pus may burroAv in various directions. A number of counter-openings will then be necessary to check the suppuration. From the acute stage the inflam- 36 AX AMERICAX TEXT-BOOK OF SURGERY. mation may pass into a chronic one, which may continue for several weeks. The fever curve now assumes the remittent type! falling in the morning to the normal point, to rise again several degrees in the evening. This is the type of the so-called hectic fever (kxrtxoc:, habitual) accompanying the chronic suppura- tions which occur as complications of tuberculosis. With the continuance of the suppurative fever there are marked emaciation and prostration. The pulse becomes weak and rapid. Diarrhoea and night-sweats are often prominent symptoms, and unless the suppuration is checked the patient may succumb to septic poisoning or to exhaustion. In the more chronic forms, Avhich may last for months, the emaciation will be more gradual. Enlargements of the lymphatic glands and amyloid degeneration of the kidneys and of other internal organs are then often found. The treatment of acute suppuration consists in the establishment of counter-openings, with thorough disinfection of the various sinuses and proper drainage. Incisions made for this purpose should be extensive and sufficiently deep to lay the pus-cavity freely open, and the walls of the cavity should be thoroughly curetted to remove the infected granulations. Where joints are involved the question of resection must be considered. The presence of amyloid degeneration in the kidney, as shown by examination of the urine, is a contraindication to resection, and in these cases amputation may offer a better chance of saving life, and may occasionally be attempted. Free stimulation and nutritious diet are indispensable. In many cases placing the patient in the open air for several hours daily may bring about a decided improvement, even Avhen his condition is a most serious one. When, however, these processes are associated with tuberculosis the prognosis is very unfavorable. Traumatic Delirium. This term is used to denote those forms of delirium which occur as the result of injury, and are not due to alcoholism. The anatomical seat of delirium is in the cortical gray matter of the brain. The delirium is due either to functional disturbance or anemia of that region or to inflammations of the cortex and meninges—more particularly of the middle and posterior lobes (Hunt). The causes of delirium are as numerous almost as the injuries which give rise to constitutional disturbance, but there are certain lesions which seem more prone to this form of functional. disturbance than others. In some cases of shock there is considerable mental exaltation and excitement which are quite characteristic, the condition being known as " pros- tration with excitement." There is usually no marked delirium, but at times a temporary mental aberration of a well-defined character. It may precede and accompany cerebral lesions, such as hemorrhage from trauma, or throm- bosis and embolism. Delirium is often noticed in children after capital operations, being out of proportion to the amount of fever which exists. In traumatic fever of a severe type, as we have seen, delirium may be present. Among other surgical lesions, severe burns and scalds and facial erysipelas may be mentioned as par- ticularly liable to be accompanied by delirium. In some individuals pain alone is often sufficient to produce a temporary mental aberration, which dis- appears immediately upon the subsidence of the pain. This form of delirium is allied to the so-called delirium nervosum of the German Avriters__a condition of nervous disturbance which comes on after injuries in hysterical subjects. It may occur in the stage of convalescence following erysipelas and other inflam- THE TRAUMATIC FEVERS. 37 matory diseases in nervous patients. It is characterized by considerable mental depression. Transitory psychical disturbances may also folloAv surgical opera- tions, and there may be developed at times not only melancholia, but a suicidal mania. A nervous delirium Avithout fever is occasionally noticed after opera- tions upon portions of the body supplied with unusually sensitive nerves. The operation for phimosis, Avith an unusual amount of irritation of the glans penis, is an example. Severe nervous disturbance and delirium following operations or injuries, Avithout a corresponding amount of inflammation or fever, should cause the surgeon to inquire as to the possibility of poisoning by iodoform or carbolic acid—conditions readily shoAvn by an examination of the urine. The treatment of this form of delirium consists in the removal of all local sources of irritation, in the application of ice to the head in some cases, and in the use of the bromides and hypnotics. If due to cerebral anemia from loss of blood, suitable stimulation is indicated. Opium is usually not Avell borne, and should be reserved for those violent cases Avhich cannot be controlled in any other way. Delirium Tremens. This disease is a form of mental disturbance characterized by delirium, and accompanied by a peculiar tremor of the muscles, occurring in individuals habitually intemperate in the use of alcoholic stimulants. It follows either a debauch or some injury which suddenly confines such a patient to bed; hence its consideration here. It is said to be much less common in countries where Avine and beer are the national beverages than in those in which spiritu- ous liquor is consumed. The habitual use of various drugs is said to produce it, as opium, tobacco, and cannabis indica, and even tea and coffee. The term mania-a-potu is used to denote an acute type of delirium following a debauch, in Avhich the patient may become maniacal. Delirium tremens was formerly supposed to be due to an inflammation of the brain. L'sually, hoAvever, the post-mortem appearances indicate no sign of active inflammation beyond some thickening of the meninges. According to Hunt, there is a condition so characteristic that it has been called " wet brain," consisting of a passive congestion with serous exudation in and under the pia mater, filling the ventricles and folloAving the convolutions. Chronic gastric catarrh is also found to exist, and atheromatous degeneration of the arteries, fatty liver, and Bright's disease. The symptoms of delirium set in gradually. The patient, removed from his ordinary surroundings, complains of feeling uncomfortable; he is restless and tremulous; there is much depression of spirits, and his sleep is disturbed Avith nightmares ; he talks in his sleep, and may Avander about during the night, but the next morning asserts that he has slept well. When it fol- lows an injury, the onset of the disease is usually sudden. With the full development of the disease there is complete insomnia, Avith a muttering delir- ium frequently broken by loud cries, and a peculiar tremor of all the mus- cles. The patient is constantly employed pulling the bed-clothes about, tear- ing off dressings and splints, and endeavoring to get out of bed. He appears to be more or less insensible to pain, and may Avalk upon a broken leg without showing any signs of suffering. He is the victim of all manner of delusions, usually of a horrible nature. The hallucinations take the form of hideous animals and insects ; occasionally they are obscene in character. The patient may be momentarily recalled to himself sufficiently to give an intelligent answer, but relapses immediately into his previous condition. There is little frver, although occasionally there may be a marked rise of temperature. The 38 ^1A AMERICAN TEXT-BO OK OF SURGERY. pulse is weak and quick, and there is rapid loss of strength, due to the small amount of nourishment taken durino; the debauch and the later inability to retain food. In favorable cases, after two or three days of insomnia sleep comes sud- denly, and on awakening the delirium is found to have disappeared. In severe or fatal forms the prostration increases rapidly and is a marked feature, the pulse failing greatly in strength. The patient may die suddenly from heart failure. Pneumonia, a complication unusually frequent in alcoholic subjects, may supervene, and bring about a fatal issue. The prognosis of the disease is, however, usually favorable. Among the most reliable symptoms which give a clue to the patient's condition are the pulse and temperature. The Aveak and rapid pulse is a measure of the prostration, and the rise of temperature is a warning of complications such as pneumonia or septic infection of the wound. The prophylactic treatment consists in the employment of alcoholic stim- ulants in moderate quantities, of capsicum and digitalis, and of nourishing food. The last is only secondary in importance to sleep. By these means the nervous system is steadied and the strength of the patient maintained. Any indica- tion of nervousness or insomnia should be met with a free use of the bromides. An attack may in this way be warded off. During the attack mild stimulation with liquor or beer is usually advisable, although the use of stimulants must be determined by the circumstances of each case. The drugs which are most frequently used at the present time are chloral hydrate and the bromides. It is probable that sulphonal in sufficient doses to cause sleep has rather too depress- ing an influence upon the heart's action. The question of the use of opium in this disease has been much discussed. In mild cases it is not necessary, but it may be of much value in quieting restlessness Avhen it is of great importance that splints or dressings should not be disturbed, or Avhen the delirium is of so acute a type that all other remedies fail to control the patient. CHAPTER V. SUPPURATION AND ABSCESS. SECTION I.—SUPPURATION. Suppuration is due to the action of the pyogenic cocci upon the tissues, and is the usual termination of infective inflammation. It is the process by means of which the exudate and the tissues involved become liquefied and con- verted into pus. The organisms most frequently found in pus are the staphylo- coccus pyogenes aureus and albus. They have a tendency to accumulate in clusters, and when growing in the tissues produce circumscribed forms of suppuration. The streptococcus, Avhich is sometimes present, on the other hand, shoAvs less tendency to cause local suppuration, but spreads rapidly through the tissues by the lymphatics, and eventually gives rise to a diffused form of suppuration. When grown on beef gelatin the staphylococcus causes a liquefaction of the culture medium in virtue of its peptonizing action, which is due to the presence of a soluble peptonizing ferment, and it is in consequence of this action that the fibrinous exudate and the inflamed tissues become converted into pus. That the pyogenic cocci are the cause of suppuration has been abundantly SUPPURATION AND ABSCESS. 39 shoAvn by microscopical investigation and experiment. They are found in the pus of all acute abscesses, and frequently in cold abscesses. The occasional failure to find them in the latter class of abscess has been explained in various Avays. By some these abscesses are supposed to be caused by the bacillus of tuberculosis alone, but the most probable explanation is the dying out of the organisms and the deposition of their remains as a sediment. Experiments on animals shoAV that these organisms Avhen injected in sufficient quantity under the skin will produce suppuration. When absorption takes place rapidly, hoAvever, a larger quantity can be injected Avithout producing suppuration. In man inoculation through abrasions or AA^ounds, and even through the uninjured skin, will cause suppu- ration. Garre produced furuncles of the forearm by rubbing in a culture of the aureus. The question of suppuration Avithout the agency of bacteria has been carefully studied recently. Experiments on animals Avith the injection of calomel, mercury, turpentine, and croton oil shoAV that certain drugs can produce in certain animals pus, or, as it would be better called, " puruloid material," containing no bacteria. Non-bacterial pus can also be produced by introducing cultures of cocci Avhich have been sterilized by heat. In this case the organ- isms have been removed, but their chemical products still remain, and are undoubtedly important factors in the production of inflammation and suppu- ration. Practically, hoAvever, the surgeon never has to deal Avith non-bacterial suppuration. Among the predisposing causes of suppuration may be mentioned diminished vitality of the tissues. The healthy body is intolerant of bacteria, and Avill resist the invasion of a mass of organisms Avhich an inflamed or diseased part may be unable to Avithstand. The milder types of inflammation seem partic- ularly Avell adapted to encourage bacterial growth. Some of the severest types of suppuration, such as acute osteo-myelitis, folloAv often slight bloAvs or inju- ries. The delicate reticulum of blood-vessels found in the medullary cavities of bones furnishes a convenient lodging-place for swarms of bacteria, owing to the sloAvness of the blood-current and the tortuous course of the blood-channels. When the circulation has been impaired or arrested by an extravasation of blood or a congestion of the part, the conditions are favorable for an intravas- cular infection if organisms happen to be circulating in the blood at the time. As Ave have seen, micro-organisms may from time to time be found in the cir- culating blood, particularly in individuals of feeble constitutions. The ana- tomical nature of the part Avill therefore favor suppuration in certain localities. A most familiar example is the lymphatic gland tissue. There the organisms Avhich have invaded the tissues through a Avound, and have found their Avay into the lymphatic vessels, are arrested, and a glandular abscess results. The condition of the blood is also a predisposing cause, as the tendency to carbun- cular inflammation in diabetes sho\vs. The material Avhich forms as the result of suppurative inflammation is pus. Pus is a yelloAvish-AAdiite fluid of the consistency of milk or cream, of an alkaline reaction, and commonly nearly odorless. It has a specific gravity of about 1030, and A\Then alloAved to stand it separates into a clear fluid knoAvn as pus serum, and a sediment Avhich averages from 10 per cent, to 20 per cent. of the Avhole amount. The liquor puris. or pus serum, is a pale greenish-yelloAv fluid Avhich does not coagulate spontaneously, and contains an albuminous substance knoAvn as peptone. The salts Avhich it contains are present in about the same proportion as in the blood. The sediment consists of pus-corpuscles, the pyogenic cocci and the other 40 ^4A AMERICAN TEXT-BOOK OF SURGERY. forms of micro-organisms that may be present, and fragments of broken-down tissue. Most of the pus-corpuscles are the altered leucocytes which have escaped from the blood-vessels with the exudation; others are derived from the prolif- erated fixed connective-tissue cells. When first taken from a fresh abscess many of them are found to possess amoeboid movements. They are a little larger than the white blood-corpuscles. Their protoplasm is somewhat gran- ular, and Avhen acetic acid is added to them they are found to contain several nuclei. This polynuclear condition was supposed to be evidence of an ability of the pus-corpuscles to proliferate, but it is now recognized as a sign of degen- eration. They also occasionally contain drops of fat; others are full of large granules, which, Avhen they break up, liberate a granular detritus Avhich may be seen suspended in the fluid. The color of pus is occasionally blue. This is due to the presence of the bacillus pyocyaneus, ordinarily considered a harmless organism, but the presence of which indicates sloAvness of repair. Orange-colored pus is caused by the presence of hematodin crystals, and is found in some forms of inflammation. It is probably due to the fact that many red corpuscles in the exudation have been broken up by the septic process. The peculiar foul odor of pus wrhich comes from the neighborhood of the vagina or rectum is due to the presence of the bacillus pyogenes fcetidus. The thick creamy, odorless pus which flows from an acute abscess Avas formerly known as healthy or laudable pus. It contains comparatively few bacteria. Pus may occasionally undergo decomposition ; in this case the micro-organisms of putrefaction also are found in it, and the pus-corpuscles are broken down and much diminished in number. This is known as ichorous pus, and when mixed with blood which is seen floAving from a rapidly-spreading abscess is called sanious pus. These unhealthy forms of pus are very acrid and give an acid reaction. A microscopical examination of the connective tissue in suppurative inflam- mation shoAvs that in the early stages of the process the stellate cells of the tissue lose their prolongations, become rounded, and undergo karyokinesis, and multiply in this Avay. In the mean time the intercellular substance undergoes a softening process, is transformed into a homogeneous substance, and the proliferated connective-tissue cells are in a state of polynuclear degeneration. This stage is the one immediately preceding that of pus formation. Many of these degenerated cells are therefore of connective-tissue origin, and under some circumstances they may even outnumber the leucocytes. When the polynuclear stage has been reached, it is impossible to tell the origin of these cells. Suppuration is always to be regarded, as it has been aptly described as a '| battle of cells," the bacteria exerting, in all probability, a chemiotaxic attrac- tion Avhich for bacteria is irresistible. When acute suppuration takes place the symptoms of inflammation all become more marked. There is great increase in redness and swelling, and the part is exceedingly hot and is the seat of a throbbing pain. The formation of pus is often ushered in by a chill or rigor, and a change in the conditions of the part will indicate the locality of the pus. The skin at this spot becomes adherent to the parts beneath, and later presents to the touch the sense of fluctuation. A deeper color is also present at this point, and in the centre of the focus a whiter zone indicates the stage immediately precedino- the breaking doAvn of the abscess and the discharge of pus. The diffused forms of suppuration in connective tissue are called SUPPURATIOX AXD ABSCESS. 41 phlegmonous inflammations. This variety is usually seen after compound fracture Avhen septic infection has occurred, and may involve the greater portion of the limb, as the forearm, the arm, or the leg. An acute SAvelling, Avith oedema of the connective tissues, ushers in the process, and areas of bogginess or fluctuation will make themselves manifest later. The constitutional disturbance Avill usually be great. A sharp rise of temperature, accompanied perhaps with a chill, will mark the beginning of the suppuration, and the pyrexia will remain until free incisions and thorough drainage have arrested the progress of the pus. The route Avhich pus takes under these circumstances depends upon the anatomical structure of the part, upon gravity, and also upon the nature of the organisms. In many cases pus Avill continue to burroAV until the integu- ments have been freely divided and the margins of the suppurating area have been fully exposed. The improvement folloAving such free incisions is due to the fact that the bacteria groAving in the Avail of the abscess are thus freely exposed to the air, a condition less favorable for their growth, and are more readily reached by antiseptic agents. Small incisions are of little use in the more rapidly-spreading forms of cellulitis, and incisions from six to twelve inches in length are sometimes required to arrest the progress of the disease. If the treatment adopted fail to arrest suppuration, it may pass into a chronic stage; the pus Avill then burrow slowly and make its appearance at many different spots. There will also be considerable constitutional disturbance, marked by a progressive emaciation and gradual exhaustion of the patient. The febrile disturbance Avill be of the remittent type known as hectic fever. Purulent infiltration of a limb is a still more malignant form of inflam- mation. Originating in a suppuration perhaps at first trivial, it will spread rapidly, and its involvement of the lymphatics of the limb will be plainly indi- cated by red lines extending up to the axilla or the groin. The protective influence of the lymphatic glands will be shown by their filtration from the lymph-stream of the cocci and their ptomaines. This leads to the formation of an abscess just above the elboAv or in the axilla or groin, which temporarily arrests further progress of the suppuration. More rarely the entire limb will be involved in an acute inflammatory swelling Avith little tendency to suppura- tion. In this case the whole part is apt to become gangrenous. Free incisions are followed by the escape of a sero-purulent fluid. There is profound constitu- tional disturbance Avith perhaps acute septicemia. Probably in these cases there is a mixed infection, and bacilli of putrefaction are mingled with the micrococci. When infection of a wound takes place the slight swelling which ordi- narily accompanies the healing process is much increased at some portion of the Avound, and is accompanied by reddening and induration. This will usually occur around one of the stitches Avhich has been the source of infection, or pus may collect in some part of the wound Avhere the surfaces Avere not accurately brought in apposition and Avhere the Avound fluids have accumulated from imperfect drainage. The rise of temperature will give speedy Avarning of the approach of suppuration in such cases. The general plan of treatment to be adopted in cases of spreading suppuration is the employment of free incisions Avhich expose the extreme limits of the suppurating area. This operation should be accompanied by a thorough curetting of the surface of the pus-cavity to remove the bacteria from the surrounding tissues and by thorough disinfection Avith appropriate antiseptic drugs. In the case of an extremity this can best be accomplished by immersion of the limb in an antiseptic bath. The agent used should be largely diluted (sublimate 1 to 10,000, or carbolic acid 1 to 500) to prevent poisoning by the drug. FolloAving the bath antiseptic fomentations may be applied. 42 AX AMERICAX TEXT-BOOK OF SURGERY. For this purpose some of the milder drugs containing carbolic acid, as sulpho- naphthol, may be used. When other methods fail, irrigation is often successful. Sterilized water may be used for this purpose or extremely weak solutions of disinfectants. If a dry dressing is preferred, iodoform or aristol or boric acid may be dusted freely upon the part, and the wound may then be packed with an antiseptic gauze. The use of stimulants and careful feeding should be the chief feature of the general treatment of the case. SECTION II.—ABSCESS. An abscess is a circumscribed collection of pus, and is caused usually by the presence of the staphylococci in the tissues. When these organisms invade a part, Ave find even at the end of tAventy-four hours an enormous number of leucocytes in the exudation which takes place. The connective-tissue fibers are SAVollen and the lymph-spaces are distended and filled Avith cells. As Ave have already seen, the fixed cells of the tissue undergo changes of an active nature, and form nucleated cells Avhich cannot be distinguished from the leucocytes: they are, hoAvever, usually much less numerous than the latter. The small vessels are dilated and distended with blood, and in many cases with leucocytes. The cocci in the mean time increase in number and tend to group in masses. As they exert a peptonizing action upon the intercellular substance and the fibrin of the exudation, liquefaction takes place in the center of the inflamed tissue, and an abscess is formed. The Avails of the pus-cavity are formed by a zone of granulation-tissue, the cells and intercellular substance of Avhich have not been broken down by the action of the bacteria, and remain to form a protecting layer betAveen the infected area and the surrounding healthy tissues. This is the mode of development of an abscess in some of the looser tissues like connective tissue. In the denser structures and in the internal organs Avhen a plug of microccocci becomes arrested at some point in the circu- laton, as, for instance, in a glomerulus of the kidney or in a lymphatic gland or in the cutis vera, Ave find that the tissue immediately surrounding it undergoes a chemical change due to the action of the ptomaines upon its cells, the result of Avhich is that coagulation-necrosis of the tissue takes place. This ring of dead tissue is readily seen in sections taken for microscopic pur- poses, as the necrosed area does not take any of the staining fluids which act upon the surrounding tissues. Outside of this area a ring of granulation- tissue forms. Eventually the necrosed area is invaded both by the bacteria and the leucocytes, and becomes liquefied by the action of the cocci. An abscess of this type, when examined microscopically, will show a mass or plug of bacteria in the center, around which is a layer of pus and shreds of tissue enclosed in a zone of granulation-tissue, the miscalled pyogenic membrane of the older pathologists, who thought that the Avail of an abscess was a sort of secreting surface from Avhich pus was formed. The symptoms of an acute abscess are usually well marked. The large amount of local swelling, with a varying amount of pain according to the density of the tissues which lie between the cavity of the abscess and the surface, is accompanied frequently by a chill or a gradual rise of temperature as pus begins to form. As the abscess forms a progressive softening of the integuments takes place until the pus reaches the surface. Considerable resist- ance will be offered by certain tissues, as fascia?, a joint capsule, or bone, and the pus may take a devious path before the abscess begins to point. Fluctua- tion will now be distinctly felt, and redness with oedema of the skin and subcu- taneous tissue will indicate the near approach of pus. The skin becomes SUPPURATION AND ABSCESS. 43 stretched and thin and its vessels compressed, and over a certain area the blood will not circulate; death of this area occurs, and the abscess then easily breaks through it. It is not usually difficult to diagnosticate the presence of an acute abscess. Acute forms of inflammation may occur, hoAvever, in Avhich the sensation of fluctuation is apparently avcII marked Avhen an incision fails to reveal the pres- ence of pus. No harm is done, the inflammation may be relieved by such an operation, and the impending abscess prevented. Deeply seated abscesses under a dense fascia, as in the neck, may be over- looked, as no fluctuation can be felt. The local oedema and braAvny feel, with other signs of suppuration, are always a sufficient Avarrant for a deep but care- ful exploratory incision at an early date to prevent Avide and dangerous burroAv- ing of the pus under the fascia. An aneurysm may, hoAvever, be mistaken for abscess, particularly Avhen its presence is obscured by the symptoms of inflam- mation, and the use of the knife in such a case Avould be a grave error. An aneurysm will declare itself by its less acute history, by the thrill, bruit, and expansile pulsation, and can exist only in connection with a large vessel. Some forms of rapidly-growing malignant tumors may also simulate suppura- tive processes. In all such cases the use of the aspirator or of the hypoder- matic needle is of great value. The heat of the part, the sense of fluctuation, the local oedema, and the rise of temperature, as shoAvn by the thermometer, are all important diagnostic symptoms, and Avill usually be sufficient to estab- lish the presence of an abscess. When an acute abscess breaks the pus Avhich is discharged is of a thick cream-like consistency, and is frequently mingled Avith soft sloughs of con- nective tissue or fascite, or fragments of lymphatic glands Avhich have under- gone a necrosis due either to the great tension of the part or to the formation of destructive chemical substances by the pyogenic cocci. The treatment of acute abscess consists in incision as soon as it can be definitely ascertained that pus has formed, and sometimes even earlier. Nothing is to be gained by delay, and extensive injury may be inflicted upon the surrounding tissues if the abscess is not opened early. In some regions the dangers of delay are very great. An abscess in the neighborhood of the appendix vermiformis may produce a fatal peritonitis if allowed to remain unopened. Deep-seated abscesses of the neck may burroAV Avidely, and may seriously interfere with respiration by pressure upon the trachea. An abscess near the rectum should be opened as soon as induration is discovered, in order to prevent a fistula. If no pus has formed the incision may prevent it. The incision, as a rule, should be a free one, and so made as to favor drainage and to leave the least conspicuous scar. The finger should then be introduced to determine the size and situation of the various pockets. In case of abscesses near large vessels or other important structures Hilton's method may be used to advantage. This consists in making an incision through the skin and deep fascia by the knife. The seat of the pus can be ascertained by pushing in a pair of closed hemostatic forceps or blunt scissors or a sinus dilator, and the opening so made can be easily enlarged by dnnving them out open. If neces- sary, to facilitate the escape of the pus by gravity, a counter-opening can often be made by pushing the hemostatic forceps entirely through the tissues to the opposite skin, and cutting betAveen its partly opened blades. The cavity of the abscess should be thoroughly emptied, curetted, and syringed out with anti- septic solutions. These may consist of corrosive sublimate 1: 5000 or carbolic acid 1 : 100, or if a milder antiseptic fluid is needed phenyl (sulpho-naphthol) 1:250. When the pus and sloughs have been thoroughly removed in this 44 AN AMERICAN TEXT-BOOK OF SURGERY. Avay, a drainage-tube of a sufficient size should be inserted, and retained either by "a safety pin inserted through its extremity or by stitching it to the skin to avoid its falling out of the abscess, or, still worse, of being lost m its cavity. An antiseptic poultice (made of aseptic cotton and cheese-cloth and wrung out of a weak antiseptic solution) may be applied, or a dry absorbent dressing may be used. In freely-discharging abscesses the dressing should be changed at the end of twelve hours or less, and the cavity washed out again. The fountain syringe fitted Avith a tube ending in a conical glass point is vyell adapted for this purpose. It gives a continuous stream, and causes but little pain to the patient in its application. In a few days the inner surface of the abscess wall "cleans off" and healthy granulations make their appearance. The tube can be shortened daily as the cavity shrinks, but the time of its removal will depend entirely upon the length and ramifications of the cavity. Cold abscess is caused in the great majority of cases by tubercular infection, although occasionally it may be of syphilitic origin. In the ordinary tubercular cold abscess we find a peculiar membranous wall formerly called the "pyogenic membrane" (the "pyophylactic membrane" of Park), which is readily scraped off and is infiltrated with tubercles. In the syphilitic abscess no such condition exists. This membrane, as also the pus of cold abscess, is more fully described in the chapter on Tuberculosis. The organisms found in the contents of the abscesses before they are opened are the bacilli of tuberculosis. Sometimes before, and always after they have opened spontaneously or have been opened Avithout due antiseptic precautions, there is added the infection with pyogenic cocci, or the bacteria of putrefaction. This is an example of what is called mixed infection. Clinically, Ave find feAv of the symptoms of acute abscess. There is in most cases no redness of the part until the abscess is about to break. Pain and heat are usually wanting. The SAvelling is frequently quite large and fluctua- tion is distinct. Such abscesses may exist for months before they burst. Dur- . ing their formation the constitutional disturbance is usually slight. There may be, hoAvever, considerable emaciation due to the progress of the tuberculosis. The temperature is usually slightly raised, and in cases of doubtful diagnosis the thermometer will give valuable information. One of the most common seats of cold abscess is the vicinity of the spinal column, and such abscesses are due to tubercular disease of the vertebrae (Pott's disease). The pus bur- rowing along the psoas muscle (psoas abscess) points above or below Poupart's ligament or on the thigh external to the vessels, or it may point in the lumbar region near the margin of the quadratus lumborum muscle (lumbar abscess). Treatment.—These abscesses should be opened with every antiseptic precaution, otherwise true suppuration Avith hectic fever will follow from the mixed infection Avhich inevitably occurs. They must be thoroughly scraped out and the wound stuffed with iodoform gauze. Such treatment is best adapted to those abscesses Avhich have feAv ramifications, and the Avails of which are everywhere accessible to the curette. In many cases it is Avell to evacuate the contents Avith the aspirator and to inject some preparation of iodoform. A large canula is sometimes necessary, owing to the thick plugs of cheesy matter which obstruct the flow of pus. The cavity is now washed out Avitli a 3 per cent, solution of boric acid. Among the preparations of iodoform recommended is a 5 per cent, ethereal solution, but not more than three ounces should be injected for fear of iodoform poisoning. It also causes considerable pain. A 10 per cent, emulsion of iodoform in olive oil can be introduced safely. The folloAving emulsion is also sometimes used, and is considered safe as far as poisoning is concerned : Iodoform 10 parts ; glycerin lio ; mucilao-. gum. Arab, SUPPURATION AND ABSCESS. 45 5 ; carbolic acid 1 ; and Avater 100 parts. From one to three ounces should be injected, and the abscess-cavity should be carefully manipulated so as to intro- duce the drug into all the pouches. Two or three such injections are made at intervals of three or four Aveeks. A cure may not be obtained for several months. Equal parts of iodoform and olive oil may be injected freely into tubercular sinuses which have resulted from the bursting of such abscesses. If this treatment fails, recourse may be had to incision, as above described. The general treatment consists of good food, cod-liver oil and other tonics, and a careful selection of climate. Mechanical contrivances may be needed for the support of joints or bones. Abscesses of different regions of the body possess characteristic peculiarities. The most common form of abscess in the integuments is the furuncle or boil. This is caused by a growth of the cocci from the deeper layers of the epidermis doAvmvard along the sheaths of the hair-follicles, and a final accumulation near the root of a hair. If the cocci are arrested in their groAvth at the mouth of the follicle, a pustule is formed, but in many cases the development continues downward and a true furuncle is developed. The boil in its early stages appears as a pustule. The amount of coagulation-necrosis is considerable, and the result is a "core" Avhich is discharged Avhen the abscess breaks. A crucial incision Avill promptly arrest the groAvth of a boil in its early stages, or an application of the liquefied crystals of carbolic acid may be used if it is desired to avoid a scar. A carbuncle is a suppuration of the subcu- taneous tissue, and is situated most frequently under the thick skin of the back of the neck. Like the boil, it is at first superficial, but rapidly spreads to the deeper parts. It has erroneously been called a collection of boils, OAving to the fact that numerous points of pus appear on the surface, and when opened it pre- sents a honeycombed appearance. This peculiarity of the carbuncle is due to the anatomical structure of the skin and subcutaneous tissues of this part of the body. The pus forms in the dense fibrous reticulum Avhich underlies the thick cutis, and makes its way to the surface through the columme adiposae, in which the fine lanugo hairs are situated (Warren). The carbuncle should be freely incised and all the sloughs removed by the sharp spoon or scissors, and the part disinfected as thoroughly as possible. Abscess of the lymphatic glands may form in the groins, as the result of suppuration complicating venereal disease; in the neck, following inflammation of an adjacent mucous membrane ; in the axilla, as the result of suppuration in the fingers or hand; or in the saphenous glands, from suppuration in the toes or foot. Felons and palmar abscesses are often supposed to be caused by direct local trauma, but are more frequently due to indirect infection by pyogenic cocci which probably follows an injury of some kind. The precise seat of the suppuration will vary according to the situation of the infection. Nowhere is an early incision of more importance, as the usefulness of the finger or hand is at stake. When abscesses form in and around the internal organs they usually are designated by special names frequently derived from the organ with which they are associated, as the perinephric and the perityphlitic abscesses and abscess of the space of Retzius. They should be opened as early as possible and treated as above. Abscesses of the liver are rare in this country, but are occasionally met Avith. They are due to infection originating in the digestive tract, and are associated with disturbances of that region more frequently seen in tropical climates. They may sometimes be cured by repeated aspiration, but frequently they must be reached by laparotomy followed by drainage and suturing the edges of the opening of the abscess to the abdominal incision. Pus in the thorax is most frequently found in the pleural cavity, constituting 46 AX AMERICAN TEXT-BOOK OF SURGERY. empyema. Such an abscess can rarelv be cured by aspiration, but should be promptly opened and drained. A cure may be retarded by the mechanical difficulty of bringing the abscess walls together, owing to the contraction of the lung and the rigidity of the chest wall. In these cases resection of several ribs is necessary to allow the thorax Avail to come in contact with the lung. (Estlander's operation). Tuberculosis is often a complication of this variety of abscess. Abscesses occur also, but much more rarely, in the lung itself. These can be opened and drained by an incision through or betAveen the ribs. The operation is much simplified if adhesion of the lung to the thorax wall has already taken place. CHAPTER VI. ULCERATION AND FISTULA. SECTION I.—ULCERATION. An ulcer is a granulating surface, usually of the skin or mucous membrane. There is also a tendency to necrosis or death of the granulations which are formed by the tissues in an effort at repair. If the retrograde changes equal the reparative, the ulcer will remain stationary, but if the former exceed the latter, the ulcer will constantly increase in size. The causes of ulceration are of widely different origin. Some develop during the course of certain infectious diseases, particularly those of a chronic type, as syphilis, tuberculosis, leprosy, and glanders. Another kind of ulcer depends upon widespread disturbances in nutrition. These are known as dyscrasic or constitutional ulcers. To this class belong the scorbutic ulcers, which appear to form as a result of disease of the blood-vessels brought about by the absence of a sufficient variety of nutriment ; also the cachectic ulcers, due to exhaustion of the system from starvation, exposure, or disease. Ulceration may also be favored by certain local conditions. A passive hyperemia due to retardation in the venous circulation may be the cause of the varicose ulcer. Decubitus, or bed-sore, is due to a feeble circulation, Avhich is easily arrested bv continuous pressure from lying in bed. causing death of 1 * TIT * • ^ the part. JSeuro-paralytic ulcers are caused by diminished innervation. The so-called trophic disturbance belongs in this class. A striking example of this variety is the " mal perforant," or perforating ulcer of the foot. We may also have ulceration as the result of the breaking down of malignant groivths, as sarcoma and carcinoma, particularly in the epithelial forms of the disease. Finally, ulcerations occur which are the result of certain mechanical dif- ficulties obstructing the healing process. Extensive loss of substance, burns of the skin, or avukion of the scalp may result in the existence of a permanent granulating surface constantly contracting or enlarging, but never fully healing. Sloughing of the flaps of an amputation stump may be followed bv'an adhe- sion of the integuments to the ends of the bones, which protrude slightly and are covered Avith granulations. Wounds may be prevented from healin^ by mechanical irritation, such as chafing or rubbing or the application of irritating ointments or acids. A section taken from an ulcer and examined microscopically shows ULCERATION AND FISTULA. 47 generally a thickening of the tissues around the ulcer due to a hypertrophy of the papillae and an accumulation of the epidermic cells, Avhich sometimes form'an overhanging mass, giving the appearance of "callous edges." In the deep layers of the rete mucosum and in the papillary layer of the true skin deposits of blood pigment are often seen. The surface of the ulcer is covered with a layer of granulation-tissue. This tissue may resemble the type seen in healthy granulations, being composed of round cells closely packed together and supplied Avith a rich capillary network of blood-vessels, or Ave may find a condition of coagulation-necrosis due to breaking doAvn of portions of the granulations. In old ulcers the cell-groAvth is much less abundant, and a gelat- inous intercellular substance is seen in Avhich clusters of cells are scattered here and there. The granulation layer is quite superficial; and beneath it we see either the nearly normal tissue or a mass of fibrous cicatricial tissue. Ulcers are classified not only on the basis of their mode of origin, but also according to certain peculiarities A\rhich are characteristic. Thus an ulcer may be healthy, fungous, erethitic, callous or atonic, phagedenic, etc. Treatment.—A healthy ulcer, in Avhich the granulations are small and florid and the edges shoAV a bluish border of cicatrization, if it be small may be alloAved to scab and cicatrize under the crust. If larger, carbolated oxide- of-zinc ointment, with or Avithout calomel (3J @3j), with suitable protection by a bandage, and rest, is all that is needed as a rule. Simple avoidance of irrita- tion by means of a bit of "protective" or gutta-percha tissue under an anti- septic dressing is often better than ointments. If sIoav in healing, stimulation by the occasional light application of nitrate of silver or a solution of chloral (gr. x @ §j) or potassio-tartrate of iron (gr. v @ 3j) will be useful. Skin-grafting is required in large ulcers, and is noAV done early in many cases of large loss of tissue which Avould result in an ulcer at a later period. For the details of its application see the chapter on Plastic Surgery. The fungous or exuberant ulcer may be caused by an obstruction of the venous circulation due to cicatricial contraction and induration, and may be seen after burns and other injuries followed by undue contraction of the surrounding tissues. The granulations will protrude above the edges of the Avound, and are congested and bleed readily. The application of the solid nitrate of silver, a solution of sulphate of copper (gr. i-x @ §j), or shaving off the exuberant granulations Avith a bistoury, followed by compression by Martin's rubber bandage or strapping or skin-grafting, will favor the healing of such ulcers. When the fungous granulations are pale and oedematous, they may be due to tubercular disease, and in this case a thorough curetting of the surface should precede the application of caustic or actual cautery. The erethistic, irritable, or painful ulcer is a name applied to ulcers which are extremely sensitive. The- cause of this sensitiveness is not always clear. They are found in regions liberally supplied with sensitive nerve-fibers, as the anus or matrix of the nail, and are then doubtless due to an exposure of the terminal nerve-branches in the Avound. They are found frequently in the lower extremities about the ankle or over the surface of carious bone, as the tibia. Fissure of the anus is a good instance of this kind of ulcer, Avhich by inducing constipation and other digestive disturbances often seriously undermines the general health. It is easily overlooked unless carefully sought for in the folds of the anal mucous membrane. It is best treated by forcible dilatation of the sphincter muscle. Ingroiving nail or ulceration of the matrix of the nail is due to irritation from a sharp corner of the nail, AArhich should be removed. The local treatment consists of drying and soothing poAvders, such as iodo- form, or, better, the removal of the sensitive granulations with the curette 48 AN AMERICAN TENT-BOOK OF SURGERY. or knife under cocaine anesthesia, and protection of the raw surface by daily packing a very small bit of absorbent cotton under the edge of the so-called "ingrowing*" nail. It is really "overgrowing granulation" rather than " ingroAving nail." The callous ulcer is sometimes called indolent or atonic, and is due to a diminution to the minimum of the reparative process. The thickened edges are caused by the ineffectual attempts of the surrounding skin to form cicatricial tissue and epidermis. It is found in laboring and ill-nourished people, and is often due to the presence of varicose veins (varicose ulcers) or to eczema of the skin. Occasionally Ave find, as the result of long-standing disease and neglect in old people, a general hypertrophy of the affected leg, simulating elephantiasis. The treatment of such ulcers consists in rest in bed, elevation of the limb, and the employment of antiseptic or emollient dressings, and later perhaps skin-grafting. These ulcers are likely to recur unless support is given to the part by an elastic stocking or a bandage of flannel cut bias, or Martin's rubber bandage. When circumstances render it impossible for the patient to rest in bed, the ulcer may be treated by strapping Avith adhesive plaster, and a band- age made of some elastic material to give support to the blood-vessels of the limb. The strips of adhesive plaster should be an inch Avide and long enough to encircle two-thirds of the limb, and should overlap each other from below upward like the clapboards of a frame house. Concentric incisions made through the indurated tissues around an indolent ulcer may relieve the cicatricial pressure on the circulation and enable the edges of the ulcer to cicatrize. The thickened margins, consisting of contracting cicatricial tissue, so inter- fere Avith the access of arterial and the egress of venous blood that the formation of healthy granulations is impossible. As much of the healing of all ulcers results from the reduction in size effected by the contraction of their bases, caused by the organization of the deep layers of the granulation-tissue into young connective tissue, rather than by epidermization, the fixation of the margins and base of a chronic ulcer to the subjacent parts must prevent healing. Upon this fact depends the utility of incisions a little distance from the margins of the ulcer. Blisters and the pressure of strapping 0A\e much of their effect to the removal by absorption of the constricting effect of the old cicatricial tissue upon the circulation through the ulcer. The phagedenic ulcer is due to infection by different forms of micro- organisms. When seen on the genitalia it usually follows venereal disease. In other regions of the body it may be caused by constitutional conditions combined with unhealthy surroundings. Intemperance and scurvy are predisposing causes, and when individuals affected in this Avay are crowded together in barracks or hospitals in time of war, such types of ulceration are not uncommon. The surface of the ulcer is devoid of granulations, and is covered with a mass of sloughing tissue. Its edges are sharply defined and appear as if eaten out, and it spreads with great rapidity. The treatment consists in curetting by a sharp spoon and removal of the overhanging edges by the knife or scissors, followed by a thorough disinfection of the part by the application of antiseptic agents, such as pure carbolic acid, bromine, sublimate solution 1 : 500, and, if these fail, in the use of the Paquelin cautery. Constitutional treatment by means of tonics and stimulants and favorable hygienic surroundings should be employed. In mild cases pure iodoform or aristol ok chloral (gr. x-xxig,gj), or the potassio- tartrate of iron (gr. v@3j), Avill often effect a cure. Ulcers depending upon specific origin, such as the strumous, scorbutic, lupoid, and syphilitic ulcers, will be considered more fully under their appropriate head- ings. The ulcerations seen in malignant diseases are chiefly carcinomatous. GANGRENE. 49 One of the most frequent forms is rodent ulcer, Avhich is situated on the nose and cheeks, and often resembles specific or tuberculous ulcerations. It is, however, due to the breaking doAvn of a genuine epithelial growth (Warren). Deep-seated cancers, wdien they reach the surface, enter upon an ulcerating stage, and may affect large surfaces in this Avay. Sarcomatous ulcers are com- paratively rare. SECTION II.—FISTULA AND SINUS. A FISTULA is an abnormal opening into a normal canal or organ—e. g. the rectum or the duct of a salivary gland—or a communicating passage between two adjacent mucous cavities—e. g. the bladder and vagina, etc. Such a fistula when it communicates with an unhealed Avound or old abscess-cavity is usually called a sinus. The terms are often used interchangeably. There is a great variety of fistula?, each kind being named from the organ Avith which it commu- nicates. Fistulae may be due to congenital deformity, as a branchial fistula, which is formed by the non-union of one of the branchial clefts. They may be the result of injury or sloughing, as the salivary or vesico-vaginal fistulae. Si- nuses which result from the failure of an abscess to heal, and which have opened into some canal or cavity, are usually called fistulae, as the urinary fistula and fistula in ano. A sinus is usually a canal opening upon the surface of the skin or a mucous membrane and terminating in the cavity of an old abscess. It may, however, result from the burroAving of pus beneath the skin, and will then form a tor- tuous series of canals extending in various directions. The failure of such a pus-cavity to heal is usually due to the presence of some secretion which pours into it, or to the presence of a foreign body, as a piece of dead bone, or to the inability of the Avails of the cavity to collapse and come in contact with each other, as in empyema or abscess in the spongy end of a bone. Frequently the diseased condition of the Avails of the sinus is an obstacle to repair. Many such sinuses are due to the presence of the bacillus of tuberculosis. In such cases they are lined with a membrane resembling that of cold abscesses, which must always be carefully extirpated or cauterized. The treatment consists, first, in the removal of all irritating or diseased substances. It is often necessary to lay the fistula fully open and thoroughly to curette its walls before healthy granulations will spring up and aid in the healing process. Special fistulae will be considered under their respective regions. CHAPTER VII. GANGEENE. Gangrene is a term employed to denote death of a part of the body in mass. Necrosis and mortification are terms used in a similar sense, but in sur- gery necrosis is often limited to death of bone: it is applied also to death of internal organs where, owing to the absence of bacteria, putrefaction does not take place and the dead mass is absorbed, new tissue growing in from the sur- rounding healthy parts to take its place. Gangrene results either from a ces- sation of the arterial blood-supply or from an obstruction to the venous outfloAv, 4 50 AN AMERICAN TENT-BOOK OF SURGERY. or purely from a stasis of blood in the capillary vessels. It may also take place independently of any disturbance of the circulation by the direct action of destructive agents upon the cells of the tissues. The most frequent non-traumatic cause of deprivation of arterial blood- supply is a diseased condition of the arteries, such as is seen in senile gangrene. It may also be due to arterial spasm, such as is produced by the action of ergot or disturbance in function of the vaso-motor nerves. Obstruction to the flow of venous blood is usually of a purely mechanical origin, as in strangulated hernia, or it may be the result of a venous thrombosis. Many causes act directly upon the tissues of the part, such as pressure, mechanical or chemical injuries, inflam- matory swelling, heat or cold, and bacterial infection. The state of the tissue, due to an impaired nutrition of the body, is often favorable to the development of gangrene. This is observed during the progress of fevers or in individuals suffering from grave constitutional conditions, such as diabetes, or in parts deprived of their nerve-supply. Typical gangrene occurs chiefly in two forms, the moist and the dry, which present striking contrasts to each other in their physical appearances. Dry gangrene (Fig. 12), or mummification, is a condition produced by the loss of water from the tissues. The skin becomes black and wrinkled, and is often of a leather-like hardness. The amount of decomposition Avhich occurs in this form is very slight, and the dead part in typical cases causes but slight disturbance to the adjacent living tissues. In this form of gangrene there is a gradual diminution in the supply of arterial blood, while the outflow of venous Fro. 12. Dry Gangrene. blood continues unobstructed. In this Avay, aided by evaporation, water is gradually removed from the part. The most typical form of this variety is known as senile gangrene, due to arterial sclerosis, the result of an obliterating endarteritis or of atheromatous changes in the walls of the vessels, combined Avith feeble heart-action. The calcareous condition of the arteries can often be easily detected at the wrist. The circulation in the capillaries becomes very feeble, and a slight bruise suf- fices to produce permanent stasis. Senile gangrene usually occurs in the lower extremities, involving the toes, where the circulation is least vigorous. The tibial arteries are frequently the seat of an endarteritis Avhich materially dimin- ishes their lumen, and a serious lessening of the blood-supply may exist in all the regions supplied by these vessels. The arterial blood may also be cut off by the presence of an embolus derived from valvular growths incidental to PWtlr VI.—TofitcrpcM.ir il SciiiiM/-' . pin* GANGRENE FOLLOWING A SHOT LACERATION OF THE FEMORAL ARTERY. GANGRENE. 51 cardiac disease. In this case the disturbance in the circulation may occur so rapidly that mummification may not take place and moist gangrene will result. Dry gangrene may, however, be produced by embolism, and a large portion of an upper or loAver extremity may occasionally be involved. Symptoms.—The disease usually originates in some slight injury, as the bruising of a toe or the tearing of a portion of the nail, and is recognized by the change of color in the part, the dark-red congestion which at first appears gradually assuming a purple hue. The surrounding tissues are deeply con- gested, and the boundary-line between them and the dead tissue is at first imperfectly marked. The gangrene slowly advances beyond the limits of the toe in which it originated, and the adjacent toes may also become involved. When the progress of the disease is arrested, the inflamed parts set up a barrier of granulation-tissue and the line of demarcation is formed. The suppura- tion which folloAvs separates the dead tissue from the living, and a spontaneous cure may be effected in this Avay. As the line of demarcation forms, the colors of the respective parts stand out in strong contrast. The inflamed tissues assume a brighter tint, while the purple hue of the dead part changes to black. An attempt on the part of the adjacent tissue to form a barrier to the advance of the disease often fails, and the gangrene spreads and may involve the whole foot, and even all the parts supplied by the tibial arteries. In the milder forms of the disease the amount of constitutional disturbance is slight, but when a large portion of a foot or leg is involved there is more or less septic infection, and a rise of temperature will indicate the presence of fever. This type is sometimes called idiopathic gangrene. The amount of pain is not great in this variety: during the early stages there may be a stinging or smarting pain, but after the formation of a line of demarcation this disappears. The pain in dry gangrene due to embolism is, hoAvever, much more severe, and generally is the cause of much intense suffering. Occasionally obliteration of the arteries of internal organs may take place also, and infarctions with necrosis may be associated with senile gangrene. Moist gangrene (PI. VI) is caused by a sudden arrest of the arterial blood- supply or a similar obstruction to the return of the blood through the veins. It is likely to occur in deeply-seated tissues Avhere evaporation cannot easily take place, as in strangulated hernia. Idiopathic gangrene may be of the moist type when the obstruction of the circulation is rapidly brought about and involves a large portion of a limb. Severely contused or lacerated wounds of the soft parts, or fractures com- plicated with laceration of the large vessels, are a frequent cause of moist gan- grene, known in this case as traumatic gangrene. Acute inflammations may be attended with such intense congestion and SAvelling that the circulation may be arrested over a considerable area, and death of the part will then occur. The same result will ensue from burns and frost-bites. In this form of gan- grene—localized traumatic gangrene—the tissues become soft and pulpy, the skin is discolored and changes to a deep purple or black or is covered with green and black spots. A thin brownish fluid filters through the skin, and raises the epidermis in the form of blisters or exudes from the open surface of wounds. Decomposition takes place through the agency of the saprogenic bacteria. In most cases a line of demarcation forms around the area affected by the destructive agency. There is, however, another form of traumatic gangrene—spreading traumatic gangrene—in which the disease extends with frightful rapidity, due to an acute infectious process. These are cases in which the main artery or vein has been ruptured and the blood-supply of a portion of an extrem- 52 ^1A AMERICAN TEXT-BOOK OF SURGERY. ity is suddenly cut off, followed by infection. In other cases acute inflammation of severe type, together with the intense septic infection, produces the death of the part.' The gangrene spreads rapidly, even hour by hour, up the limb. Acute putrefaction sets in and spreads through the agency of micrococci or bacilli. The changes in color are rapid and striking : a deep bronze hue, like rind of bacon, spreads rapidly along the line of extension of the disease, and is accompanied by streaks of green and black. The part feels dense and braAvny. The evolution of gas produced by the changes brought about by the putrefactive bacteria sometimes gives an emphysematous crackling to the sub- cutaneous tissue—a condition Avhich is often observed someAvhat in advance of the gangrenous changes. Constitutional disturbance is by this time very marked, and is due to the absorption of ptomaines, which the process of decom- position forces into the lymphatic channels and connective-tissue spaces or beneath fasciae or along the course of tendon sheaths. As the parts through which the gangrene spreads are beyond the point of injury, no opportunity offers itself for the escape of these chemical poisons, and they spread upAvard through the circulation. The result is septicemia of a grave type, from Avhich the patient succumbs unless the progress of the gangrene has been arrested by amputation. This type of gangrene is sometimes knoAvn as ful- minating gangrene or gangrenous emphysema. Fortunately, such grave results do not ahvays folloAv death of a part from trauma. The gangrene may be limited to the part the circulation in Avhich has been arrested, and a line of demarcation Avill soon separate it from the adjacent healthy parts. This form occurs frequently in a stump after amputation for railroad injury Avhen the limb has not been removed at a point sufficiently remote from the seat of injury. A considerable portion of a limb may be destroyed by injury without a tendency of the gangrene to spread. In this case the numerous lacerations permit an escape of blood and serum, and the conditions for the development and spreading of the intense forms of decom- position are less favorable. Smaller portions of dead tissue, such as the flap of an amputation stump or masses of connective tissue or skin, are usually called sloughs. These are separated from the living parts by the septic inflammation which ensues and Avhich results in suppuration; and, as the wound cleanses itself and the sloughs are thrown off, healthy granulations are found covering its surface. Gangrene may result occasionally from pressure, but unless the latter is excessive this occurs only in parts where the circulation is already feeble and the conditions are favorable for complete stasis. Decubitus, or bed-sore, is pro- duced in this way from long rest in the recumbent posture in individuals debili- tated by fevers or long-standing chronic disease. When the slough has separated the ulcer thus formed may enlarge, and sometimes becomes quite formidable in size, and may be a complication more serious than the original disease. The parts most frequently attacked are the integuments lying over the sacrum and coccyx, or, more rarely, the shoulder-blades and great trochanters. Sloughs may also be produced by bandages and splints when applied to a fractured limb. A frequent seat of such a "splint-sore" is the posterior aspect of the heel or the skin covering the tendo Achillis. This form of local gangrene is much more likely to occur if the parts sub- jected to pressure have been deprived of their accustomed nerve-supply. Neuro- pathic gangrene, as it is sometimes called, is frequently observed after fractures of the spine. Sloughs will form with great rapidity under the heels and sacrum. This predisposition to death of the part has been ascribed to a functional dis- GAXGREXE. 53 turbance of the vaso-motor nerves or to an abnormal action of the so-called " trophic nerves " which are supposed to preside over the nutrition of a part. A type of gangrene more clearly due to abnormal vaso-motor action is the symmetrical gangrene, or Raynaud's disease. This appears most fre- quently upon the tips of the fingers or the toes. It may also be found in various other parts of the body, as the tip of the nose, the cheeks, the knee, and other salient points where the heat of the body is less than in deeper parts. It is due to a spasm of the vaso-constrictors brought about by reflex action. It is extremely rare in this country. The "cold finger" often observed in bathers is ascribed to a similar cause. In symmetrical gangrene the parts affected are at first the seat of abnormal pallor and numbness, then of a purplish dis- coloration, and a small slough finally forms Avhich is thrown off and is followed by healing of the sore thus produced. Several fingers are simultaneously affected on both hands. A similar spasm of the vaso-motor nerves is produced by the prolonged use of ergot, and epidemics of gangrene have been observed in France and else- where which were due to the presence of ergot of rye USecale cornutum) in the grain employed as food. Individuals affected Avith diabetes are frequently attacked Avith diabetic gangrene. This is often seen in elderly people subjects of the disease, and may be mistaken for senile gangrene. The presence of sugar in the urine should therefore be carefully sought for. Operations upon such persons are supposed to be followed by gangrene or sloughing of the lips of the wound, and it is advised by some authorities to abstain from surgical operations if they can be avoided. A more extended experience Avith aseptic surgery, hoAvever, will probably not bear out this view. In one case known to the writer both legs were success- fully amputated for diabetic gangrene. There Avas an interval of one or two years between the two operations. Noma, or cancrum oris, is a gangrene of the cheek usually occurring in children as a complication of the eruptive fevers—e. g. scarlatina. It is the result of a gangrenous stomatitis, and is of bacterial origin, producing capillary thrombosis. The disease may even attack the bone, and in the majority of cases is fatal. If recovery takes place a large defect usually results Avhich must be restored by a plastic operation. Gangrene from frost-bite may result partly from the intensity of the cold and partly from the enfeebled condition of the individual. The part at first is blanched, but subsequently turns black. It may assume the dry or the moist condition. It may be limited to the toes, which are the most frequent seat of this form of gangrene, or the whole foot may be involved. It is frequently quite superficial, and no attempt at surgical interference should be made until the line of demarcation is clearly established. Treatment.—The prophylactic treatment of gangrene consists in the removal, as far as possible, of the causes Avhich may favor the development of gangrene, and in the adoption of such measures as will promote the circulation of blood in the part. If inflammation threatens to terminate in gangrene, free incisions may relieve the tension sufficiently to avert the impending danger. Division of the constricting ring of a strangulated hernia will remove the obstruction to the circulation in the boAvel. If, however, the obstruction cannot be removed, as in embolism or throm- bosis, attention must be given to the establishment of the collateral circulation in the limb by favoring as much as possible the flow of venous blood and preserving the warmth of the part. Moderate elevation of the limb and gentle 54 AN AMERICAN TEXT-BOOK OF SURGERY. massage may favor the return of blood through the superficial veins. Slightly flexing the joints will favor the flow of blood through the larger vessels. An equable temperature of the desired degree may be maintained by enveloping the limb in dry cotton wool, Avhich should be loosely applied. Minute abrasions or sores about the nails in feeble individuals should receive careful attention, but meddlesome interference should be avoided, as these are frequently the starting-points of senile gangrene. If death of the part is unavoidable, great care should be taken to prevent infection and decomposition. The gangrenous part must be disinfected with the same care as for an operation, and then be kept dry and odorless. Antiseptic dressings containing powders, as iodoform, boric acid, or aristol, should be applied. If the fluid products of decomposition are retained beneath the surface, they should be released by incisions into the gangrenous tissues, or if pus is bur- rowing, openings should be made into the living tissues to evacuate it. It was at one time the almost universal custom to wait for the line of demarcation to form in senile gangrene before making any attempt to remove the dead mass, and as a rule it is better to adopt this plan. If the gangrene shows a disposition to localize itself, it would be bad practice to interfere in any way with the processes that are going on in the enfeebled living tissues, as any disturbance of them might cause the gangrene to spread still farther. If, however, the line of demarcation fails to form and one area after another becomes iiiATolved, and a gangrene Avhich at first threatened the loss of a toe now involves a considerable portion of a foot, the question of amputation Avill become one of vital importance. In determining the point at Avhich to ampu- tate the pathology of the disease should be kept in mind. If Ave have to deal with a disease of the tibial arteries, it will be necessary to decide at what point in their course the circulation is of sufficient volume to maintain the life of the stump. Never amputate Ioav doAvn. An amputation of the leg below the tubercle of the tibia in some cases may be sufficiently high, but generally it is necessary to remove the leg at or above the knee. The latter point is often to be pre- ferred, since the flaps will then be largely nourished by branches of the pro- funda femoris, Avhich is rarely thrombosed. A considerable number of cases which in former times were alloAved to die without surgical interference are now undoubtedly saved by amputation. In gangrene from embolism amputation should be performed well above the gangrenous area as soon as the extent of the gangrene has been determined by the establishment of a line of demarcation. In traumatic gangrene involving portions of the integuments it is not necessary to attempt removal of the sloughs until the line of demarcation indicates clearly the extent of the injury. A partial removal of the dead skin may, however, favor drainage of the parts beloAv. When a portion of a limb is destroyed by injury, the question of an imme- diate amputation should first be carefully considered. If this is not done and gangrene sets in, and there are any signs of its spreading, this should prompt the surgeon to urge the necessity of amputation. If the gangrene is localized, the general condition of the patient will enable one to decide Avhether it is best to remove the dead portion of a limb immedi- ately or not. The effect of the presence of such a putrescible mass must be weighed against the danger of an operation in a patient suffering from shock and possibly other severe injuries. The conditions of each case Avill enable one to decide Avhether it is better to remove the limb at the line of demarcation or to amputate through sound tissue. In spreading traumatic gangrene it will of course be necessary to amputate GAXGREXE. 55 instantly and far away; that is, sufficiently high to remove all tissues involved in the septic process. There is perhaps no affection in the whole domain of surgery which demands such prompt interference in order to avert impending death. The constitutional treatment consists in attention to the condition of shock and in supporting the strength of the patient. Absolute rest, careful nursing, and a diet that will be nutritious without interfering with the digestive func- tions will best meet these indications. Alcoholic stimulants are also of great value and should be used freely, but Avith due regard to the patient's poAvers of assimilation. The treatment of bed-sores is largely prophylactic by frequent change of posture, and—thanks to the present system of nursing—the attention of the physician or surgeon is noAV rarely called to this affection. Dry dressings are to be preferred, as moisture favors the enlargement of ulcers produced in this way. Mechanical support to relieve pressure and strict attention to antisepsis will usually arrest the progress of the disease. The rules for the treatment of diabetic gangrene vary but slightly from those laid doAvn for senile gangrene. The disease is not necessarily a contra- indication to amputation. In any event a most careful attention to the diet will form an important factor in the prognosis of the case. Little operative interference is necessary in symmetrical gangrene: the main points in the treatment of such cases are attention to the diet and hygienic surroundings and the administration of tonics. Hospital gangrene is one of the traumatic infective diseases, and is characterized by a septic inflammation of the surface of a wound, causing ulceration and the formation of sloughs, and is accompanied by more or less constitutional disturbance. The disease at the present time has almost com- pletely disappeared, owing to the general employment of aseptic and antiseptic treatment. It formerly occurred Avhen patients were crowded together in small quarters Avith insufficient attendance and food and under poor hygienic condi- tions. The principal varieties usually described are the diphtheritic, the ulcer- ating, and the pulpy forms. The disease has been regarded by some as iden- tical with diphtheria, but, as the latter disease has continued its activity for tAventy years after gangrene has disappeared, this assumption does not appear probable. No bacteriological studies of value have been made, but some writers report large numbers of streptococci, and Koch produced in mice a disease resembling hospital gangrene in which the streptococcus was found. The diphtheritic form is characterized by the occurrence of coagulation- necrosis in the granulations. There is, moreover, less inflammation in the mar- gin of the wound in proportion to the depth to Avhich the tissues are involved. The discharge is at first diminished, but later becomes more watery in char- acter, the sloughs separate, the Avound has a crater shape, and its edges are eroded. In the ulcerating form there is a progressive enlargement of the Avound, chiefly on the surface, accompanied by an unhealthy or grayish dis- coloration of the granulations. The edges break doAvn, recede daily, and have a gnawed look, and the wound may finally become very large. This type is sometimes called phagedena. The pulpy form is more common in epidemics. The granulations swell, become oedematous and necrotic, the surface of the wound is soon enormously SAvollen, and a fetid discharge Avells up in large quantities from its depths. Its margins become SAvollen, everted, and are exquisitely sensitive. There are great discoloration and SAvelling of the surrounding parts, Avith profound constitutional disturbance. The Avound increases in size Avith great rapidity, and secondary hemorrhage often occurs. 56 AX AMERICAX TEXT-BOOK OF SURGERY. Joints are laid open and muscles dissected out as the disease spreads, and if the disease is not arrested, the patient finally succumbs to septicemia. The prophylactic treatment consists in the application of the rules of aseptic surgery, and when, as in time of Avar, these cannot be observed with sufficient care,' in avoiding the accumulation of great numbers of patients in confined quarters and their prompt isolation if the disease appears. The local treatment consists in a thorough disinfection of the surface of the wound and the surrounding infected tissues. This may be accomplished by removing the diseased tissue Avith the curette or scissors, and by the sub- sequent application of the cautery, bromine, fuming nitric acid, or acid nitrate of mercury. The operation will require anesthesia, as even the ordi- nary dressing of such a wound is exceedingly painful. For milder cases a weak solution of nitric acid may be used with advantage, or the wound may be freely dusted Avith iodoform. Perchloride of iron Avas used Avith success by the French in their last war. Whatever the agent employed, it must be applied as directly as possible to the living tissues. The constitutional treatment consists in the free use of stimulants and supporting diet. An entire change of the patient's surroundings may bring about a prompt improvement. Epidemics have been broken up by moving the patients from the wards of a hospital into tents. All clothing and bedding and dressings should be changed at the same time. Amputation may be sometimes called for, and can be successfully done under strict antiseptic precautions. The disease being distinctly contagious, isolation and the non-use of sponges, towels, basins, etc., from patient to patient, are evidently necessary. CHAPTER VIII THROMBOSIS AXD EMBOLISM. A thrombus is a clot of blood which forms in the blood-vessels during life. An embolus is a detached fragment of a thrombus, a fragment of a vegetation on one of the valves of the heart, a globule of fat or of air, etc., which has been transported to some other part of the arterial system and acts as a plug. Coagulation of blood may take place in one of tAvo Avays: When blood is allowed to remain stagnant in a flask, the clot Avhich forms is nearly as large as the Avhole amount of blood, and is of a deep-red color, Avhich still remains after the serum has been pressed out. It contains chiefly red corpuscles held together by fibrin. It is such a clot that is found in the red thrombus. The clot from blood beaten Avith a stick loses its red color, and is of a yel- lowish-white tinge, consisting of a tough mass of fibrin containing but feAv red corpuscles. As has been shown elseAvhere, this coagulum contains chiefly broken- down Avhite corpuscles which have yielded up their fibrin-producing material. This is one Avay in which a white thrombus is formed. The cause of coagulation of blood in the vessels was thought bv Virchow to be a slowing of the current, but it has been shown that the blood mav be kept stagnant between two ligatures and yet no thrombus form, proA-'ided the vessel be kept aseptic and uninjured. Coagulation appears to be due to slowing of the current if these conditions are not fulfilled, and also to roughness of the inner wall of the vessel, to injury to the wall of the vessel, or to septic THROMBOSIS AXD EMBOLISM. 57 Fig. 13. infection. The blood-plaques or third corpuscles play an important part in the process of coagulation of the circulating blood. When a roughness exists on the vessel-Avail and the current is less rapid than usual, the blood-plaques leave the center of the stream and accumulate at the spot in question. Numbers of leucocytes are also arrested and become attached, and form a little hill Avhich projects from the Avail into the lumen of the vessel. The cells by a process of "conglutination" form a viscous mass in which little cell-structure is seen. This is another process by Avhich a white thrombus is formed. Mired thrombi are those Avhite thrombi in Avhich an unusually large num- ber of red corpuscles are seen here and there in clusters. The white or mixed thrombus forms from floAving blood, and is the variety usually seen in the blood-vessels. Red thrombi are more rarely seen in the living body: they occur chiefly in vessels subjected to septic infection; they may also be found plugging the mouths of vessels which have been cut and have bled freely. The Avhite thrombus usually begins as a parietal thrombus, but it may finally groAV to sufficient size to obstruct the lumen of the vessel by successive deposits and may extend some distance. It is then called an obstructing thrombus. After a thrombus is formed it may undergo several changes. It may become organized, young tissue groAving into it from the vessel-Avails and forming a cicatricial tissue; as portions of the clot are disintegrated and absorbed, spaces are left in the neAvly-formed tissue, which has a spongy consistency. It is then said to be " canal- ized." Blood flows through the new channels, and the circulation is partially re-established in this way. At other times organization does not take place. The fibrin and leucocytes break up into a fatty mass which forms a slimy fluid in the inner layers of the thrombus, and the thrombus is thus broken up. When septic infection takes place, we have broken-doAvn leucocytes mingled with bac- teria and the various ingredients of the clot, and a "puriform softening" or "suppuration" of the thrombus takes place. A thrombus thus disorganized may break up into masses which become detached and are swept off into the cir- culation as infective emboli; or a thrombus which has developed so as to project into a large vessel may lose a portion of the protruding clot, and so give rise to embolism (Fig. 13). Thrombi are found in the heart and veins, and also in the arteries. Emboli are found in the arteries, but also in the veins of the liver. When an embolus is lodged in a "terminal" artery, the part supplied by this vessel is deprived of its circulation and becomes anemic, or occasionally a backward flow of blood takes place from the veins into the emptied vessels and a congestion with extravasation or a "hemorrhagic infarction" occurs. If the embolus is an infected one, suppuration will take place and a metastatic abscess forms. Many of the emboli Avhich are detached from veins become lodged in the capillaries of the lung, but very small emboli may pass through them and enter the general arterial system. Emboli may be formed from other substances than blood-clot. When tissues containing fat are broken down by injury, drops of fluid fat enter A Thrombus in a Vessel. The de- tached fragment about to be carried away in the direction of the blood-stream is an em- bolus. OS AN AMERICAN TEXT-BOOK OF SURGERY. the circulation and are lodged in the pulmonary capillaries. Fat embolism thus may follow fracture of a bone, especially at the spongy ends of the long bones. Dyspnea, and even death, may occur from this accident. Air em- bolism may occur through wounds of veins in the neck or axilla and through the uterine venous sinuses. A considerable quantity of air may be introduced without injury. The emboli will then be distributed in the capillaries of various parts of the body and eventually disappear; but if a large quantity is introduced at once, the heart may be distended with air and death will occur. Emboli may sometimes travel against the current by force of gravity, as in the vena cava and other large veins of the lower part of the body. The treatment of thrombosis or embolism is mainly prophylactic. Care should be taken that the thrombus does not give rise to emboli. The part therefore should be kept at rest until organization or absorption of the thrombus has taken place. CHAPTER IX. SEPTICEMIA. Septicemia is a disease due to the absorption of the products of putrefac- tion into the system, or to the introduction into the blood and tissues of bacteria which rapidly multiply there. It is characterized by grave constitutional disturbance, with acute fever, disorders of the nervous system, inflammation of certain viscera, and a local infection of the wound. The nature of the poison which produces the disease is not yet fully understood. Experiments on animals have shown that there are two varieties of this form of blood-poisoning. In certain cases symptoms supervene immediately upon the inoculation, and the animals die of a chemical poison, no bacteria being found in the blood or tis- sues (sapremia, toxemia, or septic intoxication). In other cases the symptoms come on less rapidly, and death is caused by the presence of bacilli or micrococci in the blood (septic infection). Many observers have sought for bacteria in the blood in the septicemia of man, and micrococci have been found occasionally, but not with sufficient regularity to identify them with the disease. Since the existence of ptomaines as a product of decomposition has been understood, it is generally recognized that the poisons elaborated by bac- teria play a prominent part in the production of the disease. Clinically, we find the same tAvo types of the disease in man. One is due clearly to the absorption of a chemical substance or ptomaine. The symptoms of this variety cease as soon as further introduction of the chemical substance is prevented by a cleansing of the wound. In the other variety there are progressive changes coming on gradually, as in the bacterial type in animals, and continuing frequently to a fatal termination in spite of efforts to check them by treatment of the wound. This variety suggests the action of bacteria, and these organisms are found in some cases, those most frequently observed being the streptococci. The method by which infection of the system takes place is through a wound which is undergoing putrefactive changes owing to decomposition of the tissues (sapremia), or through the diffusion and multiplication of the bacteria from an infected wound, even of a trivial character (septic infection). This is most likely to occur before the wound has become covered by healthy granulations. It may also take place through the intestinal mucous membrane (sepsis intes- SEPTICEMIA. 59 tinalis), as in cases of tyrotoxicon poisoning, and more rarely through the uro- genital tract. Sapremia.—The toxic form of septicemia is frequently seen in obstetrical cases in which putrefaction of retained clots or placenta has taken place within the uterus. The poison may be absorbed through the mucous membrane of the vagina or uterus, or through open Avounds in these regions or through the uterine sinuses. The disease is ushered in Avith a sharp rise of temperature, the chill usually being absent. The temperature continues high, and is accom- panied later with delirium. The skin is cold and clammy, and there is more or less tendency to diarrhea. A prompt removal of all decomposing substances from the interior of the uterus will be folloAved in a feAv hours by a disappear- ance of all alarming symptoms. Conditions favorable for such a type of poisoning are rare in general surgery, although a large, ill-drained wound, or decomposition occurring in the contents of a psoas or other abscess, is a not uncommon cause: these conditions also may be found in abdominal wounds where extensive injury of the peritoneum has favored oozing and the accumu- lation of blood-clot in the peritoneal cavity.1 Symptoms of Septic Infection.—In true septicemia or septic infection the development of the disease is more gradual. The fever curve is of the con- tinuous type as in sapremia, and as the fatal end approaches the temperature will range higher. In certain cases the temperature is, however, subnormal, as is seen occasionally in strangulated hernia or in gunshot injuries of the abdo- men. There is great prostration Avith headache and anorexia, and a typhoid condition supervenes Avhich renders the patient indifferent to surroundings. Diarrhea frequently develops, and may at times be accompanied Avith vomiting, but it is usually not severe. There is a tendency to the enlargement of the lym- phatic glands throughout the body, and more particularly of the spleen. The skin is pale and dusky, but an icteric tinge is not so common as in pyemia. The hue is due to the rapid deterioration of the blood caused by the presence of the virus. A scarlet eruption may occur resembling closely that seen in scar- let fever. The skin in the early stages is hot and dry, but later is bathed in perspiration, and finally becomes cold and clammy. The sallow hue becomes more marked. The senses are dulled and the countenance is listless. The tongue is covered with a brownish fur. The pulse is now weak and rapid; diarrhea increases, and the urine is concentrated and scanty. Delirium is folloAved by coma, and the patient becomes moribund. The pathological changes observed in the internal organs are slight. The blood is thin, of a tarry color, shoAvs no tendency to coagulation, and contains numbers of micro-organisms. Cloudy SAvelling of the liver or kidneys is usually found. In the alimentary canal there is evidence of a gastro-intestinal catarrh. The mucous membrane is SAvollen and mottled, and punctiform hemorrhages are found at certain points. Enlargement of the lym- phatic glands is noticeable, particularly of the spleen. The wound occasionally is in an extremely septic condition ; at other times there is little evidence of any pathological change. When septicemia folloAvs the infliction of a dissect- ing wound or other injury by Avhich material already loaded Avith the bacteria of putrefaction is inoculated into the tissues, there is a diffused septic inflam- 1A classification preferred by some writers makes the following differentiation of the con- stitutional conditions met with after operative or accidental wounds: 1. Asepticferer, caused by the absorption of a fibrin ferment into the blood. 2. Sapremia, due to the absorption from the wound of certain chemical bacterial products, no bacteria being found in the blood or tissues. 3. Septicemia, due to the entrance into the circulation and the multiplication there of certain bacilli or micrococci. 4. Pyemia, resulting from the entrance into the blood-stream of infected emboli from a thrombus, itself infected with pyogenic germs through the medium of the wound. 60 AN AMERICAN TENT-BOOK OF SURGERY. mation about the wound which develops rapidly and spreads along the line of lymphatics leading from the part, as shown by red streaks running to the adja- cent chain of lymphatic glands. In very malignant cases oedema of the adja- cent tissues involving a considerable area will be observed. The original focus from which septicemia is sometimes developed may be a wound involved in gangrene or erysipelas, or some deep-seated infective inflam- mation around the kidney or appendix or in the medulla of bone, or a tract of connective tissue infiltrated Avith foul urine. The principal diagnostic signs of septicemia are the continued fever, the absence of chills, the peculiar condition of euphoria or apathy, the intesti- nal catarrh, and the presence of an increased area of dulness about the region of the spleen. The general appearance of the patient and the condition of the pulse will prove valuable guides in enabling the surgeon to distinguish between this type and the less malignant forms of surgical fever Avhich occur independently of suppuration. The condition of the wound and the presence or absence of pronounced suppuration will also aid in the diagnosis, although it should be remembered that septicemia may develop even during the suppura- tive process, provided the conditions for putrefaction exist in the wound. . The prognosis of the disease is always grave, but its duration may vary greatly according to the intensity of the virus. In sapremia of a pure type the prognosis is much more favorable, as the fever will disappear as soon as the local mass of putrefaction is removed; but inasmuch as it is quite difficult to say in any given case Avhether there is not also a true septic infection in addi- tion to the toxic poisoning, the opinion expressed by the surgeon must be a guarded one. The weakness and frequency of the pulse, the extremes of tem- perature, and the mental condition are important symptoms as guides in estimat- ing the gravity of a given case. In the acute type we have to deal with one of the most fatal of diseases. When the disease takes a more chronic course, as it occasionally does, we may have reason to hope for a cure, although a very large proportion of these cases also terminate fatally. Treatment.—The prophylactic treatment consists in the application of the rules of aseptic and antiseptic surgery, Avhich have greatly diminished the number of cases of septicemia at the present time. When the disease makes its appearance the attention of the surgeon should at once be directed to the condition of the wound, and no time should be lost in carrying out a thorough disinfection of its entire surface. Stitches should be removed and sinuses care- fully exposed. All collections of blood-clot or decomposing fluids should be washed out with corrosive sublimate, 1 : 1000, and subsequently the tissues should be disinfected with strong solutions of carbolic acid (1 : 20, or pure crystals) or chloride of zinc (1 : 10). The wound can then be packed with gauze containing a large amount of iodoform poAvder, or antiseptic poultices can be applied to favor a free discharge (carbolic acid 1 : 1000, or corrosive sublimate 1 : 20,000). When the wound has deep recesses or pockets which cannot easily be reached, irrigation Avith boiled water, boric acid (4 per cent.), or a saturated solution of acetate of aluminum may be employed. In septicemia following laparotomy the prognosis is so grave that little success can be expected from local treatment. An attempt to save life, however, should be made by reopening the wound and by a thorough hot-water douching of the peritoneal cavity, followed by drainage. In sapremia douch- ing of the wound is generally followed by an immediate, and frequently by a permanent, improvement. In puerperal fever from this cause the antiseptic washing of the uterus is productive of most satisfactory results. The constitutional treatment consists principally in the fearless use of stim- PYEMIA. 61 ulants. Very large quantities will be assimilated under these conditions without producing alcoholism. The use of drugs taken internally for their antiseptic action has not proved sufficiently successful to encourage a further trial at pres- ent. The heart's action should not be hampered by any depressing agents. On the other hand, a free use of digitalis and other heart tonics may prove a valuable aid to stimulation. One of the best is strychnia administered sub- cutaneously in doses of gr. ^ ^0 every two to six hours. Nutritious diet should be administered in such form as not to impede digestion and to favor rapid assimilation. CHAPTER X. PYEMIA. Pyemia is an infective disease developed during the process of suppuration, and is due to the absorption of pyogenic organisms into the circulation. It is characterized by the development of multiple or metastatic abscesses in differ- ent portions of the body, frequent chills, and an intermittent type of fever. The name given to it by Piorry is derived from 7zuov, pus, and aipta, blood. The old view that pus formed in the wound obtained an entrance into the cir- culation has long since been abandoned, but we now know that certain elements of pus may find their way into the circulation and produce metastatic abscesses. Etiology.—Reliable investigations on the special forms of bacteria Avhich are found in cases of pyemia have been made only within the last decade. Among the most important are those of Koch, who succeeded in producing the disease in rabbits. He found in the vessels chain-like cocci which caused the blood-corpuscles to adhere and form thrombi. Ogston showed that the pyogenic cocci were partly anaerobic, and grew more readily in deep sinuses and pockets, and thus readily obtained an entrance into the circulation. The examination of the blood of individuals ill Avith pyemia has shoAvn that both the staphylo- coccus and the streptococcus may be the active agents in the formation of metastatic abscesses. When the conditions become favorable for an unusual development of these bacteria, the barrier of granulation-tissue does not prevent their growth into the surrounding tissues. From these they obtain an entrance into the system through the blood-vessels more often than through the lymphatics. Coming in contact with the Avail of a vein, an infective inflammation is started which terminates in a thrombo-phlebitis. Rough places are formed on the intima which lead to the formation of parietal thrombi and the subsequent development of an extensive thrombus, which undergoes a puriform softening; or a zooglea mass of micrococci may accumulate on the inner surface of the Avail of the vein and may be SAvept off into the circulation as an embolus. Minute emboli may pass the pulmonary capillaries, and, entering the arterial system, become lodged in the glomeruli of the kidney or other capillary dis- tricts, or even in the valves of the heart. Larger emboli detached from the softened thrombus may be lodged in the capillaries of the lung. At all these points infective inflammation and sup- puration may occur, and metastatic abscesses are thus developed. As a rare occurrence pus from an abscess may find its Avay directly into the circula- tion by the breaking of the abscess into a vein. The bacterial infection may also occasionally take place through the lymphatic system. The so-called spon- 62 AN AMERICAN TEXT-BOOK OF SURGERY. taneous pyemias occur by a process of intravascular infection. In individuals in feeble health micrococci are sometimes found circulating in the blood temporarily. If under such conditions a slight internal bruise or wound is received—as, for instance, in the medulla of bone from a fall—the micro-organisms gain an entrance from the blood-vessels into the injured part, and an acute osteo- myelitis is developed which may become the starting-point of a pyemia. Symptoms.—The first symptoms of the disease are noticed usually in the second Aveek of the healing process at a period when suppuration has been fully established. These are ushered in with a chill which may be of a widely varying degree of intensity. The occurrence of such a symptom should always put the surgeon upon his guard, and the Avound should be carefully inspected. An increase in the local inflammation may or may not be discovered. A sec- ond chill will probably occur on the following day, and frequent repetition of the chill is a characteristic feature of the disease. The fever is of an irregular intermittent type, and varies not only according to the frequency of the chill, but has an almost hourly variation of its oAvn. The undulating character of the daily fever curve is quite characteristic of pyemia, and a fall to the normal point in acute cases is rarely observed. The development of metastatic abscess is indicated by a febrile exacerbation and by the symptoms of local inflammation. A sharp pain in the side, with respiratory disturbance and fever, accompanies the formation of an abscess in the lung or a septic effusion into the pleura. The joints are also a frequent seat of inflammation, and this is accompanied Avith considerable swelling of the adjacent soft parts. The next point attacked may be the parotid gland. The skin is always markedly discolored, and frequently assumes a deep yellow hue. With the development of the icterus there is already marked emaciation, Avhich, in chronic cases, is extreme. Erythematous rashes, which subsequently become pustular, are occasionally noticed. The tongue is furred and coated, but may vary greatly in appearance. The pulse is rapid, and as the disease progresses becomes weaker. The mental condition of the patient is usually not affected. There is, however, in the later stages great hyperesthesia, and such patients are con- stantly complaining of pain in various parts of the body, due not only to metastatic inflammations, but to the sensitiveness of the nerves. An examina- tion of the heart-sounds may reveal the presence of an infective endocarditis. Brain symptoms are rarely present, although metastatic inflammations may occur in this organ, and hemiplegia may result from emboli due to the endo- carditis. The mind usually remains clear until the development of delirium and coma in the latest stages of the disease. The duration of the disease will vary according to the acuteness of the attack. Chronic pyemia may be prolonged for Aveeks or even months. Usually in acute cases a fatal termination will be reached in the course of a week or ten days. Pathological Anatomy.—The wound is of a gangrenous color or odor, or the granulations are still present and have a glazed and indolent appearance. Extensive thrombi are found in the adjacent veins. In amputation stumps of the lower extremity the femoral vein may be filled as high as Poupart's ligament with a puriform mass. In the lungs metastatic abscesses are found chiefly in the lower lobes and near the pleural surface. Infarctions are also not infrequent. The pleural cavity may be the seat of a serous effusion. The liver is in a state of cloudy swelling, and, less frequently than in the lung, meta- static abscesses are found. Miliary abscesses may be found in the kidney, in the valves of the heart, in the intestinal mucous membrane and in fact in ERYSIPELAS. 63 almost any organ of the body. Metastatic inflammations are also seen in the connective tissue and in the joints. The synovial membrane is at first con- gested, and later suppuration may occur. The knee and shoulder are the joints most frequently affected. The bones may also be the seat of metastatic foci. Icterus is caused by the breaking down of the red blood-corpuscles, and is said therefore to be hematogenous (i. e. of blood origin). Diagnosis.—In the early stages of traumatic inflammation a chill may be due to the development of some other form of infective disease, as erysipelas, but repeated chills are characteristic only of pyemia. The clearness of the mind, the hyperesthesia, the emaciation and great prostration, are all well marked and significant in this disease. The presence of metastatic abscess and joint inflammations when they finally occur leave no doubt as to the diagnosis. The prognosis is exceedingly grave. It has been maintained that no case of pyemia ever gets Avell, but many cases of undoubted recovery have been reported, particularly in the chronic forms of the disease. Treatment.—The prophylactic treatment consists in the prevention of suppuration. The antiseptic treatment of wounds has almost abolished the disease in hospitals, Avhere it Avas formerly of frequent occurrence. When the first septic disturbances have developed in the wound and adjacent veins an attempt should be made to arrest the further progress of the disease by a thorough disinfection, not only of the wound, but of the interior of the vein. Such attempts have been successfully carried out in thrombosis of the lateral sinuses and jugular veins following suppuration in the mastoid cells. If the interior of the vein cannot be thoroughly disinfected, a ligature may be placed upon it at a point betAveen the puriform thrombus and the heart. When the infected area is seated in an extremity amputation may be performed, provided the surgeon can be reasonably certain that the thrombus does not extend above the point selected for the operation. When it is possible all metastatic ab- scesses or suppurating joints should be laid open and thoroughly disinfected. Drugs are of little use in the internal treatment of the disease. Antipyretics depress the heart's action. Carbonate of ammonium and digitalis are more likely to be of service during the stage of prostration. Alcohol should be given freely, and in as large quantities as the patient will bear. Easily- digested food should also be administered unsparingly. If the patient is in a hospital he should be immediately isolated from all other patients, and as strict a quarantine as possible of those in attendance should be preserved. Ventila- tion should be free, and the patient may be placed in a tent, or even for a por- tion of the time in the open air, in certain cases. CHAPTER XI. EEYSIPELAS. Erysipelas is an acute infective inflammation spreading along the upper layers of the integuments of the body and mucous membranes through the lymphatic system. It is accompanied by a remittent type of fever and shows a tendency to recur. The name is probably derived from ipu&poz, red, and xetta, skin. Erysipelas was knoAvn to the ancients, but authentic accounts are of comparatively recent date. Severe epidemics of erysipelas raged in France in 1750, in Great Britain in 1800, and in 1842-43 both Europe and 64 AN AMERICAN TEXT-BOOK OF SURGERY. this country were visited by an epidemic of a most virulent type. Since then there are no records of epidemics of similar severity. Although much less frequently met with since the introduction of the antiseptic treatment, it is the most common of the traumatic infective diseases seen at the present time. Etiology.—The organism which is the cause of the disease is the strepto- coccus erysipelatis. This has been abundantly proved by experiments in ani- mals and man. Opinions vary as to the identity of the streptococcus pyogenes with the streptococcus of erysipelas. The cocci groAV in serpentine chains; each measures from 0.3 to 0.4 micro-millimeters in diameter. These cocci are said to be someAvhat larger than the streptococcus pyogenes, but smaller than the staphylococcus. They are found in the capillary lymphatics of the skin chiefly, but they may also be seen occasionally in the capillary blood- vessels. They are most active near the margin of the erysipelatous blush, and the lymphatics are crowded with them at this point. They are not found in any numbers in the circulation, but it is probable that the constitutional disturbance is due to their presence or to the presence of ptomaines in the blood. The organism usually obtains an entrance through a wound. In idiopathic erysipelas, when no Avound is seen, it is probable that small abrasions of the skin are the route through which the virus enters the body. Probably also cases of internal infection occur, the organisms having been previously absorbed through the respiratory or digestive tract. The contagiousness of erysipelas had been abundantly proved clinically before the nature of the poison was understood. The disease has been conveyed to a large number of children through the medium of vaccine virus taken from a child affected with erysipelas. Instances of erysipelas carried from a distance to certain localities Avhere no such disease had existed previously, and produ- cing there an epidemic, abound in literature. The close relationship between erysipelas and puerperal fever has long been recognized, and examples of the transmission of the virus of erysipelas to puerperal women by the medical attendant, and the consequent production of puerperal fever, are far too numerous. Both diseases are produced by the streptococcus, and experiment has shown that this organism can be cultivated from a puerperal case and can then be injected into rabbits, producing erysipelas. It seems probable that the disease is more prevalent at certain seasons of the year, particularly in the early spring months. Symptoms.—This disease is usually ushered in Avith a chill Avhich is accompanied Avith vomiting or more or less gastric disturbance. In chil- dren a convulsion not uncommonly takes the place of the chill. An examination of the wound at the time shows no perceptible change, although the nearest lymphatics are apt to be enlarged, and it is not until the end of twenty-four hours or longer that a blush is seen in the skin at this point. There is an increased tension in the part, accompanied by an itching or burning sensation. When the local inflammation has developed the color of the skin is a yellowish red, and there is considerable infiltration of the inflamed part, which has a doughy feel. The area invaded is well defined and its margins are quite irregular, presenting a zigzag outline. During the height of the inflammation vesicles form on the surface and sometimes become quite large. When resolution takes place there is considerable desquamation. The inflammation does not remain long in one spot. It spreads widely, and may involve large areas or even the Avhole surface of the body. In the'mean time, at the end of three or four days the part first attacked begins to improve. During the height of the inflammation the constitutional disturbance is well marked. The temperature ranges from 102° to 104° F. The pulse is rapid ER YSIPELAS. 65 and sIioavs a tendency to become weak. The tongue is heavily coated and the urine is charged with urates. With each fresh outbreak of the cutaneous inflammation there is an increased pyrexia and the fever curve presents a most irregular outline. There are marked remissions, but usually no return to normal until the dermatitis has subsided. The duration of the disease is quite uncertain. In favorable cases it will last no longer than a Aveek or ten days, but frequently the attack may last a month. ToAvard the close of the disease when the case is terminating favorably there is usually a tendency to subnormal temperature, shoAving the great prostration Avhich the disease has produced. This depression of the vital poAvers is a feature of the affection which it is ahvavs important to bear in mind. Varieties.—When the virus does not confine itself to the superficial capil- lary lymphatics, but spreads to the subcutaneous connective tissue, Ave have the variety knoAvn as phlegmonous erysipelas. Under these circumstances sup- puration, Avhich is extremely rare in ordinary erysipelas, is likely to occur. The foul, acrid, and thin pus infiltrates large areas, and there are sloughs of the connective tissue Avhich are discharged in masses. In some of the severe epidemics of this type the muscles Avere attacked and the periosteum Avas destroyed, giving rise to necrosis. Gangrene of the skin may also occasionally occur from deprivation of blood due to death of the underlying connective tissue. The presence of a phlegmonous inflammation is indicated by the increased amount of local SAvelling and constitutional disturbance. Fluctuation or bogginess is soon felt, and if the pus is not liberated by incision it burroAvs freely in all directions. Phlegmonous cellulitis, or inflammation of the subcutaneous cellular tissue, is regarded as identical with phlegmonous erysipelas by many writers. It is probable that the streptococcus rather than the staphylococcus is most frequently found in this form of inflammation, but the question must remain open until the identity or non-identity of the streptococcus pj^ogenes and the streptococcus erysipelatis is settled. Clinically, the two types are readily dis- tinguished by the absence of cutaneous erysipelas in phlegmonous cellulitis. There are other forms of rapidly-spreading inflammations of the skin and cellular tissue, particularly those which folloAv infected wounds of the fingers or hand, which are regarded by some authors as akin to erysipelas. These at times take the form of lymphangitis; at other times they occur as acute swell- ings of the integuments and connective tissue, extending Avith great rapidity, shoAving but slight tendency to suppuration, and frequently terminating fatally Avith symptoms of acute septicemia. They are probably due occasionally to infection with streptococci or Avith saprogenic bacilli. Facial erysipelas, which at one time was regarded as idiopathic ery- sipelas, is hoav supposed to be due to infection through some slight wound or abrasion on the face. It usually begins Avith a blush near the root of the nose or the lachrymal duct and spreads laterally toAvard the ears. The color is a scarlet red, and the amount of SAvelling is usually great and is accom- panied Avith oedema about the eyelids, obliterating all facial expression and causing entire closure of the lids. Vesicles and bullae also form on the cheeks. The inflammation may extend to the scalp or the neck, but the chin is rarely involved. The glands at the back of the neck are enlarged. In some forms the fever runs high, and there is usually considerable delirium. This may be due to reflex irritation of nerves or rarely to a suppurative meningitis, the result of a direct extension of suppuration in the orbit or to the meninges. Ordinarily, the delirium disappears Avhen the fever subsides. There is more or less conjunctivitis, and some oedema in the orbital tissues. If sup- 5 66 AX AMERICAN TEXT-BOOK OF SURGERY. puration should occur, blindness may result, a complication Avhich is for- tunately rare. Erysipelas neonatorum occurs usually in epidemic form in hospitals. It begins as a slight inflammation about the umbilicus, but as it spreads to the genitals and thighs the constitutional disturbance is great and the prognosis grave. It may be complicated with phlebitis of the umbilical veins extending to the liver. Erysipelas may involve the mucous membranes. In severe epidemics of erysipelatous angina the tonsils are greatly inflamed and the tongue is often swollen. Diphtheritic or gangrenous inflammation of the fauces may also occur. These epidemics are rarely seen at the present time. Erysipelas may extend to the glottis, and erysipelatous pneumonia, or pneumonia migrans, is described by some authors. The female genitals and the rectum may also be invaded by the disease. The curative influence of erysipelas is shoAvn not only in the effect pro- duced by it on old ulcers, but even by the wound itself, Avhich, AA'hen in the granulating stage, appears to heal more rapidly. Tumors also have sometimes disappeared during an attack. Lympho-sarcoma of the neck has been absorbed, the cells having undergone fatty degeneration. Both lupus and epithelial ulcers of the face have been known to break doAvn, healthy granulations subsequently appearing which healed rapidly. Fehleisen took advantage of this circum- stance to inoculate certain ulcers with cultures of the streptococci of erysipelas, and thus demonstrated the identity of the virus of the disease. The prognosis of erysipelas is usually favorable, as there is a tendency to self-limitation. The severity of the disease cannot, however, be predicted in any given case, but in small granulating wounds the disease is usually lighter than in large fresh wounds. Danger frequently arises from complications, as oedema of the glottis or secondary hemorrhage. Treatment.—Attempts to restrain the infective process by antiseptic applications have thus far not been very successful. The apparent success of many drugs may be due to the spontaneous arrest of the process Avhich so often occurs. Hot fomentations, containing corrosive sublimate of the strength of 1: 10,000 or 1:15,000, or carbolic acid may be used; but care must be taken to avoid increased local irritation or poisoning by absorption of the drugs when a large surface is covered. An ointment of carbolic acid and vaseline, 1 to 100, may be brushed on the face Avith a soft brush or applied to other surfaces and protected with a thin layer of gutta-percha tissue or oiled paper. Zinc ointment is often useful. In phlegmonous erysipelas free incisions are indicated. The sloughs should be removed, and the pus-cavities must be disinfected as thoroughly as possible. Pressure with plasters or bandages in situations Avhere they can be conveniently applied, has been advised to arrest the spread of the disease. The constitutional treatment should ahvays be supporting, and any deplet- ing measures should be carefully avoided. The presence of delirium does not necessarily contraindicate the use of stimulants. Tincture of the chloride of iron has been recommended in large and frequent doses on account of its action upon the red blood-corpuscles, Avhich are found crenated, and when placed under the microscope run together readily. This method was at one time received Avith great favor, but is less used at'present. Quinine has also enjoyed a great popularity. Antipyretics as a rule have little effect upon the fever, and should be avoided, owing to the depressing influence upon the heart's action which many of them exert. Opium in some form and hypnotics are indispensable to allay the pain and procure sleep. Food should'be carefully TETANUS. 67 and frequently administered. AVhen the blush has disappeared a complete change of bedding and clothing, with careful disinfection, may serve to protect the patient from a relapse due to a reinfection of the system. CHAPTER XII. TETANUS. Tetanus is an infective disease, almost always originating from a Avound. The central nervous system is the region chiefly affected by the bacterial poison which is the cause of the disease. The bacillus of tetanus (PI. II, Fig. 5) has only recently been dis- covered. It is a short rod Avith an enlargement at one end, due to sporulation, which gives it the characteristic drumstick shape. Although it is found in the dust of the street, it rarely finds an opportunity to groAv in the living tissues, owing to its anaerobic properties ; hence the rarity of the disease. It is found principally in the tissue near the wound, and is rarely, if ever, seen in the internal organs or blood. Several ptomaines have been extracted from the cultures of this bacillus, such as tetanine and tetano-toxine, and it is probable that most of the symptoms of irritation of the nervous system are due to the presence of these substances, as but few bacilli are found there. Punctured Avounds naturally offer the best opportunity for the groAvth of the anaerobic bacillus, and if such wounds are inflicted in dirty parts of the body, as the hands or feet, or foreign bodies covered Avith dust containing the bacilli are lodged in the tissues, the conditions favorable for infection are obtained. The state of the Aveather is said to have an influence upon the development of the disease. It has appeared in epidemic form with sudden changes in the Aveather after battles. It is also said to be much more common in tropical climates. Tetanus is said to be traumatic or idiopathic. It is probable, however, that all cases of tetanus are traumatic, but that the wound is so slight in many cases as to escape notice. It has been knoAvn to folloAV such injuries as simple fracture, in Avhich case internal infection probably occurs. Acute tetanus most frequently makes its appearance at the end of the first week after the infliction of an injury, although this period varies consid- erably. The first symptom complained of is a stiff neck, which the patient attributes to a slight cold. The muscles of the face and ja\v are next involved, and the patient is unable to open his mouth, this symptom giving rise to the popular name " lock-jaw." The muscles of the fauces and the pharynx are often in a state of spasm, rendering deglutition difficult. The muscles of the thorax and abdomen are next involved, and the muscles of the back are so painfully contracted that the head is throAvn back, the spine is arched, and the body assumes the position knoAvn as opisthotonos. The lower extremities may also become rigid; the arms are, however, only partially affected. The muscular spasms, which are tonic, permit of little rest, and the sufferings of the patient are excessive and almost continuous. The expression of the face is totally changed by the contraction of the various muscles, Avhich produces the characteristic risus sardonicus. The patient often experiences considerable difficulty in passing urine or in having a movement of the boAvels. Any dis- 68 AX AMERICAN TEXT-BOOK OF SURGERY. turbing influence, especially noise, instantly evokes the muscular contractions and adds to the patient's sufferings. These have been known at times to be so severe as to produce rupture of a muscle or fracture of a bone. Such a condition permits of little sleep, and in the acute cases the patient rarely obtains any rest from the moment the disease makes its appearance. The temperature is usually not much elevated, but the skin is bathed in perspira- tion. The pulse is weak and rapid, and as the disease progresses the exhaus- tion becomes marked, OAving to loss of food and sleep. Sudden death often occurs in a paroxysm of dyspnea. The mind is usually clear to the last. Such an attack Avill run its course usually in tAvo or three days. In chronic tetanus the disease makes its appearance at a later date. The muscles are extensively involved, but there are periods of comparative relief, and as these intervals become gradually prolonged the patient has an opportunity to sleep. In the chronic form the disease may last several Aveeks. There is little change to be observed in the Avound, although in some cases there are evidences of an infective inflammation. Trismus is a name given to a milder form of the disease when the con- tractions are limited to the group of muscles about the neck and face. Tetanus neonatorum or trismus nascentium is a general affection of the muscles in the newborn infant, beginning Avith trismus, and is due to an infection through the navel. It occurs occasionally in epidemic form in lying- in hospitals, and is a fatal disease. Post-mortem examinations of cases of tetanus do not usually show any evident pathological changes. Some observers have found hyperemia of the medulla and cord, but others have detected no change. Brown-Sdquard described an ascending neuritis, and Lockhart Clarke observed softening of portions of the gray substance of the cord. The diagnosis of tetanus is usually not difficult in the acute cases, but in the milder forms it may be mistaken for other affections, as rheumatic inflamma- tion of the jaAvs or hysterical contractions of the masseter muscles and excessive muscular spasm during the dressing of a sensitive wound. In strychnia-pois- oning the muscles of the jaAv are not rigid at first. Where the dose is small and repeated there will be intervals of rest. There is hyperesthesia of the retina and objects are colored green. Tetany is a disease characterized by attacks during which tonic spasms of the various groups of muscles occur, principally of the upper extremities. According to Weiss, these attacks are due to an irritable condition of the gray matter of the medulla and spinal cord. It sometimes follows childbed and fevers and some mental shocks. It has also been frequently observed after operations for the removal of goitre. The spasms are tonic "and give rise to great rigidity of the muscles. BetAveen the attacks the patient appears well. The majority of cases get well without treatment. It occurs chiefly in young persons. Opisthotonos may occur, but trismus is absent. Pressure upon the nerve-trunk leading to the affected muscles will always bring on an attack. It is a rare disease in this country. Hydrophobia, which is popularly thought to resemble tetanus, is easily distinguished from it. The paroxysm of hydrophobia is not a true muscular spasm, and is limited to the muscles of respiration. The intervals of repose in the early stages and the mania in the later stages are also distinctive. One who has once seen the two affections Avould not be likely to mistake them a second time. The prognosis of acute tetanus is of the gravest character. The only hope in such cases is that the acute form may gradually assume a chronic type. SCURVY. 69 According to Yandell's statistics, those patients AA'ho live beyond the fifth day are more likely to recover. Every day beyond this period improves the chances for recovery. Cases occurring after injury received in battle are much more fatal. The prophylactic treatment consists in the thorough disinfection of all suspicious Avounds. As soon as symptoms appear the patient should be iso- lated and kept in a darkened room, and extreme care should be taken to disturb him as little as possible. Any method of treatment Avhich involves motion should therefore be avoided. Of all drugs, chloroform appears to have the most sooth- ing effect upon the nervous system, and can be administered in small quantities by inhalation at frequent intervals. Chloral can also be given with the same end in vieAV, and it may be combined with bromide of potassium. Inhalations of nitrite of amyl often act Avell, the relief persisting for some time after each inhalation. Morphine may be injected subcutaneously. Calabar bean has been used successfully. All of these drugs must be given in unusually large doses and for a considerable time, as a hesitating policy entails great suffering upon the patient. Retention of urine must be relieved by catheterization, and if the muscular spasm of the throat is excessive it may be necessary to admin- ister nutrient enemata. There are feAv diseases Avhere skilled nursing is of so much importance. ScliAvarz of Padua has recently published cases of cure be- lieved to be due to injections of the tetanus antitoxin of Tizzoni and Cattani. CHAPTER XIII. SCUKVY. Scura'Y is a constitutional disease traceable to the use of improper diet, defective chiefly in suitable vegetable food, and to imperfect hygienic surround- ings. It is characterized by great disturbances of nutrition and a tendency to hemorrhage in the various tissues of the body. History teems Avith accounts of diseases strongly resembling scurvy, but no reliable descriptions of any epidemic are to be found before the fifteenth century, when the great extension of navigation exposed the creAvs of vessels to prolonged privations such as had not before been experienced. During the present century it has been noticed chiefly in Arctic voyages and in many Avars. The Allied armies suffered from this disease in the Crimea, and during the late Civil War the troops on both sides were affected. Perhaps the most striking epidemic of any occurred at Andersonville. During the siege of Paris in 1871 many cases of scurvy Avere discovered and carefully studied. It is rarely seen at the present time, and no opportunity has been obtained for studying it Avith the care Avhich modern methods of investigation offer. Scurvy has been supposed to be a contagious disease and also one of miasmatic origin, but it is iioav conclusively proved that imperfect nutrition is the most important factor in the causation of the disease. All are agreed that a deficiency in the variety of the diet is the principal cause of scuryy, but opinions differ Avidely as to the particular alimentary substance the absence of Avhich brings out the symptoms of the disease. Some have supposed that the disorder Avas due to the lack of fresh vegetables. Others have thought that the excessive use of salt meats produced conditions favorable for the disease. Garrod's theory that a deficiency of easily assimilated potassium salts in the 70 AX AMERICAX TEXT-BOOK OF SURGERY. food is one of the causes of scurvy has excited a good deal of attention. The most important factor, however, 'is certainly the absence of variety in diet. In certain instances the use of impure water has caused an outbreak of the disease, as was the case in Ranke's expedition into the interior of Australia. L nhealthy surroundings, as foul quarters in a ship; a bad state of the health, such as might result from great fatigue or dissipation ; and mental depression, such as might occur among convicts,—are all predisposing causes. Symptoms.—The early stages of the disease are marked by a condition of extreme lassitude. On slight exertion the heart's action becomes rapid and the respiration is increased in frequency. The patient complains of muscular pains in various portions of the body and is extremely sensitive to low tempera- tures. He is drowsy and apathetic and has an appearance of depression. There is no febrile disturbance and the pulse is sIoav and feeble. The skin is of a pale yelloAv hue, and is mottled here and there Avith brownish-colored spots. The epidermis is dry and brittle and there is considerable desquamation. The cutaneous follicles are unusually prominent, giving the appearance of " goose- flesh/' This condition will last for several weeks before the symptoms dis- tinctly characteristic of scurvy make their appearance. The gums then begin to be swollen and cedematous, and the mucous membrane of the mouth assumes a bluish tinge. The alveolar membrane is sensitive and bleeds easily, and the breath has a characteristic foul odor. Petechiae and numerous small extravasations are seen beneath the surface of the skin. They are at first observed about the roots of the hair, and appear as round bluish-red spots the size of a pin's head, Avhich do not disappear on pressure. Later, some of the extravasations which take place are of consider- able size and appear like bruises. Small vesicles form Avhich later grow to large size and become occasionally the starting-points of ulcerations. The latter may, hoAvever, result from a septic infection and breaking down of the extravasations themselves. The ulcers vary in size, are covered with a broAvnish scab, and are surrounded by a violet discoloration of the skin. The granulations are unhealthy and give vent to a foul-smelling discharge. The muscles and the connective tissue are also the seat of hemorrhages, some of which break down and discharge an ichorous fluid. At other times they indicate their presence only by peculiar indurations to be felt in those tissues. Hemorrhages may occur also from the mucous and serous membranes. Inflam- matory hemorrhagic effusions may take place in the periosteum. SAvellings occur at the epiphyseal line, and the epiphyses may be separated from the shafts of the bones. The joints also may be involved. Even the eves may be affected, and more or less disturbance of vision result (hemeralopia). The quantity of the urine is decreased, as also the urea and all the solid elements of urine. Fever is present during the height of the disease only Avhen inflam- matory complications prevail. The post-mortem changes observed are the hemorrhagic effusions in various parts of the body and such inflammatory complications as may have occurred, especially croupous pneumonia and ulcerative endocarditis. Hemorrhagic infarctions are often found, the result of embolism derived from thrombi Avhich form in the right auricle. Analyses of the blood have not as yet thrown much light upon the hemorrhagic tendency so conspicuous in this "disease. Water is found in excess and an increased number of Avhite corpuscles is observed. It is probable that a diminished power of resistance exists in the Avails of the capillaries. Diagnosis.—Scurvy may be distinguished from purpura by the cachexia and the persistent pains and the fetid breath accompanying the peculiar con- TUBERCULOSIS AXD SCROFULA. 71 dition of the gums. It may be distinguished in the same way from anemia, hemophilia, and leueocytheinia. The prognosis of the disease Avill depend greatly upon the stage at Avhich the patient comes under treatment. Under favorable conditions improvement soon begins in most cases, but the duration of the convalescence is usually a prolonged one. If the use of the limbs is regained after a feAv days of treatment, the prospects of ultimate recovery are excellent. The recovery in uncomplicated cases is usually a complete one. The prophylactic treatment consists in strict attention to the hygienic conditions, especially as to dryness and cleanliness on ships and in laying in a supply of live-stock. Among the antiscorbutics of repute at the present time may be enumerated eggs, milk, potatoes, beets, carrots, cabbages, onions, fruits, cocoanuts, pickles, cranberries, cider, lemonade, and lime-juice. The various meat extracts are also valuable and portable articles of food. Good drinking- Avater is also of the greatest importance as a prophylactic. The curative treatment of the disease is almost exclusively dietetic. Nitrate of potassium is said to be of especial value. It may be used alone or mixed with vinegar (Wales). Antiseptic mouth-Avashes and lotions for the ulcers are also indicated. Any medication contemplated should be of a distinctly tonic character. CHAPTER XIV. TUBERCULOSIS AND SCROFULA. SECTION I.—TUBERCULOSIS. The inoculability of tuberculous material Avas regarded as a possibility by Laennec and others, but Villemin in 1865 was the first to demonstrate the fact that the disease could be transmitted by inoculation to animals, and Avas therefore infectious like small-pox or syphilis. These views were con- firmed in 1877 by Cohnheim, AArho successfully inoculated the anterior chamber of the eye in animals, and Avas able to observe through the trans- parent cornea, after a period of incubation, a development of numerous miliary tubercles in the iris. The search for the-bacillus Avas from this time pursued Avith energy, but the observations of Baumgarten gave the only reliable results. His discovery of the bacillus Avas almost simultaneous with that of Koch, A\rho, hoAvever, in 1882 Avas the first to establish fully the identity of the organism and to culti- vate it successfully. The length of the bacillus tuberculosis is about one-half the diameter of a red blood-corpuscle. It is a thin rod, found single, in pairs, or in clusters. In tubercle in the human subject it is seen usually either single or in small numbers, and at times is quite difficult to demonstrate. It is found, however, in large numbers in experimental tuberculosis in certain stages of development, and therefore Avhen it is not possible to discover bacilli with the microscope a diagnosis can be made by inoculation of a suspected tubercle into animals. The miliary tubercle consists of a minute gray non-vascular nodule about the size of a mustard-seed. Under the microscope it is seen to contain a mass of leucocytes, near the centre of AA'hich are to be found a number of larger cells with one or more nuclei knoAvn as epithelioid cells and one or more 72 AN AMERICAN TENT-BOOK OF SURGERY. giant-cells. The appearance of such a cluster of cells is so characteristic that a tubercle can usually be recognized bv the presence of the giant-cells Avithout a demonstration of the'bacilli, although these cells are also found in other growths besides tubercle (PL IV, Fig. 9). The structure of these giant-cells is peculiar, the nuclei being arranged in a somewhat radiating manner around the periphery of the cell, the center of which is made up of a granular protoplasm in a more or less advanced stage of degeneration. In studying experimentally the development of a tubercle it has been found that the first change consists in a division of the fixed cells of the part involved (by karyokinesis), by means of Avhich process the epithelioid cells are formed. The giant-cell formation is due to the fact that the epithelioid cells do not' shoAV a tendency in the less active forms of tuberculosis to proliferate, but the division of the nuclei of certain cells continues, and the unusual cell-growth is thus produced. In acute miliary tuberculosis the cell-division is more active and giant-cells are less frequently found. As the growth of tissue-cells begins to subside, the number of leucocytes which have Avandered in from without begins to increase. The fine reticulum or network of fibers Avhich supports the cells of the tubercle does not appear to be a new formation, but is merely the remains of the intercellular substance of the pre-existing tissue. The bacilli are found either in the larger cells or between them; at times but one or tAvo bacilli are found in the giant-cells. They are seen usually near the nuclei at the border of the cell. More rarely they are found in large num- bers in the human subject. Hoav they are brought to the part affected is not clear: it is thought by some that, not possessing any movements of their own, they are transported by the leucocytes, but this vieAv would not accord with that first expressed (Baumgarten)—namely, that the leucocytes appear only at a later stage in the process of development. The bacilli are rarely found in the circulating blood. Sections of tubercle are well shown by the double staining process, the fibers of the tissue being colored red by eosine, and the giant-cells being Avell brought out by the hematoxylin. In order to show the tubercle bacilli a special staining method is necessary. The staining fluid consists of the follow- ing ingredients: Saturated alcoholic solution of fuchsin, 10 parts: 5 per cent. aqueous solution of carbolic acid, 90 parts. The section should be placed in a small quantity of this fluid in a watch- glass, and alloAved to remain from one to twenty-four hours according to the degree of staining required. The section should then be decolorized with a 5 per cent, solution of sulphuric acid for a feAv seconds. If, Avhen the specimen has been washed in alcohol 60 per cent., it is found not to be sufficiently decolorized, it should be replaced in the sulphuric acid. It should finally be dehydrated in absolute alcohol, cleared in oil of cloves, and mounted in Canada balsam. Tubercle shows a tendency at an early period of its existence to undergo a caseous degeneration. This tendency is favored by the absence of blood- vessels, and the part which first succumbs to this process is the center of the tubercle, the portion farthest removed from the supply of nutriment. The change is principally due to a coagulation-necrosis, presumably caused by the action of the bacilli upon the cells. As a result of this change the mass pres- ently assumes the appearance of a caseous nodule. If the progress of the dis- ease is arrested at this point, the tubercle becomes enclosed in°a fibrous laver the result of a reactive inflammation, and is said to be encapsuled, and the cells, having all undergone cheesy degeneration, are finally absorbed or the caseous TUBERCULOSIS AND SCROFULA. 73 product is calcified. If, hoAvever, the process extends, the caseous nodule becomes larger, the necrosed material breaks up into a granular de'bris, and a fluid is produced Avhich in appearance resembles true pus. These products of degeneration frequently contain the bacilli, and when inoculated into animals may reproduce the disease. This tuberculous pus or puruloid material contains the broken-doAvn masses of cells and a certain number of leucocytes and fragments of the coagulation- necrosis. The contents of cold abscesses arising from tuberculous processes are usually of this character, but occasionally the pyogenic organisms are found in this fluid, in Avhich case true suppuration occurs. The tubercular pus is thin and of a peculiar Avhite or chalk-like color: it contains lumps of cheesy matter the product of tubercular softening, and fragments of sloughs of the connective tissue. Crumbs of bone may occasionally be felt in it. If the tubercular nodule is on the surface of the skin or a membrane, such degenerative changes will lead to ulceration. The local spreading of tubercular inflammation is caused by the growth of the bacilli, Avhich involve neAv areas of tissue. Adjacent cavities or organs may thus be invaded. By the breaking doAvn of bone-tissue the bacilli may gain an entrance into a joint, or the peritoneum may become infected from a tuberculosis of the intestine. When the bacilli enter the blood-vessels or lymphatics, they may be transported alone, or in the interior of small emboli, to a distant organ, and a general miliary tuberculosis may be thus produced. Tuberculosis is probably the most common of all diseases, for it is estimated that 18 per cent, of all cases of death occur from this cause. According to Baumgarten, it arises more frequently by inheritance than in any other way; but, although the bacillus may undoubtedly be transmitted from parent to off- spring, it is probable that only a predisposition to the disease is the more fre- quent result of heredity. The disease easily arises then in such predisposed persons Avhen the bacillus gains an entrance to the body through the respiratory organs, Avhether inhaled Avith the air as dust arising from dried sputa and other excretions, or taken into the alimentary canal Avith food and penetrating the intestinal mucous membrane. It may also be introduced through A\Tounds of the skin, chiefly of a trifling character, such as bruises or scratches. It is undoubtedly an infectious disease, and may be contracted by persons of healthy ancestry by continued exposure to its germs. Tuberculosis of the skin includes a number of diseases which until recently have been regarded as different affections. The most frequent form is that knoAA'n as lupus. This disease is noAV recognized as a lesion due to the pres- ence of the bacillus of tuberculosis, although it is often extremely difficult to find the organism. The tendency of the disease is to remain local, but it may occasionally lead to a general tuberculosis. Lupus vulgaris is most frequently seen on the face, but other portions of the body may be the seat of the affection, particularly the extremities. It is characterized by a chronic inflammatory process, forming brown-red nodules Avith a tendency to ulceration and subse- quent cicatrization. In this Avay a considerable area gradually may be involved. When the tendency to ulceration is excessive Ave have the form knoAvn as lupus exedens, although this name is often given erroneously to ulcerating forms of cancer of the face. In other cases the amount of granulation-tissue may be a prominent feature, and then Ave have the form known as lupus hypertrophic us. When there is a tendency to the formation of cicatricial tissue the disease may produce exten- sive superficial alterations in the skin, and give rise to great deformity, the 74 AN AMERICAN TENT-BOOK OF SURGERY. whole surface of the face being occasionally involved. Patients with lupus not infrequently die of pulmonary tuberculosis. The affection known to surgeons as anatomical tubercle, and frequently found on the fingers and hands of assistants in the autopsy and dissecting rooms, is noAV recognized as tubercular, and is regarded as almost identical with the variety knoAvn chiefly as tuberculosis verrucosa cutis or verruca necrogenica. It is characterized by plaques situated chiefly on the backs of the hands, arras, and finders, looking at first sight like a cluster of inflamed Avarts. There are also erythematous patches and pustules. Scrofuloderma is a name applied to certain tuberculous affections of the skin Avhich formerly Avere not regarded as allied to lupus. It occurs as a more or less deep-seated, chronic inflammatory process in any part of the skin, prefer- ably on the neck, body, or extremities, and shows a tendency to the formation of granulation-tissue, which breaks down and gives rise to sinuses or minute ulcerations. It is occasionally associated with disease of the lymphatic glands and bones. It is sometimes called scrofulous gumma, owing to its resemblance to syphilis. Primary tuberculosis of the panniculus adiposus is observed, particularly in children, in the form of flat subcutaneous nodules Avhich gradually soften and break down and discharge. In some cases they may burrow extensively with- out coming to the surface. Tubercular abscesses of the deeper connective tissue are, hoAvever, usually secondary to some affection of the bones or joints or lym- phatic glands. The larger abscesses, generally knoAvn as cold abscesses, originate most frequently from tuberculous disease of the bones. Such cavities, when opened, present a characteristic appearance. The walls are covered "with a membrane of a grayish-yelloAV or grayish-red color, Avhich is loosely attached, and can readily be removed with the finger or sharp spoon in large fragments. It consists of a very soft and slimy material, which con- tains great numbers of miliary tubercles closely packed together and imbed- ded in masses of fibrin. When scraped aAvay healthy tissue is exposed. At one spot the persistence of a small islet of granulations indicates the opening of a fistulous track Avhich leads to diseased bone. Occasionally no such fistula can be found. This is the case in the so-called peri- or para-articular abscess when the septic infection of the connective tissue is transmitted from a diseased bone or joint through the lymphatics. Such abscesses, although at first not communicating with the affected joint, may later establish an opening into it. Fistulre leading to tubercular abscesses are also lined Avith a tuberculous mem- brane. The pus of these abscesses may contain a feAv leucocytes, but consists chiefly of the products of caseous degeneration. The presence of the bacilli of tuberculosis, although not easily determined with the microscope, is often demonstrated by experimental inoculation in guinea-pigs. In the typical cold abscess pyogenic cocci are not usually found under the microscope, nor can they be obtained from cultures of this pus. The absence of fever in cases where these large abscesses are found is thus explained, and the constitutional dis- turbance Avhich frequently follows the opening of a cold abscess is undoubtedly due to a subsequent additional infection Avith the pyogenic cocci. Adjacent muscles are rarely infected by tubercular abscess: it is now well understood that striped muscular fiber is not liable to tuberculous disease. Tuberculosis of the mucous membranes may follow or accompany lupus of the skin. A direct extension may take place from the ahe of the no"se or from the lips to the nostrils, gums, or pharynx. Tuberculosis of the tongue is a comparatively rare affection, and is liable to be mistaken for cancer or syphilis. It appears as a chronic inflammatory pro- TUBERCULOSIS AND SCROFULA. 75 cess Avhich produces an infiltration extending to the deeper muscular tissue. On the surface ulceration may take place. It may be associated with tubercu- losis elscAvhere, and the presence of pulmonary signs or fistula in ano would serve as aids to diagnosis. The prognosis w ill depend largely upon the general condition of the patient. Lupus of the velum, tonsils, and pharynx is often found associated with lupus of the skin, and, according to Lennox BroAvne, is more likely to be seen in skin than in throat clinics. It appears in the form of numerous super- ficial ulcerations surrounded by inflamed and thickened borders, which shoAv a tendency to become confluent. There is less loss of substance than in syphilitic lesions of these parts, as the ulcer tends to cicatrize. The adjacent mucous membrane is often found studded with miliary nodules, which run together, break down, and form neAv ulcerations. The" miliary tubercles are situated immediately beneath the epithelial layer, and may also involve the intermuscular and connective tissue. The giant cells are numerous and well developed; the number of bacilli is, however, usually small. Many of the patients Avho are the subjects of these affections succumb to pulmonary tuber- culosis. Tuberculosis of the throat or lungs may give rise to tubercular disease of the intestinal canal. As a result of such infection ulcers may form in the neighborhood of the crecum and appendix, and may perforate the bowel and give rise to a tubercular abscess. Tubercular inflammation of the large intestine has been knoAvn to give rise to so much obstruction as to necessitate laparotomy, Avhich has been successfully performed. The development of tubercular peritonitis from this source is supposed to be much less common than from the Fallopian tubes. Most cases of fistula in ano are tuberculous. They are characterized by the formation of fungous granulations and a tendency to burrow beneath the skin and mucous membrane. In many of these cases symptoms of pul- monary disease are also present, and the prognosis is then exceedingly unfavor- able. All portions of the genito-urinary tract appear to be affected by tuber- culosis. Lupus is found occasionally on the labia majora. Cornil has found the bacilli in ulcerations of the vagina adjoining a vesico-vaginal fistula. In six autopsies of cases of tuberculosis of the uterus he found in three a number of bacilli. Tubercular infection of the Fallopian tubes often supervenes upon a chronic catarrhal salpingitis in cases of tubercular disease of other portions of the genital mucous membrane. It is possible that infection of the female genital organs may result from coitus, as the bacilli of tuberculosis have been found in the semen of tuberculous men even in cases Avhere the genital organs are not the seat of tuberculous disease. Tuberculous peritonitis not infre- quently accompanies tuberculous pyosalpinx. Tuberculosis of the mamma is rare. Tuberculous ulcerations or sinuses may occasionally be seen about the nipple, and yield readily to treatment. Several cases are reported by Cornil AA-here miliary tubercles containing giant cells and bacilli Avere found in the ducts of the gland. Tillmans recommends, in every case of tuberculosis of the mamma, extirpation of the breast and the lymphatic glands. Tuberculosis of the male genital organs has usually an unfavorable prog- nosis. Tuberculosis of the testicle occurs most frequently in early adult life. Many cases of cure occur Avithout operative interference, although there is danger that the disease may propagate itself along the course of the vas deferens to the vesiculre seminales, the prostate, and the bladder if the testicle 7G .4 A AMERICAN TENT-BOOK OF SURGERY. is not removed. Tubercles are found in the urethra, in the membranous por- tion chiefly, but the disease is more frequently described as existing in the bladder. It may at times be quite extensive and involve the kidneys. It is one of the most difficult forms of the affection to deal with, and early diagnosis by detection of bacilli in the urine is therefore important. The tubercular affections of bones are found most frequently in the vascular spongy tissue of the epiphyseal ends of the long bones. Tuberculosis of the shaft of the long bones is comparatively rare. The disease is found in the short spongy bones, as the bodies of the vertebra; and the bones of the tarsus and carpus. It is also seen occasionally in the flat bones, as those of the skull and the pelvis, the orbital portion of the superior maxilla, and the ribs. In the epiphysis the tuberculous nodule is usually formed some little distance from the cartilage. On section of the bone one sees, in the beginning of the disease, a yelloAvish-Avhite or pure yellow Avell-defined mass lying in the spongy tissue, which even with Ioav poAvers can be seen to be made up of miliary tubercles, some of them already in a state of cheesy degeneration. As this nodule groAvs in size it becomes softened, and finally forms a cavity containing a more or less softened material mingled Avith minute fragments of bone: or the degenerated bone becomes necrosed in a mass and forms a sequestrum. This is generally of a roundish form and frequently as large as a Avalnut, and is surrounded by a layer of granulation-tissue which is also infected Avith tubercle bacilli. More rarely the tuberculous nodule may break doAvn and form a small abscess. Such pus-cavities are most often seen in the extremities of the tibia?. Occasionally the nodule may remain for a long time unaltered, and is then surrounded by a dense capsule. Sclerosis or eburnation of the surrounding bone may occur under these circumstances. The bacilli reach the epiphysis usually through the circulation. They are most frequently conveyed there as single organisms floating in the blood, but they may be transmitted in emboli, possibly from a tubercular mass in the bronchial glands. If such an embolus should plug a terminal arteriole, an infarction of the bony tissue may result, forming a wedge-shaped sequestrum Avith its base directed toward the joint and the apex pointing toward the diaphysis. These Avedge-shaped tubercular infarctions have been produced experimentally in animals by injecting tuberculous pus into the tibial artery. It is possible that a groAvth of granulations may invade the tubercular mass, and that complete absorption may take place; and the part may be thus restored to its normal condition. Even a tubercular seques- trum may be disposed of in this Avay under favorable conditions. Usually, hoAvever, the nodule softens and the tubercular pus breaks into the joint or into the adjacent connective tissue. When the joint is involved, tubercular infection of its surface Avill occur and disorganization will probably take place. When the pus discharges through the periosteum, a cold abscess w ill form which may burrow extensively and finally break externally. Tuberculous osteomyelitis of the shaft of the long bones occurs chiefly in the phalanges of the hands and feet. The disease appears first in the marrow, which with the cortical bone is changed into granulation-tissue: at the same time the periosteum is stimulated into a neAv bone-formation, which in its turn becomes involved. In consequence of these progressive changes the bone is much distended in the middle of its shaft, the so-called spina ventosa. The disease may undergo spontaneous cure or suppuration may take place. Con- siderable deformity may be caused by atrophy of the affected bones in early life. Tuberculosis is also frequently observed in the short spongy bones, par- ticularly in the bodies of the vertebra?, giving rise to Potfs disease, and in the bones of the carpus and tarsus. The changes produced in bone-tissue by TUBERCULOSIS AND SCROFULA. 77 the bacillus of tuberculosis is that known hitherto as caries; that is, an absorp- tion of the bony tissue, giving it a Avorm-eaten appearance. Necrosis is more frequently the result of acute inflammation produced by the presence of the pyogenic cocci, but, as Ave have seen, it may occasionally be due to the action of the bacilli of tuberculosis. Tuberculosis of the joints (knoAvn often as Avhite SAvelling, tumor albus, hip disease, ankle disease, etc.) usually results from infection by the opening of a primary nodule from the bone into the joint. A primary tuberculosis of the synovial membrane, however, may also occur. As the consequence of infiltra- tion Avith miliary tubercles we find a thickening of the membrane with forma- tion of granulation-tissue Avhich may not be accompanied by any collection of fluid in the joint. At other times there is considerable turbid or bloody fluid, or suppuration may take place and the joint contain the characteristic thin and pale tubercular pus. When the tendency to the formation of granulation- tissue is excessive, the condition knoAvn as caries sicca exists. Little or no pus is formed, but there is extensive loss of bone as the result of caries. Occasionally circumscribed tubercular nodules form on the synovial membrane and project into the joints as small pedunculated tumors, consisting of fibrous tissue, but containing a softened tuberculous mass in the interior. In the serous form of tuberculous synovitis numerous " rice bodies" or '■'■melon-seed''' bodies are seen in some cases, either free in the joint or attached to the capsule by a pedicle. They are composed of concentric layers of fibrin, a substance Avhich is so often associated Avith the formation of tubercles. As the disease progresses the articular cartilage is attacked by the granu- lation-tissue in the joint, and ulceration takes place, or granulation-tissue may form in the epiphyses and perforate the cartilage from beneath. In cases of long standing the disease spreads from the capsule to the surrounding tissues, and the connective tissue, the tendons, and even the muscles, become involved in a gelatinous degeneration. This peculiar change is supposed by some to be a saturation of the diseased tissue with a fluid of a mucous or synovial character. Under favorable conditions a more or less complete restoration of the joint- cavity may take place, but Avhen the disease is once well developed the best that can be hoped for is a fibrous or bony ankylosis. If suppuration takes place, the abscess may open externally, and fistulae communicating with the joint may be established. In long-standing cases of joint-suppuration amyloid changes are found in the internal organs. Tuberculosis of the tendon sheaths is usually secondary to bone or joint disease, but it occurs occasionally as a primary affection. A thickening of the tendon sheaths takes place and develops into a cylindrical doughy swelling, which is usually most painful. Rice or melon-seed bodies often form, A por- tion of the new tissue softens down and fistulous openings occur. If the sheath is laid open by a longitudinal incision, a mass of gelatinous tissue is found which can easily be stripped off. Such an operation may result in cure. Tuberculosis of the lymphatic glands is a very common affection. Enlarged glands may be found at the autopsies of children dying of almost any disease, and on examination prove to be the seat of tubercle. The disease may occur in the glands secondarily to the involvement of some adjacent organ, as in the bronchial or mesenteric glands from pulmonary or intestinal tuberculosis. In the glands of the neck, which are by far most frequently affected, the disease often appears to occur primarily, but is in reality usually secondary to a catarrh of a mucous membrane or to a cutaneous eczema. The bacilli are feAv in num- ber except in the glands nearest to the primary focus, and in many glands they cannot be found. In abscesses of lymphatic glands they may be found in the 78 AN AMERICAN TEXT-BOOK OF SURGERY. tuberculous membrane which lines their walls. In the bronchial glands the bacilli are often seen in the capsule and the periglandular tissue. As a result of caseous degeneration and infection with pus cocci abscesses may form, and a spontaneous cure may be rarely effected. Where an extensive invasion of the lymphatic system takes place the bacilli eventually reach the circulation, and acute miliary tuberculosis may result; but this is brought about more frequently by the entrance of the bacilli into the veins and their dispersion in emboli to different parts of the body. The diagnosis of tuberculosis can usually be established by the clinical symptoms and history of the case, but in doubtful cases a microscopic examina- tion may reveal the presence of the bacilli. This can be done by an exami- nation of the sputa or urine. (See Surgical Bacteriology.) If the case is one of doubtful lupus, a fragment can be punched out with the Mixter exploring canula, and sections can thus be obtained for microscopical study. In those cases in which the bacilli cannot be found recourse must be had to experimental inoculation. A fragment of the suspected tissue can be implanted into the subcutaneous connective tissue of the groin of a guinea-pig, and if the speci- men is tuberculous a miliary tuberculosis Avill be produced in from five to six weeks. The prognosis of the disease depends greatly upon its locality. In tuber- culosis of the skin and superficial tissues it is more favorable than that of internal organs. In children the prognosis is generally more favorable than in adults. Any tuberculous nodule is always a source of danger, and should not be alloAved to remain if it can be removed. There is always the possibility of recurrence even after operation. The operative treatment consists either in complete removal of the dis- eased tissue by incisions carried through the surrounding healthy tissue or in a thorough curetting, followed by free irrigation with iodine-Avater, packing with iodoform, or occasionally by the actual cautery. In laying open healthy tissues the possibility of an infection of the system with bacilli should not be forgotten ; hence thorough removal or no operation is the rule. The special methods of dealing with the local conditions will be considered in their appropriate places. The general treatment of the disease is of the greatest importance. This consists chiefly in the selection of a suitable nourishing diet and an appropriate climate. When change of residence cannot be effected the patient should be kept as much as possible in the open air. Among the most valuable of internal remedies are cod-liver oil, the hypophosphites, and alcohol. Koch's remedy, Avhich is at present attracting so much attention, is prepared as folioavs : Tuberculin, or paratoloid, is obtained from a pure culture in nutrient bouillon of the bacillus of tuberculosis by extraction Avith 50 to 60 per cent. of pure glycerin. As dispensed for use," it is put up in small vials holding about five cubic centimeters, and consists of a viscid dark-brown fluid of an alkaline reaction and somewhat bitter taste. The fluid as at present prepared does not consist entirely of the active principle, of which there is estimated to be but about 1 per cent. This is not one of the ordinary ptomaines, for the reason that it is not decomposed by any ordinary degree of heat, as are these latter. The material may be subjected'to a sufficient temperature for complete sterilization without affecting its potency. The activity is supposed to be due to a compound belonging to the class 'of toxalbumins that are coming into prominence and that are not changed by heat. It is precipitated bv alcohol as a heavy flocculent white precipitate,' which disappears at once upon the dilution of the alcohol. TUBERCULOSIS AND SCROFULA. 79 The original material is prepared for use by the addition either of Avater or, if one desires to keep the dilution for some time, of a 0.5 per cent, of carbolic acid. The dilution should be made with the greatest care and Avith thoroughly sterilized pipettes, solutions, etc. The usual proportion is 1 per cent., so that in a syringe divided into tenths of a cubic centimeter each division Avill contain one milligram of the original material, this being the average dose at the beginning of the treatment. After the dilutions have been opened and their use is over for the day, they may be sufficiently sterilized by placing them in a sterilizer for five minutes after the steam has begun to pass. With this precaution they may be used for a period of at least ten days. Human beings are much more susceptible to the action of the material than are the lower animals, especially guinea-pigs. In the latter there has been injected as much as four centigrams of the original material Avith no apparent effect. The syringe used for the subcutaneous injections is pistonless, and its con- tents are expelled by a rubber ball. It Avas designed by Koch for the purpose of obtaining an instrument that could be easily sterilized. The point usually selected for injection is the skin of the back beneath the scapula. The mode of action of this remedy is to produce an inflammation of vary- ing degrees of severity in the tissues Avhich are the seat of the tubercle. It is analogous to the effect produced by an acute inflammation upon a chronic one. The surrounding connective tissue is inflamed, but the miliary tubercles remain unchanged beyond a certain diminution in size. In ulcerating forms of the disease the tuberculous tissues are more readily separated and throAvn off. The material is injected subcutaneously, either with the Koch syringe or the ordi- nary hypodermatic syringe. The smallest dose is one milligram, but ten milli- grams are often given after the treatment has been continued for some time; and this is occasionally increased later to five hundred milligrams. At the conclu- sion of the treatment as large a dose as one gram has been given by Bergmann. Thus far, a primary improvement has been noticed, but the disease usually returns after a cessation of the treatment. It has been found by Bergmann in cases of lupus that a preliminary curetting and cauterization of the nodules, folloAved by a course of injections of tuberculin, offers the most favorable pros- pects of success. But very feAv cases of permanent cure by this method have as yet been reported. Cheyne has obtained more satisfactory results by substituting for the inter- mittent dosage of Koch a continuous dosage, Avhich consists in giving the injec- tions two or three times a day, and increasing the dose, sometimes sloAvly, sometimes rapidly, until occasionally as much as three decigrams Avere given three times a day. Of 9 cases so treated, 6 improved to such an extent that no evidence of disease was seen some Aveeks after treatment. Treatment should be continued for a long period. In conjunction Avith other treatment, he found it useful in lupus and in cases of bone and joint disease after operation Avhen healing had not taken place. He found by experiment that tuberculin predis- poses the tissues to fresh infections. In guinea-pigs Avhich had been previously treated Avith tuberculin the disease appeared earlier and progressed more rapidly than in others. He also treated a number of patients Avith the derivatives of tuberculin obtained by Dr. William Hunter. According to the latter observer, tuberculin owes its activity not to one principle, but to at least three, and probably more, different substances. By taking advantage of the action of absolute alcohol on tuberculin he obtained by precipitation a fluid consisting of proteid materials and a small quantity of salts. This caused no pyrexia Avhen injected, but pro- 80 AN AMERICAN TENT-BOOK OF SURGERY. duced the depressing effects of tuberculin and the local inflammatory reaction. The residue from the filtrate contained the salts in excess and a small quantity of proteid materials. This fluid when injected caused fever, but produced no local inflammation. The local disease, however, appeared to improve under its use He also obtained from the residue of the filtrate, by a process of dialysis, a substance which produced very distinct local improvement, but was unaccom- panied by fever or local inflammatory reaction. Still a fourth material was obtained by precipitating more thoroughly the proteid substances of tuberculin ammonium sulphate being employed instead of alcohol. The action of the substance thus obtained Avas very much like the one last mentioned, but a little more rapid. A somewhat limited experience Avith the last tAvo substances in cases of human tuberculosis shoAved that the disagreeable features Avere avoided, but that the remedial effects were nevertheless obtained. SECTION II.—SCROFULA. Scrofula (from scrofa sus, a SAvine) is a name formerly applied to all tuberculous affections except those of the lungs. At the present time the term is synonymous Avith tuberculosis of the glands, joints, or bones. It is still, hoAvever, an open question in the minds of some pathologists Avhether the name should not be reserved for a certain class of cases clinically resembling tuber- culosis, but Avhich are caused by the presence of some other form of micro- organism than the bacillus of tuberculosis. By others there is supposed to be a certain type of constitution which is peculiarly susceptible to external irritants of various kinds Avhich may produce inflammation of the skin, mucous mem- branes, or lymphatic glands. Such individuals arc considered equally suscepti- ble to tuberculosis. The observations of several observers have given some support to this theory. Charrin and Roger examined a guinea-pig Avhich had died of a disease which resembled tuberculosis, but Avere unable to find the characteristic bacilli. Cultures, hoAvever, were obtained Avhich were found to consist of bacilli much smaller than those of tuberculosis. When other animals were inoculated from these cultures a similar disease Avas produced. Similar observa- tions have been made by Eberth and Pfeiffer. Babes describes a case of acute bronchitis Avith miliary tubercles of the lungs in which oval and fusiform bacteria 0.8 micromillimeters in length were found in the tubercles. Observa- tions of this kind have given rise to the name '* pseudo-tuberculosis,"and it does not seem improbable that certain affections of this class may be due to other organisms than the bacilli of tuberculosis. Two types of the affection are usually described—the torpid and the erethistic. The torpid form is the most characteristic. Such children have light or reddish hair, a sallow and pasty complexion, puffy cheeks, and protruding lips. The eyelids and conjunctiva? are often the seat of a chronic inflammation. Catarrhal affections of the nose and ear often exist, the skin is eczematous, and the cervical glands are enlarged. The general appearance of such a patient suggests the origin of the name " scrofula." In the erethistic form there is less tendency to glandular enlargement. The individuals are dark-colored, of a nervous temperament, and are subject to catarrhal affections. Undoubtedly there are certain types of children of delicate constitutions who need an unusual amount of care; and, although the above description savors somewhat of an antiquated pathology, it is well to remember that not all enlarged glands or swollen joints or inflamed bones are tuberculous. Such children should be RHACHIT1S. 81 placed under the most favorable hygienic conditions, and exposures and fatigues of all kinds should be avoided. They should not be subjected to too rigor- ous a school discipline. Adults should seek the most favoring climates. Cod-liver oil and iron are the most useful tonics for these cases when medical treatment is indicated. CHAPTER XV. RHACHITIS. The term rhachitis is derived from pd^cz, the spine. The English name rickets is, however, more commonly used, ft is a general disturbance of the nutrition of the body in infancy and childhood, and consists principally in an insufficient deposit of lime-salts and in absorption of already-formed bone. Etiology.—It is a disease seen chiefly among the poor in large cities, less frequently in the country. It is much more common and severe in Europe than in this country. In America the disease is neither very prevalent nor very severe, and except in colored children or in Italians and Portuguese very great deformity is rare (Bradford). Bad hygienic influences, such as poor venti- lation, damp dAvellings, and croAvded rooms, are frequent causes of the disease, but the most important cause of all is improper feeding. The substitution of patent foods for the mother's breast-milk is said to favor its development In menag- eries, where animals live under highly artificial conditions, the disease is frequently observed. In congenital syphilis changes in the bones closely resembling those of rickets are occasionally seen. The disease begins in the first or second year of life, exceptionally after the fifth or sixth. It is not often seen in newborn infants, but rhachitic changes are occasionally found in the bones during fetal life. The pathological changes are most frequently seen at the epiphyseal junctions. In consequence of a hyperemia of the bone-forming tissues there is an increased growth of cartilage at the epiphyseal line, an insufficient deposit of lime-salts, and an absorption of those already deposited. After the disease has run its course calcification may take place on an increased scale, and scle- rosis of the bone may occur. The most marked anatomical changes are seen at the epiphyseal line, which is much broader than normal, and bone, cartilage, and medullary tissue are irregularly distributed among one another. Rhachitic bones are frequently so soft that they can be cut with the knife, and as a result of this change great deformity often occurs. In older children such changes are seen in the bones of the thorax, spine, and extremities; less fre- quently in the skull. The ligaments are relaxed and movements of the joints are often painfnl. The promontory of the sacrum is depressed and the pelvis thus greatly narroAved. Curvatures of the spine, as scoliosis or lateral devia- tion, kyphosis or curvature with convexity backward, and lordosis or curvature with convexity forward, are also observed. In the skull the bones are often unnaturally thin and crackle under pressure like parchment. The condition is knoAvn as craniotabes. Dentition is often delayed, and during convalescence progresses with great rapidity. It is always irregular. The brain may be hypertrophied, and sometimes is sclerosed; hydro- cephalus may also occur. The bronchial tubes are filled with mucus, and emphysema of the lungs is occasionally found. Evidences of intestinal catarrh are seen. The spleen is often enlarged. Among the early symptoms is restlessness at night, Avith a tendency to 6 82 AN AMERICAN TENT-BOOK OF SURGERY. profuse perspiration especially about the head; the bowels are constipated and the belly becomes distended. The urine is large in amount and loaded with phosphates. In the bones the earliest changes are seen at the epiphyses, Avhich become thickened chiefly at the end of the radius, and in the ribs, where the row of beaded enlargements is quite characteristic. With the softening of the bones deformities of the spine and extremities begin. The head is increased in size, particularly the forehead and the frontal eminences. The distortion of the ribs gives rise to the characteristic pigeon-breasted deformity. Catarrhal affections, as bronchitis, and even pneumonia, may occur as complications, as also laryngismus stridulus. Among important diagnostic symptoms are delayed dentition and delayed closure of the anterior fontanel. A search for the epiphyseal enlargements will usually settle the diagnosis. Rickety children are often stunted in stature. The prognosis is usually favorable. Deformity disappears in 90 per cent. of the cases. A few cases terminate fatally from complications, such as broncho-pneumonia. In the treatment of rickets careful regulation of the diet is of the utmost importance. Fresh food should be given in preference to prepared foods; fresh milk properly diluted for infants, and meat-juice or raw beef for older children. Fresh air and light in the nursery should be obtained if possible. Salt-water bathing is highly recommended. Cod-liver oil is considered the most valuable of drugs. Phosphorus is also a favorite remedy ; syrup of the iodide of iron is perhaps to be preferred. Lacto-phosphate of lime is given on theoretical grounds chiefly, but is a good tonic for children. Those modern inventions, " sea-shore homes " and " day nurseries," are particularly adapted for the treatment of this disease. The surgical operations for deformities of bones are described elsewhere. CHAPTER XVI. CONTUSIONS AND WOUNDS. SECTION I.—CONTUSIONS. An injury produced by a blunt body in which tissue-elements are more or less rent asunder, but in Avhich there is no gross or manifest external breach of tissue, constitutes a contusion. In a simple contusion or bruise the area of damage is limited by the area of impact of the bruising body, but the amount of damage may be of any grade, from the imperceptible molecular division of a slight bruise to the purification of large masses of tissue. The element of contusion is present as a complication of most wounds, and in many constitutes a grave and most important factor. The distinction between a contusion and wound is therefore one of degree and not of kind. A contusion should be defined more properly as a hidden Avound, the firmer tissues of the skin being able to resist the rending effect of the bloAV, Avhich produces its greater effect upon softer tissues underneath. Whether an injury shall be defined as a con- tusion or a Avound depends also upon the character of the injured structures and the nature of the tissues Avhich lie underneath the surface. Thus a hard, bony surface, so related to the tissues on Avhich a blow is struck that they are forced against it by the bruising body, will necessarily aggravate an injury, and much CONTUSIONS AND WOUNDS. 83 more readily cause an absolute destruction of all the tissues, including the skin, and so produce a wound, than if a thick cushion of soft tissue alone is involved. The results of bloAvs over the shin are examples of the first, AAhile those upon the surface of the abdomen or upon the fleshy masses of the nates or the thighs are examples of the second. Pathology.—The pathology of a contusion is that of a subcutaneous wound. The more delicate and easily-torn tissues suffer first and most exten- sively ; ruptured blood-vessels give rise to more or less hemorrhage; injured nerve-fibrils are the sources of pain; functional disability folloAvs according to the extent and character of the tissues inj ured; local swelling, both from hemorrhage and from serous effusion, quickly ensues. When the effused blood shows itself as a somewhat diffused subcutaneous discoloration, an ecchymosis is said to be present; when, hoAvever, it is collected in a more or less well-defined cavity, so as to constitute a blood-tumor, it is knoAvn as a hematoma. When blood-vessels of some size are involved in a contusion, special conditions of hemorrhage may arise ; thus they may be either ruptured outright or their walls so bruised that they subsequently slough, and so occasion a later hemorrhage. The hemorrhage from the smaller vessels is usually soon controlled after moder- ate escape of blood by the reactive pressure of the surrounding engorged tissues. The force of the blood-current in large veins and in most arteries is likely to be such as to cause a considerable loss of blood, especially when it escapes into any of the great cavities of the body or when the locality involved is one in which there is present much loose connective tissue. Contusions of nerves may produce more or less paralysis of the regions supplied by them. A pro- gressive degeneration of a nerve may result from the changes produced in it by a violent contusion. The effects of contusions of muscles depend upon the extent of the damage done; local soreness and pain upon movement attend less severe injuries; rapid recovery under rest and proper treatment is to be expected in such instances; from even quite extensive lacerations ultimate recovery with full functional power often takes place. In less favorable cases, however, atrophy, contracture, and permanent loss of power may result. The contusions of bone Avhen short of absolute fracture are usually rapidly recov- ered from, but may develop into acute or chronic inflammatory conditions or determine caries or necrosis, or even the development of malignant changes. Diagnosis.—The symptoms which indicate the occurrence of a contusion are easily recognized. The part is tender and quickly becomes somewhat SAvollen, with some elevation of temperature. In simple and superficial con- tusions discoloration of the skin soon declares itself as the result of the subcutaneous hemorrhage. In cases where deeper structures are especially contused the appearance of the external discoloration may be delayed for some days, owing to the slowness Avith which the effused blood finds its Avay to the surface. Loss of function may be present, dependent upon the character of the tissues injured and the extent of the injury inflicted. The amount of pain in the part may vary. At first there is numbness, folloAved quickly by severe acute pain, which gradually subsides with the lapse of time. Shock is almost ahvays present to some extent. Contusions of moderate severity pro- duce a degree of shock characterized by momentary stunning ; others of greater severity may produce faintness or total loss of consciousness for a variable period; Avhile in the more severe cases, as in contusions of the abdomen, immediate death may ensue. Treatment.—For the general shock and the local pain the treatment required for such conditions accompanying any injury is indicated. For the contusion itself the first thing to be secured is rest to the injured part. *4 AN AMERICAN TENT-BOOK OF SURGERY. This is especially important when the contusion is severe and the injuries to deeper structures are extensive. For securing rest, if voluntary immobiliza- tion is not sufficient, the use of apparatus of some kind may be required. Bandages, slings, splints, a recumbent position in bed, all may have their use. By rest local irritation is diminished, hemorrhage and inflammatory effusions are restricted, the absorption of effused fluids and of necrotic tissue is favored, and the normal repair of the injured tissue is fostered. Of all means for treating these injuries, rest is the one of primary and greatest importance. Next, hemorrhage and serous effusion may require attention. Equable, elastic, and firm compression is to be recommended for their control. Com- presses of cotton avooI secured by proper bandages are especially serviceable for this purpose. A simple flannel bandage alone will often be of great service. When, for any cause, the use of compresses and bandages is inconvenient or undesirable, some advantage may be obtained from the application of cold, by ice-bags, evaporating lotions, or affusions of cold water. In the more severe forms of contusion cold is to be used with caution, since by its continued use the vitality of the parts is depressed, and tissues which under more stimulating treatment might be preserved from necrosis and regain their normal condition may be precipitated into absolute death. In the slighter and more superficial forms of contusions evaporating lotions are frequently both convenient and effi- cient. As an example of such a lotion a solution of chloride of ammonium and alcohol (gr. v (a f§j) is to be recommended. Tincture of camphor, tincture of arnica, tincture of Avitch-hazel, all favorite popular applications for contusions, are of use, but depend for their efficiency chiefly upon the alcohol Avhich they contain. In cases in which much bruising and disorganization of tissues are present great care must be taken to avoid everything which may still further depress the vitality of the part. The indications are, then, to support and stimulate. In addition to the rest already recommended, a moderate amount of heat will be of use; hot-water bags, the hot-Avater coil, masses of cottonwool, or flan- nel previously heated, may be found useful. In the later history of many contusions massage and stimulating liniments are of value. They promote the activity of circulation in the part, break up and diffuse among the tissues blood-clots and serous accumulations, and hasten their absorption; they pro- mote the nutrition of the injured tissues, break up adhesions, and expedite the return of the normal functional activity of the contused parts. Blood- extravasations as a rule should be left to the natural processes of absorption for their removal. Blood-effusions widely dispersed along connective-tissue planes, infiltrating tissues already lowered in their vitality by a contusion, present conditions eminently favorable for the development of widespread and disastrous septic infection, for which reason an attempt to evacuate a hematoma by incision under ordinary circumstances is always to be deprecated. When, however, continuous subcutaneous hemorrhage is present, showing the existence of a wound of a vessel of importance, it is imperative to make a free incision, so as fully to expose the wounded vessel, and to apply a ligature to it. In such cases the incisions through the external parts should be very free, and all recesses into which the effused blood has found its way should if possible be opened up. All clots should be turned out, and the most perfect disinfec- tion and drainage of the infiltrated areas provided for. Circumscribed blood- tumors may sometimes be relieved by aspiration. After the lapse of tAvo or three Aveeks from the time of the original injury any persisting blood-tumor may be more freely laid open and its contents evacuated; by this time it will CONTUSIONS AND WOUNDS. 85 be surrounded by a layer of condensed connective tissue reinforced by inflam- matory exudation ; the surrounding tissues will have recovered from the state of depression immediately folloAving the injury ; and as the result of these con- ditions the danger of septic infection will have greatly diminished. Severe inflammatory reaction folloAving contusion must be treated upon general surgical principles, including rest, elevation of the parts, evaporating lotions, together with such constitutional measures as may be required for relieving pain, reducing temperature, and lessening the intensity of the general febrile reaction. If suppuration occurs, adequate incisions must be made for the evacuation of the pus; if local gangrene threatens, stimulating applications are first required, as dry heat or stimulating liniments, until the line of demarcation of the slough is distinctly formed. Fomentations should now be used, composed of compresses wet with some antiseptic solution and covered with rubber dam or oil silk, to hasten the separation of the slough. If phlegmonous inflamma- tion advances into adjacent parts, free incision into the inflamed tissues, with abundant antiseptic irrigation and iodoform tampons, should be used. SECTION II.—WOUNDS. A wound is a solution of continuity of any tissue, produced either directly or indirectly by sudden mechanical force. The occurrence of a solution of continu- ity in any of the solid tissues of the body may be due to sloAvly-acting causes, as the gradual waste of atrophy, or the more active disintegration of ulceration; but a breach of tissue thus effected Avould not be a Avound. There is involved in the idea of a Avound the action of a force outside of the tissue itself, Avhich by mechanical violence has rent or divided its substance. The term "wound," therefore, is susceptible of a very wide range of application. Contusions, sprains, fractures, subcutaneous as well as cutaneous breaches of tissue, are included in the term. In all essential particulars they are identical accidents, involving the same methods of repair and subject to the same principles of treatment, their apparent differences depending upon accidental differences of structure, function, nutrition, relation to other parts, extent of traumatism suf- fered and of exposure to influences from Avithout. In the present chapter the wounds of bones will not be considered. Classification.—Wounds may be divided primarily into the two great classes of subcutaneous and open wounds. Subcutaneous wounds include all which are unaccompanied by breach of the skin. Protected by the unbroken skin from external irritation and infection, their repair is usually rapid and undisturbed by untoward irritations. The preceding paragraphs devoted to the consideration of contusions are descriptive of the greater number of subcuta- neous Avounds. Open Avounds, as a class, include all in which there has been a breach of the skin or mucous membrane. Open Avounds are subdivided, according to the manner in Avhich they are produced, into incised, punctured, contused, lacerated, gunshot, or poisoned Avounds, according as the wounding agent has been a sharp cutting edge, a penetrating point, a dull and bruising body, a tearing force, a projectile impelled by the force of an explosive, or one Avhich carries Avith it into the wound a poison. Penetrating Avounds are those in Avhich the vulnerating body enters a cavity Avithout emerging; perforating Avounds, those in which the vulnerating body both enters and emerges from the cavity. All Avounds are accompanied by death of tissue in their track ; even the path of the keenest knife-edge through a tissue is lined by disorganized particles that have been killed by its impact. BetAveen a slight and clean incised wound, in Avhich the destruction of tissue is limited to the molecules traversed by the 86 AN AMERICAN TENT-BOOK OF SURGERY. cutting instrument, and an extensive lacerated wound, with roughly torn and contused edges, or between a slight bruise and a contusion producing the death and disorganization of large masses of tissue, the difference is one of degree and not of kind. The important practical difference which has always been recognized in the healing of these different classes of Avounds depends simply upon the difference betAveen the facility Avith which the devitalized tissue is prevented from becoming a source of disturbance to the healing of the Avound in the several instances. Wounds may be again classed as aseptic and septic. Aseptic ivounds include all which are preserved from contamination by poisonous bacterial products, whether such poison come in contact Avith the wound directly or be generated in it by the action of germs that gain access to it. An aseptic condition in a wound may be obtained either by the protection which the wound received from the first against the access of any septic agent, or by the power of tissues to resist and destroy septic agents, or by the application to the Avound of substances which destroy them. Subcutaneous wounds, as a rule, remain aseptic in consequence of the protecting covering which the skin affords; operative wounds inflicted under certain precautions may be aseptic; all open Avounds in Avhich union by first intention is secured without special and adequate aseptic precautions are examples of the power of living tissues to resist septic infection. Septic wounds include all those in which any agent capable of exciting fermentation or putre- faction lodges and grows. In all cases they are attended with some degree of inflammation and suppuration and with sloughing of dead tissue. Symptoms.—The symptoms indicative of a wound are local, dependent upon the effects produced at the point at which the wound is inflicted, and con- stitutional, dependent upon the effects on the body at large. Local Symptoms. — First, Impairment of Function. — A certain amount of disability is the inevitable result of a division of tissue. Its extent and nature will depend upon the amount of injury and the tissue injured. The duration of the disability will depend upon the promptness of healing and the susceptibility of the wounded tissue for perfect repair. Divided tissues tend to retract from each other, and thus a greater or less amount of gaping becomes a Avound-symptom. Pain is a usual accompaniment of a wound. It is due to the irritation sustained by the sensory nerves. The amount of pain is of variable quantity. At the moment of the infliction of a wound no pain at all may be experienced, OAving to mental preoccupation or excitement or to the rapidity with which the Avound Avas inflicted. The temperament of the individual may modify the amount of pain. Some individuals experience great pain from causes Avhich in others produce but little suffering. The sharp pain usually felt at the moment of the infliction of a wound soon gives way to a dull aching or smarting pain, which may last for some hours, but will finally subside and disappear, provided the wounded parts are kept at rest and their repair progresses Avithout disturb- ance. Attempts at motion in a Avounded part, Avhich tend to pull apart the divided tissues, or the occurrence of a high grade of inflammation, causing tension and excessive congestion, awakens pain anew. When large sensory nerve-trunks have been involved in Avounds, later and continuous pain may be due to slight inflammatory conditions extending from the wound upward along these nerves; hence the pain often complained of in the stumps of amputated limbs during the first few days folloAving operation. Hemorrhage.—Some amount of bleeding is the immediate effect of every wound. It is always the invariable and most manifest symptom that a wound has been inflicted, but the amount of the blood lost may vary greatly according CONTUSIONS AND WOUNDS. 87 to the constitutional condition of the Avounded person, to the character of the tissue Avounded, and to the size of the blood-vessels implicated. In scorbutic conditions of the system, and in those occasional instances Avhere a hemor- rhagic diathesis exists, prolonged and even dangerous loss of blood may result from a trifling Avound. Ordinarily, Avhen merely capillaries or small arterioles or venules are divided, spontaneous cessation of hemorrhage quickly occurs, especially if the tissues Avounded are retractile, so that the wounded vessels become withdrawn among and embraced by them. Whatever favors the production and retention of a clot about a wounded vessel favors the arrest of hemorrhage; hence lacerated Avounds, where the Avound-edges are ragged and the openings of the vessels themselves irregular, the coats of the larger vessels, being unevenly divided, are not likely to bleed much, on account of the entan- glement of the blood-fibrin in the irregularities of the Avound-surfaces and the speedy production of blood-clot. When large blood-vessels are opened profuse and speedily fatal hemorrhage may occur. Shock.—The primary constitutional symptom of a wound is "shock." Shock is that condition of general vital depression Avhich marks the immediate effect upon the individual as a Avhole produced by the local wound. It may be of any grade of intensity, from a slight, evanescent, and hardly appreci- able disturbance of mental force to the most profound general depression and speedy death. Its manifestations are through the nervous system, and are exhibited most markedly by depressed action of the circulatory organs—vaso- motor paralysis. Shock is to be distinguished from the effects of hemorrhage; and in cases of surgical operations from the effects of anesthetics, although in many instances it may be aggravated by either or both. Martin and Hare have recently proposed to use the hemoglobinometer as a means of distinguish- ing hemorrhage, especially intra-abdominal, from shock. In shock the hemo- globin would be unaltered; in hemorrhage the hemoglobin Avould be greatly diminished. The pathology of shock cannot be determined by the ordinary methods of research. In such cases death leaves no change which can be detected in any of the tissues. The effects manifest themselves chiefly through the agency of the nervous system in the same Avay as all the phenomena of life which are controlled by that system. Sometimes, hoAvever, as seems to have been shoAvn by Goltz, a marked distention of the intra-abdominal veins exists. The phenomena of shock must be accepted as the measure of the ability of an individual to resist hurtful influences from without. The same injury Avill produce different degrees of shock in different individuals, and different degrees likewise in the same individual at different times. Women, as a class, are less susceptible to shock than men. Persons Avho are inured to suffering, or who by long confinement to bed or by the influence of drugs have acquired a cer- tain torpidity of the nervous energies, are less susceptible to shock than indi- viduals whose nervous forces are in a high degree of activity. Temperament modifies the manifestations of shock. The phlegmatic and lymphatic tem- peraments resist shock; the sanguine and mobile temperaments favor it in the highest degree. Mental conditions modify shock ; fear, despair, despond- ency, disappointment, depressed mental states of any kind, aggravate shock ; on the contrary, hope, joy, cheerfulness, glad expectation, success, diminish shock. Age modifies shock. The young bear injuries Avell, and rally quickly from shock Avhen unaccompanied with much loss of blood; in the aged the frequent presence of organic disease often renders shock more severe and prolonged. In the absence of organic derangements the dulled nervous susceptibility of the aged diminishes their liability to shock. Symptoms of Shock.—The symptoms of shock are those of general depres- 88 AN AMERICAN TENT-BOOK OF SURGERY. sion: the skin is pale and cool; the pulse is feeble and rapid, the respiration is shallow and irregular; the body-temperature is lowered; a sense of faintness is experienced by the individual, and in the more severe forms total loss of consciousness ensues; the functional activity of all the organs of the body is retarded; muscular tone is diminished, with a sense of general muscular pow- erlessness; the sphincters may fail to act, causing involuntary evacuations; nausea and vomiting often occur. Every degree of intensity in these symp- toms of depression which have been enumerated may exist in different cases, from a transient feeling of weakness and momentary mental confusion to abso- lute death. The symptoms of shock are the immediate consequence of the injury sustained. The assumption of the possibility of a condition of delayed shock is not consistent Avith Avhat has been said as to the nature of shock itself. Whenever a condition of sudden and marked depression declares itself some time after the reception of an injury, it is always due to some dis- tinct cause other than the original injury, and when recovery from shock is delayed and manifests oscillations of improvement and retrogression, distinct diseased conditions, possibly directly resulting from the injury, are always its cause. For this reason the terms which are found in older text-books, and which are still often used in ordinary surgical parlance—namely, delayed shock, secondary shock, and imperfect reaction from shock—may be misleading, as they tend to divert the attention from real conditions. The conditions which most frequently cause these symptoms of later depression are concealed hemorrhage, septic infection, and fat embolism. Pulmonary oedema and renal congestion are also possible conditions always to be inquired after Avhen a sudden unfavorable turn occurs in the condition of a patient soon after an injury has been sustained, especially Avhen ether has been used as an anesthetic. The occurrence of any of these conditions may, of course, produce its own shock, but this shock arises de novo. Prognosis of Shock.—Very quick and complete recovery from a state of most profound shock may occur. The chief elements upon Avhich recovery from shock depend are these: First, whether the injury has to do Avith a vital part; and second, whether it entails a continued source of irritation and depres- sion. Thus in injuries to the head the immediate shock may be ovenvhelm- ing in consequence of the vital relations of the injured part, or when not at once fatal may be continued and masked by inflammatory conditions arising in the cerebral tissues as a consequence of the injury. So in crushing injuries of the extremities: the immediate shock of the injury may be pro- longed and intensified by the pain and irritation arising in the mangled tissues, so that the surgeon is often called upon, even in the presence of much general shock, to run the risks of subjecting his patient to the additional brief shock of an amputation, rather than to leave him exposed to the continued irritation of his mangled limb, with possible added septic infection, while Avaiting for reac- tion to be established. In general it may be said that Avhen an injury is not primarily fatal through shock, and continually reneAved shock can be prevented, speedy recovery therefrom may be confidently looked for under proper treat- ment. Severe shock is so often complicated Avith the acute anemia caused by loss of blood that it is difficult to separate its prognosis and its treatment from those of the latter condition ; nor in practice is it essential to do so. Reaction.—The symptoms which indicate the passing away of the effects of shock are a gradual increase of the strength and volume of the pulse, a dimi- nution in its frequency, a more natural color and heat of the skin, return of con- sciousness, and the manifestation of muscular power, as the shifting of his position by the patient. The appearance of such favorable symptoms constitutes what CONTUSIONS AND WOUNDS. 89 is termed a state of reaction. In the most favorable cases reaction is gradual and progressive, though it may occupy many hours or even days in its course. Returning color to the face and an increased poAver in the heart's action are unmistakable signs of its occurrence. In certain cases fluctations in the reac- tion occur, relapse alternating with improvement for a variable time. The real significance of such fluctuations has already been (hvelt upon. In other cases, before perfect reaction has been accomplished, there supervenes a condition characterized by a rapid and Aveak heart's action, cerebral excitement and delirium, muscular tremor, and high body-temperature. These are the signs of septic infection. Reaction from shock is commonly attended by some ele- vation of the body-temperature, quickening of the pulse, thirst, derangement of the secretions, restlessness, and headache. This fever attending reaction may be so trifling and evanescent as to escape notice. Its grade of severity depends chiefly upon the nervous activity of the patient, his previous constitutional condition, and the amount of local irritation produced by the injury. Chil- dren manifest it most readily. It makes its appearance usually Avithin a few hours after the reception of an injury, and may be expected to decline on or after the second day. This aseptic fever is to be distinguished from the traumatic or surgical fever which sometimes complicates the repair of injuries, which does not develop until two or three days after an injury, and is depend- ent upon general blood-infection by absorption of septic matter from the injured part. Prophylaxis of Shock.—In cases of surgical operations it is possible for the surgeon to diminish to some extent the shock resulting from the wounds inflicted. These means include moral, physical, and medicinal measures. The patient should be inspired to believe that success m\\ crown the surgeon's efforts, and to place implicit reliance upon his skill. HoAvever plainly the surgeon should state the possibilities of mischance to the friends of the patient, nothing but hope and happy expectation should usually be expressed to the patient himself. Among physical means are included all measures of a general character which tend to diminish nervous irritability and promote the general resisting power of the individual. Confinement to the bed for some days is of value as a nervous sedative. The regulation of all the secretions of the body so as to secure as nearly a perfect condition of Avell-being as possible is not to be overlooked. The choice of the period of the day for operating Avhen the vital poAvers are at their best is likewise to be considered. As a rule, this is during the morning hours. All unnecessary exposure of the body occasioning loss of body-heat is to be avoided; if the operation is to be long, artificial heat by hot- water bags and bottles should be applied during the operation. Hemorrhage is to be carefully guarded against and restrained. Medicinal measures include the use of narcotics, as opiates, the bromides, and the free administration of alcohol. These may be of benefit Avhen a state of excessive nervous irritability has to be antagonized. They are of special value in preparing alcoholic subjects for operation. In patients the subjects of malarial cachexia the free preliminary use of quinine should be resorted to. The administration of an anesthetic should be conducted Avith great care, lest the depressing effect of excessive anesthesia should be added to that of the surgical procedure, but at the same time complete anesthesia should be secured. For the same reason, Avhile avoiding undue haste, operations should be done as quickly as possible. Strychnia may be used hvpodermatically in full medicinal dose, -^ to A^ of a grain, after anesthesia has been induced, at the beginning of serious surgical procedures, as a prophylactic against shock through its stim- ulating action upon the cerebro-spinal centers. 90 AN AMERICAN TENT BOOK OF SURGERY. Treatment of Shock.—Shock, having once become established in a severe degree, requires prompt treatment, If it occurs in the course of a surgical operation, the operation must be brought to a conclusion as speedily as possible, or may even have to be suspended. The head should be lowered and the body placed in the recumbent position, if it is not already so. Respiration should be kept free from impediment, and when practicable the stimulating effect of inhala- tions of oxygen should be resorted to. Heat should be applied not only to the extremities, but to the whole surface of the body as far as practicable. Hot- water bottles and hot blankets should have been provided for this purpose. In cases of severe shock an efficient and speedy method of applying heat is to wrap the whole body in blankets Avrung out of hot water. Diffusible stimulants should be instantly and freely administered. Hypodermatic injections of Avhiskey or brandy in doses of one-half to one dram should be given every five or ten minutes until a distinct effect from them can be discerned by a more full, slow, and regular pulse. A rectal enema of turpentine (f § ss—j), rubbed up to an emulsion with a raAV egg in Avarm water (f 3iv), acts as a powerful stimulant. A warm strong infusion of coffee will be of much use. In digitalis and atropia two most valuable remedies for sustaining a flagging heart are found. They should be administered hypodermatically, the tincture of digitalis in fifteen-minim doses every fifteen minutes till the pulse is affected ; not more, however, than four such doses should be administered consecutively. If any benefit is to be obtained from the remedy, it will have been developed by that time. The first dose of digitalis may be combined Avith one one-hundredth of a grain of atropia. When the pulsations of the heart become more sIoav and regular, and the superficial capillaries show that the blood-stream is again filling them, and an increasing muscular power and general Avell-being is beginning to be established, a gradual withdrawal of these stimulating measures is to be practised; the pulse is to be watched, and according to its indications of recurring weak- ness or progressive strength the stimulants and cardiac tonics are to be resorted to anew or entirely withdrawn. When the patient begins to com- plain of the temperature of the hot appliances by Avhich he has been sur- rounded, they may be removed. Where there has been much hemorrhage the copious administration of hot liquids by the stomach and by the rectum should be resorted to to the full amount Avhich these organs are able to dispose of. Recovery from shock under proper treatment, if it occurs at all, is usually quite speedy ; delay in recovery or alternations of improvements and relapse, as has already been stated in a preceding page, are due to the nature of the injury itself or to new complications introduced, and are not to be attributed to or classed as shock. Death from shock may be immediate or gradual. When instantaneous death takes place the nerve-centres must be considered as having been overwhelmed beyond the power of resistance. In some such cases the heart has been found contracted and empty. More commonly the fatal issue occurs only after some minutes or hours of struggle against the" inevitable. The fatal approach is then more gradual; the action of the heart becomes more and more feeble; the pulse, weak and thready and counted with difficulty on account of its rapidity, becomes finally lost; the extremities become cool, the face pinched and haggard; the mind, apathetic, gradually sinking into unconsciousness; the temperature continues to fall until it becomes a degree or more subnormal; the respiration is feeble and shallow, until finally, by combined respiratory and cardiac failure, death closes the scene. Fat Embolism.—Injuries, especially those of bones and of soft parts involving much adipose tissue, Avhen there is much crushing of the parts, CONTUSIONS AND WOUNDS. 91 through the fact that many fat-cells are broken doAvn and minute fat-globules set free, mingling Avith the effused fluids and wound-secretions, may exhibit a train of symptoms which are due to the entrance into the circulation of this fluid fat. The condition is known as fat embolism. A slight amount of fat embolism occurs in almost every fracture in adults and in operations involving the cancellated tissue of bone. In extensive compound and multiple fractures its most severe forms are likely to be developed, causing symptoms complicat- ing and succeeding those of shock, and often resulting in death. These deaths have commonly been attributed to shock ; their real cause has only within a feAv years been appreciated, and even now is frequently overlooked. Fat embolism is rare in children, because their skeletons contain relatively little fat. The severity of the symptoms depends on the quantity of fat Avhich has gained entrance to the circulation, on the rapidity with Avhich it has entered, and on the proximity of its source to the heart. The conditions which predis- pose to it are patent blood-vessels bathed in secretions containing fluid fat, and some pressure tending to force the fat into the open vessels. The local conges- tion and abundant secretions poured out among the wounded tissues during the first thirty-six hours after an injury supply by the tension of the part the pressure needed to cause the entrance of the fat into any open vessels which may be present. Having once gained access to the general venous current, the fatty globules are carried to the right heart, and thence are driven with the blood-stream into the pulmonary capillaries, Avhich they plug up to a greater or less degree, and by their presence here determine the first symptoms of fat embolism. The capillary vessels of a lung in which this has happened may be seen more or less distended Avith fat-drops by the use of a glass of but Ioav magnifying power. Sometimes they may be clearly made out by the naked eye, particularly in the loAver lobes of the lungs. When the amount of fatty material Avhich is poured into the capillaries of the lungs is not very great, or Avhen it arrives but sloAvdy, the disturbance Avhich it causes may be but slight; gradually the oil-molecules are forced through and pass on into the general circulation. They may noAv again be arrested in the capillaries of the brain or spinal cord, and here excite the special disturbances incident to lesions of these organs. More frequently they are arrested and disposed of in the liver and in the kidneys. The urine secreted by kidneys thus blocked up by fat will present oil-globules floating on its surface. When the power of the heart is Aveak in the old, in the intemperate, and in all cases Avhere the general power of resistance is much diminished from any cause, local congestive pro- cesses may be awakened in the lungs by the persistent embolism, and pulmo- nary oedema and hypostatic pneumonia result. Should these fatty particles carry with them septic micro-organisms—a condition not impossible after surgi- cal operations and in compound fractures—they might become the agents for establishing multiple septic foci in many parts of the body. It is rare that the obstruction to the circulation through the lungs by fat embolism is so extreme as to cause immediate death or to produce death at a later period by obstructing the brain or the smaller vessels of the spinal cord, except in those instances where, through primary shock of the injury, loss of blood, or pre- vious disease, the resisting power of the patient has already become nearly exhausted, and the superadded disturbance caused by the inundation of fat is sufficient to determine a fatal result. The symptoms of fat embolism as a rule develop within from thirty-six to seventy-tAvo hours after an injury, though fatal cases are recorded in which the symptoms developed and ran their entire course in less than twelve hours. The symptoms indicative of the lesser degrees of fat embolism are restlessness, 92 AN AMERICAN TENT-BOOK OE SURGERY. anxiety, slight dyspnea, and accelerated breathing, with quickening of the pulse. In the more severe degrees these conditions become aggravated, general prostration rapidly increases, the countenance becomes pallid and anxious, and later cyanosis, mental excitement, delirium, somnolence, an.I coma succeed in turn. The dyspnea becomes intense, the respiration very rapid, and finally stertorous. (Edema pulmonum develops; hemoptysis may occur; the pulse is Aveak, frequent, irregular, and finally imperceptible. The temperature at first is subnormal, and may remain so, or may rise later, according to the develop- ment of secondary complications. The urine will display oil-globules floating on its surface. Diagnosis of Fat Embolism.—Fat embolism is to be distinguished from shock, the effects of anesthetics, acute septicemia, acute congestions of the lungs and of the kidneys, and cerebral hemorrhage or embolism. It is to be distinguished from shock by the fact that its symptoms make their appearance at a time when the symptoms of shock should have greatly subsided, and in many cases Avhere in the first place the amount of shock has never been very great. The remote effects of ether are not so easily to be distinguished from the effects of fat embolism. The irritative effects upon the lungs and the kid- neys of the prolonged administration of ether to persons predisposed to pul- monary or renal congestion often declare themselves in severe congestion, which determines symptoms not unlike those of fat embolism. In cases, therefore, in which such administration of ether has been resorted to the diagnosis may be made obscure. The appearance of oil-globules floating on the urine Avould be sufficient to determine the presence of fat embolism. The symptoms of acute septicemia are later in their development than those of embolism. They are accompanied by marked elevation of temperature. They are more gradual in their onset, hoAvever active their course may be, and not infrequently are engrafted upon those of fat embolism. The sequence of the conditions of shock, fat embolism, and acute septicemia is not infrequent, and, when its pos- sibility is borne in mind by the surgeon, Avill readily explain the course of many otherwise anomalous cases. Acute inflammatory states of the lungs arising from conditions entirely independent of fat embolism may develop rapidly after operations or injuries, and are to be distinguished from the effects of fat embolism, Avhich may also be present and Avhich may be masked by them. The symptoms indicative of such acute inflammatory lung congestion are suffi- ciently clear for diagnostic purposes if attention is only directed to them. The danger is rather that the symptoms of fat embolism will be confounded with them than that they should be mistaken for fat embolism. The not infrequent occurrence of acute renal congestion, Avith total arrest of the urinary secretions, after a severe operation, is to be borne in mind by the surgeon in making his diagnosis as to the cause of threatening symptoms Avhich complicate or super- vene upon the shock of the original operation or injury. The disturbance of cerebral conditions likewise, through embolism or cerebral hemorrhage, is to be borne in mind as a possible occurrence. Prognosis of Fat Embolism.—When the symptoms indicating the presence of fat embolism are severe the probabilities of recovery are very slight. In its lesser degrees the disturbances caused by it are transient and are speedily and spontaneously recovered from. The prognosis depends upon two factors especially—the amount of fat that has gained access to the circulation, and the ability of the heart to force the oil-globules through the capillaries of the lungs. Should this first danger have been overcome, possibilities of renewed danger from arrest of oil-globules in the capillaries of the brain or spinal cord in vital regions still exist. In such conditions a fatal result is not long delayed, a CONTUSIONS AND WOUNDS. **;> feAv hours only sufficing to bring the case to a close. When the pulmonary trouble is the chief one, a longer time may be required to determine the final result, Avhether recovery or death. At best, however, the struggle is a brief one, and is determined one way or the other Avithin less than forty-eight hours. Treatment of Fat Embolism.—The first indication for treatment is to pre- vent, if possible, and at all events to diminish, the entry of fatty matter into the blood-current. The tAvo conditions that foster this accident are the churn- ing up of bruised and broken fatty tissue by movements of a part, and the tension resulting from the accumulation of Avound-secretions that have no vent. Immobilization of the injured part and relief to tension by provision for free drainage are therefore of primary importance. The second indication for treatment is to sustain and stimulate the action of the heart. For this purpose alcohol, digitalis, and strychnia in full doses will be found useful. REPAIR OF AATOUNDS. The repair of all breaches of tissue is accomplished by essentially the same process, subject only to minor peculiarities of structure. This process has been described in a preceding section (Process of Repair). By reference to this section it will be seen that the essential element of repair consists in a modifi- cation of the normal nutritive processes at the seat of injury, by Avhich the tissues to be repaired return to their embryonic state and new embryonic tissue is formed between them, Avith which they blend. By the organization and development of the neAv tissue a permanent bond of union is formed. In no case is union of divided tissue effected Avithout the interposition of new material. When divided tissues are at once brought into perfect apposition, and there retained and shielded from disturbance, the amount of new tissue required for the accomplishment of union will be extremely small, and may be Avith difficulty recognizable; but its existence in some degree is nevertheless undeniable. When the process of repair whereby the union of divided surfaces is secured proceeds without complication or interruption, union by first intention or by primary adhesion is said to have taken place. (See Chapter III.) This pri- mary union is the ideal to be sought for Avhenever possible. To secure it it is necessary that the divided surfaces be brought together and kept in close apposition ; that the wound be protected and kept from all further injury ; and that adequate local nutritive conditions be maintained. Whatever interferes with any of these conditions w ill introduce a complication in the healing of a wound. It is not infrequently the case that wounds occur in Avhich from the outset it is apparent to a surgeon that in some one or all of these respects it will be impossible to secure the necessary conditions, so that no attempt to secure union by first intention can be made. Thus the loss of tissue may be so great that apposition of the divided surfaces is impracticable, or some motion is unavoidable, or there is pre-existing infection, or such relation of the Avound to the bodily excretions or secretions exists that some contamination is inevitable. The presence of any of these conditions will make it obvious that a Avound should not be closed. Again, the tissues bordering the Avound may be so bruised or reduced in their vitality by general or local causes that their poAver of sustaining the necessary processes of repair is uncertain, perhaps obviously hopeless. In all such cases the method adopted by the surgeon for the treat- ment of the Avound will be quite different from those in Avhich primary union is expected. Healing by second intention is the process which is noAV the resource of the surgeon, as it is also in those cases in which attempts at primary 94 AN AMERICAN TENT-BOOK OF SURGERY. union have been made and have failed. By its means the ultimate healing of the wound is secured. The conditions which may thwart the ideal primary repair of the wound will have to do with either* the apposition, the protection, or the nutrition of the wounded parts. Under the first of these headings the surgeon must consider the natural gaping of divided tissues and the necessity of supply- ing adequate means of retaining them in coaptation. The inevitable aggrava- tion of this natural gaping by certain positions of the body or of the limbs and by motion at joints suggests at once the necessity of considering a favor- able posture for wounded parts, so that relaxation of the injured tissues as complete as possible may be secured. The accumulation of blood and of wound-secretions betAveen the divided surfaces is a frequent cause of lack of success in attempts at securing primary union. Under conditions of typically perfect protection from external infection, as in most subcutaneous Avounds, and in some operation-wounds made under rigid conditions of asepsis, such accumu- lations of blood and Avound-secretions may not introduce any serious complica- tion into the healing of the wound. Later, these effusions become absorbed, or they are diffused among the adjacent connective tissue-spaces, and the nat- ural processes of repair proceed. In yet other cases the blood-clot, remaining as an intervening mass betAveen the wound-surfaces, serves as a support and scaffolding for neAv tissue which is throAvn out from the surrounding parts, and which penetrates the mass of the clot and coalesces Avith it, and finally replaces it by fibrous tissue that unites the previously separated wound-surfaces. Union by secondary intention is thus accomplished without suppuration or waste of nutritive material. As a rule, the most assiduous effort of the surgeon must be to prevent any accumulation of blood or Avound-secretions in any Avound Avhich he is called upon to treat. Perfect apposition may, again, be prevented by the presence of foreign matter between the wound- surfaces. Shreds of clothing, splinters of wood, sponges, bits of foreign matter of every conceivable character, at times are found in wounds, and their removal is to be carefully secured by the surgeon. For the protection of a wound it is requisite that it be guarded first from motion, since by motion the apposition of the Avound-surfaces is disturbed, the delicate neAv adhesive material which has already been formed is ruptured, and the conditions of the original injury are renewed in tissues already Aveakened by that injury. The wound must be protected also from mechanical violence, such as rude handling, friction, and gross mechanical injuries of every kind. It must be protected from chemical irritants, and especially from the products of decomposition of retained secretions or of portions of dead tissue; and, lastly. it must be protected from infection from poisonous agents, especially the more common infecting organisms everywhere abounding in nature. The local nutritive conditions to which attention must be paid have to do with the circulation and the innervation of the parts to be repaired. A depend- ent position of the injured part or an impediment to the free return circulation by improper bandaging may produce excessive and persistent congestion and interfere with its repair. Temperature is not unimportant: prolonged cold will impair nutrition, and too high a temperature may cause local death. Too great tension of Avound-flaps or tension from pent-up secretions impairs loeal nutrition by obstructing the flow of blood in the capillaries, as well as by the reflex effects of irritated nerve-fibrils, and also mechanically prevents rest and coaptation of deeper parts. The details of treatment to be applied in every wound have their rational basis in the principles thus outlined, which will serve for the safe guidance of the practitioner. CONTUSIONS AND WOUNDS. 95 Treatment of Wounds.—Arrest of Hemorrhage.—To stop bleeding is the first care of the surgeon in his treatment of a Avound. The physi- ology of spontaneous hemostasis and the methods of securing artificial arrest of hemorrhage are given at length under Injuries of the Blood-vessels. The aim of the surgeon should ahvays be to secure the arrest of bleeding by means that shall cause the least disturbance in the future repair of the wound. Unnecessary ligatures are therefore ahvays to be avoided. When ligatures are unavoidable, those made of absorbable material, as catgut, are to be preferred, and the size of the thread should be as small as is consistent with the strength required to occlude the vessel. When non-absorbable mate- rials are used for ligatures, as silk thread, if it has been perfectly disinfected and primary union of the wound can reasonably be expected, this too may be cut off and left buried in the Avound. The first and most generally applicable means for restraining hemorrhage is that of direct pressure made upon the bleed- ing point. This may be by the finger or by a tampon, or by an instrument, as a pressure-forceps. These means are often, in the nature of the case, but temporary expedients. In many instances, however, the temporary use of pressure w ill be all that will be required for the arrest of hemorrhage that at first Avas very abundant. When copious and continuous capillary oozing persists, it may frequently be controlled by pressure Avith compresses Avrung out in Avater as hot as can be born by the hand—115° to 120° F. The use of heat as a hemostatic is to be preferred to cold, as being more favorable to local nutrition and subse- quent active repair. The use of hemostatic forceps, which when once applied automatically compress the orifices of bleeding vessels, is a very efficient and convenient means of applying pressure. Many vessels, AAdiich at first bleed freely, after a few moments' compression in this manner will no longer bleed Avhen the forceps are removed. If the bleeding does persist, torsion may be applied, which, being effectual in many instances, will reduce the ultimate need for ligatures to a minimum. As a rule, hemostatic agents which produce tough clots of blood, as the salts of iron, or which are strong irritants, such as turpentine, or which destroy tissue outright, as the actual cautery, are to be carefully avoided. The free access of cold air is an active hemostatic and the least harmful. Often Avhen continuous oozing persists from a wound under a mass of soft blood-clot, if the wound is freely opened and the accumu- lated clot thoroughly removed further oozing becomes definitely arrested. A dilute solution of iodine has both hemostatic and antiseptic properties, and may sometimes be used with advantage. Iodoform added to a compress applied upon a bleeding surface has a distinct hemostatic effect. From among all these resources the surgeon will be called in a given case to make use of those Avhich shall be available, efficient, and least harmful, keeping in view always the ideal of wound treatment—subsequent union by primary intention. Complete immediate hemostasis is not to be sought for in the treatment of Avounds in Avhich easy apposition of the Avound-surfaces cannot be obtained, and in Avhich dead spaces or open defects remain Avhich it is possible for the surgeon to fill in by tissue organized in and supported by a moist blood-clot. When a surgeon is master of a sufficiently perfect antiseptic technique to secure healing under such a blood-clot, and the circumstances are favorable, he may make the attempt. He will then encourage, or even provoke, sufficient bleeding to fill up all the dead spaces and the wound-defects Avith blood previous to the appli- cation of a dressing, and will subsequently protect the clot from adhesion to or disturbance by the external dressing. (See page 29.) Cleansing of the Wound.—Great care should be taken to remove from a Avound not only all foreign matter Avhich may have been deposited Avithin it, 96 AN AMERICAN TEXT-BOOK OF SURGERY. but also all dead or dying tissue, and, as a rule, all blood-clots. The means required for effecting such cleansing must be adapted to the nature of the material to be removed. The forceps, scissors, curette, sponge, irrigating stream, each may find its use. By means of these simply the more gross and perceptible impurities may be removed. Of greater importance ofttimes is the cleansing of the wound of those microscopic organisms which may induce suppuration and putrefaction. (For the consideration of the means required for this latter degree of cleanliness or sterilization see Operative Surgery.) Suffice it here to say that in his treatment of wounds the surgeon should never lose sight of the natural resisting power of living tissue to such organisms, and that in his efforts at sterilization he should irritate and injure the living tissue as little as possible. Strong and irritating antiseptic lotions are there- fore, as a rule, to be avoided as direct applications to wound-surfaces. When, however, a wound is already manifestly contaminated, it will be good practice to irrigate it thoroughly for a considerable period of time with a germicidal lotion of sufficient strength to secure the destruction of whatever septic material may have gained access to it. A solution of carbolic acid, 1: 40, or of corrosive sublimate, 1: 1000, will be found most generally suit- able for such a purpose. When the full sterilization of a wound, even by the use of antiseptic irrigations, is impracticable, or it is so situated that it cannot be kept free from subsequent reneAved contamination, as in many wounds involving the outlets of mucous canals or Avhen the Avound opens into suppurat- ing cavities, resort must be had to tamponing the Avound-cavities with materials impregnated with a permanent antiseptic, as iodoform or boric or salicylic acid. In these latter cases, of course, union by granulation is what commonly occurs, but what is practically primary union may sometimes be attained by "secondary sutures." Coaptation.—In the coaptation of wounds the aim of the surgeon must be to bring the severed parts as far as possible into the same relations with each other as existed before the Avound was inflicted, and especially to secure the closest possible apposition of every portion of the wound-surfaces. When important nerves, muscles, and tendons have been divided, especial care must be taken to bring and secure together the divided ends; all dead spaces where secretions may gather are to be prevented; and by various means and devices the tissues are to be retained in their restored relation until definite reunion has been accomplished. Under the term "coaptation " all the various aims and methods referred to are included. In the section devoted to Minor Surgery the means of accomplishing coaptation are described in detail. Here, however, it will be proper to speak of the general principles which should guide the surgeon in the choice of means and methods. First, much tension must be avoided. When tissues are put unduly upon the stretch in an effort to bring them together, the circulation of the blood within them is impeded, nutrition is impaired, the formation of sloughs is invited, and suppurative disturbances are promoted. It is far better to be content with whatever amount of coaptation can be easily secured, and to seek for the healing of any surfaces left uncovered, either by granulation and ulti- mate cicatrization or by skin-grafts. In the second place, care must be taken Avhile securing coaptation to avoid such adjustment of sutures or other retentive apparatus as would be likely to produce strangulation of any portion of the tissue. Sutures too closely applied and too tightly drawn are a frequent cause of necrosis of Avound-edges; the pressure of compresses and bandages may likewise be so great as to produce local tissue-necrosis, so that good judg- ment should always be used in their application. Thirdly, the relaxation of CONTUSIONS AND WOUNDS. 97 tissues by position should not be overlooked by the surgeon. The spontaneous gaping or falling together of Avounds in varying attitudes of a Avounded part need but be noticed to suggest the advantage to be derived from placing a part in that position or attitude in which any tendency to gape during the healing process will be reduced to a minimum. The general rule is, therefore, in order to favor coaptation of a Avound, to put the part in that position in Avhich the greatest relaxation of the Avounded structures can be secured, and in this position they should be fixed and held until firm union has been accomplished. As an accessory to the use of position for securing relaxation is the device of sliding toAvard the Avound tissues someAvhat distant from it. By the use of sutures traversing a deeper portion of the Avound, and made to embrace portions of tissue on either side at a considerable distance from the wound-edges, and then secured after the manner in Avhich an upholsterer secures the tAvo sides of a mattress together, Avounds Avhich gape Avidely at first may often have their edges so approximated that they are easily brought together Avithout tension. The choice of materials for ensuring continued coaptation is worthy of con- sideration. When a Avound is small and there is no tendency to gape, or when that tendency has been overcome by attention to position, the use of a simple compress held in place by a roller bandage may be all that is required to ensure undisturbed healing. In general, hoAvever, additional means for secur- ing undisturbed coaptation will be required. For this purpose are used adhe- sive strips and sutures. Adhesive strips, as direct applications to wound-flaps to secure their appo- sition, should rarely be used, Being disinfected with difficulty, they are always to be looked upon as surgically unclean. They favor infection likewise by retaining wound-discharges underneath them and in their substance; they cover up a wound from the surgeon's inspection; they often irritate the skin to which they are applied; and, finally, from their tendency to become loos- ened, they are unreliable in the support Avhich they give. Strips of gauze fixed Avith collodion are more effective and are perfectly aseptic. For purposes of supplementary support, hoAvever, placed outside of the immediate wound- dressing to prevent tension, to produce compression, and to ensure fixation of the dressings, adhesive strips are invaluable. Sutures.—The most certain, exact, and generally available of the means for retaining divided surfaces in coaptation is the suture. As "stitches of coaptation," applied superficially and close to the Avound-margins, they keep the cutaneous edges of the wound together. As "stitches of approximation," having been passed more deeply and at a greater distance from the wound- margins, they approximate and hold together the deeper surfaces. As "stitches of relaxation," embracing tissues at some distance on either side of the Avound, they relax the adjacent tissues, so that the Avound-surfaces may be brought together and tension be avoided. The materials available for sutures Avill be discussed elsewhere. (See Operative Surgery.) Whatever form of thread is chosen should have been rendered aseptic by previous preparation, and should likeAvise be immersed anew in the antiseptic solution at the time it is used. Drainage.—As the surgeon proceeds with his efforts at securing coaptation of a AA'ound he must make provision for the escape of the secretions which are the immediate result and accompaniment of every wound. When perfect coaptation, deep as Avell as superficial, has been secured, and Avhen by the most scrupulous and exact observance of antiseptic precautions the surgeon is assured that his Avound when dressed is as free from infection as a subcutaneous one, means of drainage may be dispensed Avith, and the local absorbents may 7 98 AN AMERICAN TENT-BOOK OF SURGERY. be relied upon to remove whatever secretions are poured out in excess of the quantity needed for repair. As a rule, however, it will be important for the surgeon to provide means for the free and continuous escape of wound-secretions. It will often be sufficient to leave open the most dependent portion of the wound. In some cases enlargement of Avounds by free incisions or the making of coun- ter-openings may be practised for the purpose of securing free escape of secre- tions. In many instances it will be good practice to introduce the sutures at the operation, but not to tie them until after the cessation of the primary copious bloody and serous oozing Avhich occurs during the first twelve to tAventy-four hours after the occurrence of a Avound (secondary suture). Septic infection having been prevented by the use of antiseptic dressings, at the end of this period the wround-surfaces may be brought together, with an increased prob- ability of securing union by first intention without the necessity of any further means of drainage. Frequently, hoAvever, the surgeon Avill be compelled to resort to the introduction into a Avound of some foreign material for the purpose of conducting away its discharges. This substance may act by capillarity, serving to keep the wound-surfaces apart and permitting the outflow of liquid along the interstices among its strands, or it may provide tubes through which their free flow is secured. For the escape of pus a tubular drain is always required, and Avhenever provision is to be made for the escape of much secre- tion, if absolute certainty of drainage is desired such a tube must be used. Rubber tubing is the most universally applicable means of drainage, being flexible, unirritating, easy to manipulate, easily sterilized, nearly always attainable, and cheap. A drainage-tube, of whatever substance composed, is a foreign body, and as long as it remains in a Avound is liable to produce disturbance. It should therefore be removed as soon as the period of profuse secretion which made its original use necessary has passed away, or as soon as the cavity Avhich it Avas intended to drain has become obliterated. Dressings.—In the treatment of a wound after hemorrhage has been checked, its surface has been cleansed and purified, coaptation has been accomplished, and drainage has been provided for, a suitable dressing must be applied. Two main objects are to be accomplished by a dressing: first, the absorption of Avhatever secretions may come to the surface; and second, the protection from infection and from injury and motion. The materials Avhich may be available for surgical dressings are fully treated of in the section devoted to Operative Surgery. Here, hoAvever, some general considerations concerning dressings are in place. Septic infection is to be guarded against by cover- ing the part Avith soft and absorbent material that Avill receive and keep aseptic the discharges that drain aAvay from a wound, and that Avill prevent the access of septic infection from other sources to the wound. For this purpose many substances may be found useful: among those more com- monly employed are cotton wool, loosely-Avoven cotton cloth from which all oily matter has been removed, jute, saAvdust, moss, etc. While all these substances are more or less hygroscopic, their usefulness as absorbent dress- ings depends chiefly upon the multitude of minute spaces existing betAveen their meshes or fibers, and a certain degree.of openness of mesh or loose- ness of fiber is requisite to enable them continuously to absorb thick and viscid fluids. It is not enough that these materials when applied should themselves be simply sterile, for Avhen they are filled with Avound-secretiohs they may then be infected from Avithout and become the medium of conveying infection to the wound. It is better that portions of the dressings should themselves be impregnated with antiseptic materials, which could actively antagonize or inhibit the activity of any septic matter that might gain access CONTUSIONS AND WOUNDS. 99 to the secretions imbibed by them. The necessity of this is realized if the extreme difficulty, almost impossibility, of sterilizing absolutely the skin of the patient or the fingers of the surgeon is recalled. For this reason the best results in securing the healing of their Avounds Avill be obtained by those surgeons, all other things being equal, Avho make use of Avound-dressings containing proper proportions of corrosive sublimate, the double cyanide of zinc and mercury, boric or salicylic or carbolic acid, or similar antiseptic agents. By the use, further, of very voluminous dressings it is possible to give additional security against the conveyance of infection from Avithout to a Avound, and to protect it more certainly from mechanical violence and from motion. Changes of dressings are made at long intervals, and thus the ideal rest is secured to the injured part while repair is going on. As to Avhen such changes are required, various considerations must determine the action of the surgeon. The body-temperature of the patient, as indicated by the thermometer, should be especially relied upon as an index to the character of the processes going on in the Avound. If, after an elevation of one or tAvo degrees above the normal for the first forty-eight or seventy-tAvo hours after a Avound has been inflicted and dressed, the temperature sinks to nearly the normal point, and remains there with but slight fluctuation, the surgeon is assured that undisturbed repair is progressing, and that no demand for interference is present by reason of any- thing in the AA'ound itself. If, hoAvever, the temperature continues elevated after the first two or three days, or if, after having once fallen, it again rises, and especially if a series of morning remissions and evening exacerbations show themselves, the evidences are unmistakable that inflammatory and sup- purative disturbances, with retention of secretion and septic absorption, are going on, and that a change of dressing with thorough exploration of the wound is required. When also the external layers of the dressings become moist Avith the secretions that have been imbibed from Avithin, it is imperative that the dressings be reneAved. This does not apply, however, to the frequent staining of the external layers of a dressing by the copious sero-bloody primary wound- secretion, which, AA'hen very hygroscopic materials are used, often occurs within a short time after the application of a dressing. In these cases the dressings quickly become and remain dry, and do not require to be changed. When drainage-tubes have been employed it is desirable that they be removed, in most cases, Avithin a week or ten days, or often much earlier, for Avhich purpose the dressing must be reneAved. When for the purpose of controlling hemorrhage tampons have been left in situ, these should be removed as early as the third day, and thus they AArould form another indication for a change of dressing. If the Avound becomes the seat of suppuration or of sloughing, such fre- quency of dressings is required as may be needful to secure the adequate drainage and cleansing of the infected part. In general, changes of dressings should be made as rarely as possible, and only for the purpose of meeting dis- tinct indications. In changing dressings the same strict antisepsis should be observed as in the operation itself. Local Treatment.—While proper attention is being given to a Avound the needs of the Avounded part should not be overlooked. Nothing which could interfere in any Avay Avith its most perfect Avell-being should be con- sidered insignificant. The natural warmth of the part, perfect freedom of the circulation, the control of muscular spasm, and the most perfect quiet and comfort are all of importance to be secured. Position.—A position that Avill be comfortable to the patient should if pos- sible be selected. This Avill always be one in Avhich the muscles are relaxed 100 AN AMERICAN TENT-BOOK OF SURGERY. and the return circulation of the blood to the heart is favored. The relation of position to drainage should be kept in mind, and in the arranging of the means for drainage whenever possible the drains should be so placed as to be most efficient when the part shall have been placed in a position of the greatest comfort. Compression.—Gentle, uniform, and continuous pressure is of great value in promoting rapid repair after injury. It restrains excessive local hyperemia, limits effusion, and promotes absorption of effusions already present; it antag- onizes muscular spasm and contributes to rest of the part. A greater and more methodical application of pressure than is needful for maintaining simple apposition of the separated parts is required in order to obtain the full poAver of compression in favoring the repair of a Avound. Compression should be smooth and uniform, gentle but firm, carefully avoiding any constriction. In most cases it may be best effected by covering the Avounded part Avith layers of cotton avooI and applying compression Avith bandages. The avooI by its elas- ticity tends to distribute evenly the compression exercised by the bandage and to keep the pressure continuously uniform. Immobilization.—While the means of compression just described Avill in many instances be sufficient to give Avhatever extraneous aid is required to pre- vent motion in the Avounded part, in many others there will be needed some further assistance in securing the desired immobility. For this purpose splints of various kinds are available. Whenever any form of plastic splint can be used, it should be chosen; such splints accurately take the shape of the part, forming a firm mould that encases and fixes the limb without pressing unduly on any one point. As a result, such splints are borne Avith comfort, and thus indirectly contribute still more to the Avell-doing of the Avound. In an emer- gency, hoAvever, the ingenuity of the surgeon may be able to bend to his pur- pose, for giving support and fixation to a Avounded part, a multitude of differ- ent substances. Constitutional Treatment.—The existence of pain or general restless- ness requires the administration of opiates for their relief. The age of the patient, his previous constitutional condition, the coexistence of disease or tendencies to disease, and the hygienic conditions in which he is placed, each must engage the attention of the surgeon in order that Avhatever special indica- tions they present may be met, and every possible influence that might inter- fere Avith repair be guarded against. Even the mental state of the wounded should be regarded. The surgeon avIio is able to arouse hope, expectation, and faith in the minds of his patients Avill see their Avounds heal more rapidly and certainly than when opposite states of mind exist. As regards the influ- ence of age upon the healing of Avounds, although in some cases aged persons display unimpaired ability to repair their wounds, yet as a rule in the aged healing is much more sluggish and more likely to suffer from disturbance. In aged patients especial attention must be paid to their nutrition, to maintaining their bodily warmth, and to giving them the stimulating effects of abundant sunlight and pure air. In all cases whatever departures from a perfect standard of health a patient may present should engage the attention of the surgeon. Plethora, anemia, obesity; that peculiar vulnerability associated with the scrofulous diathesis; alcoholism; the exhaustion from overwork, underfeeding, or mental strain; the depression produced by vicious habits and the habitual inhalation of vitiated air,—these are some of the conditions for the relief of which the surgeon should see that proper constitutional treatment be given. Closely allied to the conditions just named are certain well-marked diseased CONTUSIONS AND WOUNDS. 101 states, such as syphilis, tuberculosis, malaria, diabetes mellitus, and scurvy, which by the nutritive defects which they determine delay repair, often arrest it, and subject wounds to the most serious complications. The pre-existence of pyemia, septicemia, erysipelas, phlebitis, or any diffuse inflammation AA'ill add special dangers to any traumatism. Diseases of the various organs of the body, and particularly cardiac, pulmonary, hepatic, and renal diseases, modify the effects of Avounds, both directly by the constitutional states which they create and Avhich are unfavorable to repair and diminish the resisting poAvers of the tissues in general, and indirectly by the reaction of the injury upon the pre-existing affection, producing in it temporary exacerbation or per- manent and excessive aggravation, with, not infrequently, speedy death. Each of the conditions named Avhen present will demand constitutional treatment in order to neutralize as far as possible any influence for evil Avhich it might exert upon the healing of the Avound. The general hygiene of the patient should be made as favorable as possible. Food insufficient in quantity or bad in quality, extremes of tem- perature, absence of sunlight, depressing climatic conditions, lack of exercise, insufficient and impure air.—these not only create previous constitutional con- ditions unfavorable to repair, but, Avhen continued after the reception of a Avound, directly diminish the activity of its reparative processes. The diet of the patient should be regulated so that his supply of food should be ample, palatable, and digestible, due regard being paid to personal taste and instincts. In connection Avith the subject of alimentation attention should be paid to the action of the boAArels and all the excretions and secretions of the body. An abundant supply of sunlight and of pure air is especially important for the Avell-doing of a person avIio is confined by a Avound to one place, and thus is dependent upon Avhat is brought to him from Avithout for the purification and reneAval of the air Avhich he must breathe. This is alike necessary for isolated cases in their oAvn homes and for those in the croAvded Avards of a hospital. After-Treatment.—The least possible interference Avith a AA-ound Avhile the healing process is going on is a cardinal principle in surgery. Too early and too frequent interference inevitably prevents the steady progress of the healing process. Infrequent dressing is eminently conducive to that absolute rest Avhich is to be kept in vieAv Avhatever method of treatment is adopted. When the first dressing of the wound has been conducted in accordance Avith the principles that have been described, the after-care from the surgeon will be limited to a Avatchful oversight of the means of protection and immobilization, of drainage, and of apposition that have been employed, so that they may be removed, substituted, or reinforced by others as soon as they are no longer called for or have become inefficient. The prevention of the access of septic organisms, and the removal as fast as formed of materials that may decompose or become the lodging-places of these organisms, constitute tAvo great indications, to fulfil both of Avhich the surgeon must continually strive to the best of his ability if he Avould acquit himself of reproach for the results of dis- turbance that may supervene in the progress of the Avound. Inflammatory, erysipelatous, gangrenous, or septicemic complications attacking wounds are not always to be regarded as unfortunate and unavoidable accidents, but must some- times be accepted as the results of errors or failures in the treatment Avhich the Avounds have received. When in the first dressing of a AA'ound it has been possible to close it after perfectly satisfying the indications for treatment that have been detailed, it should not be disturbed until a sufficient time has elapsed for the adhesion of the Avounded parts to become firm. From ten to fourteen days 102 AN A MERICAN TENT-BOOK OF SI RGER 1'. . may often be permitted to pass before the dressings are removed. The indica- tions which might call for earlier interference, such as the removal of drainage- tubes, have been detailed in a preceding iiaragraph; but whenever the external protective dressings remain dry, the Avound is free from pain and fetor, and there is no acceleration of the pulse or elevation of the temperature, the dressings may be left undisturbed. Sutures may be allowed to remain as long as their support seems to be desirable, provided they are not causing irritation or sup- puration. In the latter case they should be removed at once. It is impossible to fix arbitrarily the periods for the reneAval of the dressings: each case must be a laAv unto itself. In the changing of the dressings and in all the manipu- lations required about the wound the utmost gentleness should be used. INTERCURRENT COMPLICATIONS. The regular course of the healing of a v\round may become disturbed by inflammation, entailing suppuration and possibly gangrene, and if healing is ultimately secured it is accomplished only by a prolonged process of granula- tion. By the absorption into the general circulation of materials formed in wounds thus complicated the general phenomena of septicemia and of pyemia may be produced. Inflammation.—With but feAv exceptions an inflamed wound is a septic wound, and the cause of the inflammation is the irritation of the products of decomposition of retained secretions. It is accordingly those wounds in Avhich the retention of secretions is most difficult to prevent, as of Avounds of joints and other cavities, Avounds leading down to fractured bone, and deep irregular punctured wounds, in Avhich severe inflammation is frequently met with. To give free vent, therefore, to all Avound-secretions that may have been retained is the first thing to be attended to in the treatment of such a Avound. This may require nothing more than the cutting of a stitch, so that the natural gaping of the Avound may suffice for the required vent, or it may require counter-incis- ions and the use of drains. Whenever an inflammation shows a tendency to spread into the adjacent parts, abundant, thorough, and systematic incisions into the affected area must be made, sufficient to provide for the free escape of all irritating secretions. Wherever there is a possibility of a foreign substance having been left in the wound, such as a splinter of wood, a piece of glass, a rusty nail, a bit of clothing, a detached piece of bone, etc., it should be care- fully sought for and removed. If the inflammation has been caused or aggra- vated by mechanical irritation, by motion, or by the premature use of the wounded part, the recognition of such a fact Avill at once lead to its correction. When the causes of the inflammation have been removed, the parts should be placed in an elevated and comfortable position and subjected to such additional means for relieving the pain, heat, and SAvelling of the part, and overcoming the vascular congestion on Avhich these depend, as the judgment of the surgeon may determine. In brief, hoAvever, it may be said that for the relief of inflamed wounds the surgeon will find of especial value the use of irrigation with cooling antiseptic solutions. Gangrene.—The appearance of gangrene in a Avound calls for the imme- diate adoption of even more energetic and thorough antiseptic methods of treatment than have been prescribed in the preceding paragraphs. All loose gangrenous tissue should be removed at once with knife and scissors, and the living tissues exposed should be freely and thoroughly cauterized by an 8 per cent, chloride-of-zinc solution, which "should be injected into every cavity and recess of the Avound. Free incisions and counter-incisions should be made into CONTUSIONS AND WOUNDS. 103 the SAvollen and infiltrated tissues leading from the gangrenous focus, so as to permit the escape of secretions and de'bris and to enable the disinfecting liquid to reach every infected part. The wound should be left uncovered, and contin- uous irrigation with an antiseptic solution established. For such irrigating liquid a 1 per cent, solution of carbolic acid or of acetate of aluminium or a 1 : 15,000 sublimate solution may be used. The antiseptic irrigation should be continued until the permanent arrest of the gangrenous process is manifest, all necrotic tissues have come aAvay, and a healthy granulating surface has been formed. Erysipelas.—The appearance of erysipelas is ahvays due to some defect or neglect in the antiseptic precautions. It is ahvays of specific septic origin, and it most especially calls for that method of treatment adapted to septic wounds. (For a full consideration of this subject see the chapter on Ery- sipelas.) Suppuration.—The occurrence of suppuration in a Avound makes it neces- sary that full provision should at once be made for the easy and perfect escape of the pus. This has already been considered in Avhat has been said in regard to drainage. Some further thought, hoAvever, should be given to the manage- ment of a suppurating wound, Avith a view to the restriction of the process of suppuration and the hastening of the healing of the AA'ound as much as possible. When the Avound is shalloAv and widely open, and not too extensive, iodoform gauze may be applied upon its whole surface as a dressing, and Avill diminish greatly the amount of pus secreted and stimulate the granulating process. The final healing may then be accelerated by the application of a secondary suture when possible or the employment of skin-grafts. When the suppurating cavity is deep or tortuous, or its external opening is comparatively small, antiseptic irrigations are of value. Care should be taken in the use of all such irriga- tions not to inject the fluid with so much force as to break up adhesions already formed. Care must also be taken that the possibly poisonous antiseptic be not retained in the wound. This is best accomplished by finally flushing the wound with Avarm boiled water to Avash aAvay the antiseptic solution. Injecting a fresh solution of peroxide of hydrogen into a suppurating Avound answers the same purpose, and is an efficient means of decomposing any retained pus and of sterilizing the Avound-cavity. Solutions of bichloride of mercury, 1 : 2000, of carbolic acid, 2 per cent., or of boro-salicylic acid in saturated solution, are also efficient. When, notAvithstanding the use of these means, the granulating process remains sluggish and the Avound-cavities delay in contracting and healing, more strongly stimulating applications are indicated. Naphthalin in poAvder freely sprinkled over the sluggish surface, or the balsams of Peru or of copaiba freely instilled, or tampons of gauze saturated Avith these agents, may be used. If these are not efficient, superficial cauterizing agents, such as carbolic acid of full strength, fused nitrate of silver, or an 8 per cent, solution of chloride of zinc may be used. In all these cases constant attention should be paid to keeping the deeper parts of the Avound-cavities in apposition by properly-applied pressure, and to securing absolute rest for the injured parts. Especial care must be taken that the external dressings that are applied are such as Avill freely absorb the pus Avhich is brought to the surface. Nothing will more aggravate the condition of a suppurating Avound than a dressing that dams back and causes retention of its secretions. Viscid pus is not absorbed to any great degree by the ordinary cotton dressings, and if they are used they must be frequently removed and the Avound cleansed. In ordinary pine saAv- dust of moderate coarseness the surgeon will ahvays find an easily obtainable substance which absorbs pus freely. It can be made aseptic by baking, and 104 AN AMERICAN TENT-BOOK OF SURGERY. then antiseptic by Avetting with a sublimate solution. This sawdust made into convenient-sized pads by enclosing in any thin gauzy stuff, like cheese-cloth, may be used as a dressing, with a certainty that retention will not be caused by it, so that infrequent dressing may be the rule even in such Avounds. When by any of the means described a vigorous granulating surface has been obtained and the case is not suitable for secondary suture or skin-grafting, the further treatment of the granulating surface must be one of protection Avhile the gradual process of cicatrization by extension of the cuticle from the edges is going on. Bland or mildly stimulating ointments spread on soft antiseptic dressings of some kind are commonly used for this purpose. Suit- able material for such ointments are the simple cerate of the Pharmacopeia, oxide-of-zinc ointment Avith Avhich a little carbolic acid has been incorporated (f^ss to Ij), boric-acid ointment 15 per cent., iodoform Avith a petroleum basis, such as carbolated cosmoline (3j to 3j), make invaluable applications to such surfaces, and should be employed by preference Avhen the wound is near a mucous outlet or other possible source of infection. An efficient protection, and one even more cleanly and in harmony with ideal asepsis, is to be found in strips of rubber gauze or in the fine oiled-silk material known as "protective." These should be sterilized by immersion in a carbolic or bichloride lotion of suitable strength for some time before they are used, and Avhen applied upon a granulating surface Avhich has previously been sterilized, and then covered by a suitable antiseptic absorbent dressing, the Avhole forms an ideal dressing for a granulating surface. Whenever the granulating surface is of any size, resort should be had to skin-grafting for the purpose of hastening its cicatrization whenever practicable. This is a most valuable means for shortening the period of cure in cases of open Avounds, and deserves to be frequently used by surgeons. (For the technique of skin-grafting see the chapter on Plastic Surgery.) INCISED AVOUNDS. By incised wounds are meant those clean-cut divisions of tissue which are produced by the edges of a sharp instrument. They may vary in size from the most trivial to formidable and deep incisions of many inches in length—from a superficial scratch to Avounds opening deep cavities or almost severing entire members from the body. Their surfaces present in a minimum degree an imperceptible layer of devitalized tissue destroyed by the impact of the cutting instrument, tissue, Avhich is quickly removed in the early stages of normal repair and produces no disturbance in the healing of the wound. For this reason they present conditions most favorable for speedy healing, and deserve from the surgeon careful attention to all the details of cleansing, apposition, and rest Avhich have been described in previous pages, so that primary union may be obtained. Symptoms.—Pain resulting from an incised wound is severe and sharp at the moment of its infliction, subsiding into a smarting or burning Avhich persists for some time; hemorrhage is free, and the gaping of the tissues is restrained only by the limits of the contractility of the tissues divided. Treatment.—In the arrest of hemorrhage, Avhich in general will be accomplished with but little difficulty, care must be taken to avoid any means or agents which could later prove a source of disturbance in the heal- ing process. The use of all styptic agents should be especially avoided. Bleeding from all but vessels of considerable size will be arrested by temporary pressure, by exposure to the air, or by the application of hot water aided by compression. The mutual pressure of the wound-surfaces against each other CONTUSIONS AND WOUNDS. 105 after they have been brought into apposition serves to restrain any tendency to further hemorrhage. When large blood-vessels are Avounded ligatures are required; wounds involving such vessels are most dangerous, and may quickly terminate fatally from loss of blood, so that the most energetic and instant resort to measures for the arrest of hemorrhage is called for in such cases. When a vessel is but partially divided, it is more difficult to stay the bleeding from it than if it is cut through entirely. In such cases the first thing to be done is to complete the division of the vessel, ligating it later if necessary. The drainage of incised Avounds, Avhen with proper care their deeper parts can be maintained in apposition, is very simple. In the more extensive Avounds capillary drains or small tubular drains during the first tAventy-four or thirty-six hours Avill suffice. In a large proportion of cases Avhere compression and immobilization of the part can be effected no provision for drainage is required. The apposition of the Avounded surfaces should be attended to Avith the utmost care and minuteness, so that, by the use of sutures, compresses, bandages, and position, coaptation of every part should be perfect and no spaces be left for the collection of secretions. The protective dressings required by incised wounds the coaptation of the surfaces of Avhich is possible are very simple. Exposure of the line of suture to the air, so that the desiccation of the slight amount of secretion that gathers there may form a protective crust, gives excellent results when the conditions of the wound are such as to make it practicable. A light, dry, clean absorbent dressing of some kind is all that is required at any time. The provisions for rest in the case of incised Avounds may and should be made absolute by splints. The removal and readjustment of dressing should be long deferred. The ideal to be aimed at is perfect healing without local discomfort or constitutional disturbance under a single dressing. LACERATED AND CONTUSED AVOUNDS. A lacerated Avound is one in which the tissues have been forcibly torn asunder ; a contused wound, one in Avhich the AA'ounding force has been of a crushing character. In many instances both the lacerating and crushing elements are mingled. In any case the character and course of both classes of wounds are similar, so that they may properly be considered together. The surface of such wounds is irregular, shreddy, possibly presenting long dangling strips of fibrous and tendinous tissue, Avith more or less blood-clot filling the exposed cavities, and Avith a variable amount of dead or partially disorganized tissue scattered upon its surface. The skin-wound is irregularly torn, less in extent than the Avounds of the deeper structures, from which it is more or less separated, Avhile its borders present an area of variable dimensions that is livid and cold, ready to fall into necrosis. The great increase in the use of machin- ery in modern times, and of rapidly-moving and heavy vehicles operated by steam, electric, and horse-poAver, has vastly multiplied the frequency of lace- rated and contused Avounds. Such AArounds produce greater shock than do incised Avounds, but are accom- panied by less appreciable pain. The pain is dull and aching in character; the hemorrhage is generally slight. OAving to the surface irregularity that favors the coagulation of the blood floAving over it, and to the fact that the larger blood-vessels have had their coats so irregularly torn that an occlusive clot is at once formed in the torn ends. The tissue-interspaces for some distance. from the Avound-opening become infiltrated Avith diffused and clotted bloocLv and in many instances foreign material, dirt of every conceivable character, is ground into the wound-surfaces, so as to defy every effort to remove it 106 AN AMERICAN TENT-BOOK OF SURGERY. entirely. In cases of severe injury of this kind the partial syncope resulting from shock so diminishes the force of the circulation as also materially to lessen the tendency to hemorrhage. Although for these reasons primary hemorrhage is generally slight, serious later hemorrhage is not infrequent, either Avithin a feAv hours, when the heart's action has regained its power and local reaction has set in ("intermediate" or "reactionary" or "consecutive" hemorrhage), or at a more distant period, Avhen by the separation of sloughs the vessels are again opened (" secondary " hemorrhage). The external appearance of these wounds often gives no suggestion of the extent of the damage Avhich has been done. They should therefore ahvays be examined with great care, and the possibilities of far-extending subcutaneous injury should be kept in mind. More or less death of tissue is inevitable in the after-course of such Avounds. Some tissue, often much, is killed outright by the violence, Avhile yet more is left in a seriously damaged state, prone to fall into necrosis from the defective nutrition that for a time exists in the part. Much of the abundant and irreg- ularly diffused blood-clot Avhich is present will subsequently disintegrate and liquefy. When, with greater or less rapidity according to the activity of the nutritive processes in the part, all necrotic tissue has separated and been removed, and the blood-clot has either been absorbed or has broken down and escaped, there remains behind a uniform granulating surface, and the further course of the wound is toward healing by granulation. All the conditions presented by these wounds are such as to render them specially liable to septic infection of serious character. Treatment.—Although there may be but little hemorrhage at the time of the first dressing of a lacerated or contused Avound, yet if vessels of any size have been torn it is the part of wisdom to apply ligatures to them, though they may not be bleeding at the time. The period of reaction from shock is to be watched Avith especial care to guard against possible hemorrhage. Should this hemorrhage at any time occur, the application of a ligature is imper- ative, even though the bleeding may have ceased spontaneously as the heart's action is weakened; for so soon as the reaction again conies on and the heart beats strongly once more, the hemorrhage Avill surely recur. The primary cleansing of the Avound should be conducted Avith great care by rubbing SAveet oil thoroughly over the surface, including the adjacent skin, then cleansing by soap and Avarm Avater Avell scrubbed on, folloAving this by Avashing with alcohol, and finally by thorough scrubbing with sublimate solution, 1:1000. All detached particles of bone and of the soft parts should be carefully removed, and tissues into Avhich foreign matter has been so ground that the complete removal of the dirt is impossible should be trimmed aAvay Avith scissors or knife. Bruised portions of tissue that are still attached should be carefully cleansed and replaced and preserved from further traumat- ism, since much that appears to be hopelessly destroyed may be saved in many cases by care in fostering its nutrition. Thorough scrubbing and irrigation of a contused and lacerated Avound with a Avarm antiseptic lotion until no element of sepsis is left within it is important, for all the conditions of these wounds are such as to create and present to a large degree the material favorable for the rank development of septic organisms. The natural resisting poAver of the tissues, which enables the surfaces exposed in ordinary incised wounds to resist the development of sepsis and to preserve the minute devital- ized fragments of tissue that are present from undergoing putrefaction, is no longer to be relied on, for the bruised Avound-surfaces have to struggle to retain their oavh vitality, and large masses of devitalized tissue and more copious effusions of putrefiable secretions have to be disposed of. CONTUSIONS AND WOUNDS. 107 The fullest provision must be made for drainage from all the recesses of the wound. Free counter-incisions must be made Avherever necessary for this pur- pose. Efforts at accomplishing apposition of the Avound-surfaces must be sub- ordinated to the need for drainage and the provision for the unhindered separa- tion of necrotic tissue. In cases of severe contusion a degree of uncertainty will ahvays exist as to the ability of the injured tissue to retain its vitality, and a certain amount of necrosis is to be expected and provided for. This necrosis Avill be reduced to a minimum in proportion as the provisions for making and keep- ing the Avound aseptic are thorough and successful. When adequate antiseptic measures are practicable, greater efforts at securing coaptation of the wound- surfaces are proper. Special care should be observed to avoid all tension of the Avounded tissues in the endeavor to approximate them. In a large propor- tion of contused and lacerated Avounds there will be such an amount of destruc- tion of tissue that any attempt at closing them to secure primary union Avill be manifestly contraindicated. In such cases the efforts of the surgeon should be chiefly directed toAvard protecting the Avound from sources of disturbance dur- ing the time that the separation of the sloughs and the process of granulation are going on. These are the cases in Avhich local septic inflammations, gan- grene, erysipelas, and general septic infection are most prone to occur. The manner in which such disturbances are to be met has been fully discussed in preceding pages. While the constitutional symptoms produced by them will often require special treatment, they Avill spontaneously subside if adequate local antiseptic measures are employed. The latter, therefore, should ahvays engage the first and most constant attention of the surgeon. Brush Burn.—By this term is meant a peculiar form of superficial lace- rated and contused Avound caused by friction applied to the surface of the body, as Avhen a portion of skin is brought into contact Avith a rapidly-moving belt of machinery, or by an involuntary slide doAvn a steep incline, or by the slip- ping of a rope through the closed hand. In this injury the superficial tissues are ground off and an eschar of considerable depth results. They should be treated by antiseptic fomentations until the eschar has separated and a granu- lating surface has formed, Avhich should then receive the treatment elsewhere described. PUNCTURED AVOUNDS. Deeply perforating wounds made by pointed substances will partake of the nature of either incised or contused and lacerated Avounds, according to the sharpness of the point of the Avounding instrument. Punctured Avounds made with sharp, clean-pointed instruments, as pins, needles, trocars, dagger and stiletto points, partake of the nature of limited incised Avounds, and unless in their course they have Avounded organs of importance, as large blood-ves- sels or nerves, the AvithdraAval of the instrument is folloAved by rapid and per- fect recovery. Should the puncturing instrument, however, be contaminated Avith active septic material, an acute septic inflammation will result, depending upon its depth from the surface for its importance, and demanding free incisions for the relief of the pent-up secretions. For its further care those measures which have been described as required for inflamed and infected incised wounds will be indicated. Punctured Avounds Avhich are formed by the thrusting into the tissues of irregularly-shaped and blunt substances, such as splinters of Avood, nails, a bayonet, and the like, form deep and narroAv AA-ound-tracks, the Avails of which are contused and lacerated, Avhile minute fragments of devitalized tissues or small fragments of infected material are driven in and deposited 108 AN AMERICAN TENT-BOOK OF SURGERY. in the depths of the wound. The dangers and difficulties attending ordinary contused and lacerated wounds are aggravated in these cases by the long and narrow track which leads from their bottom to the surface. Should no septic material have been introduced by the wounding body, such wounds may yet be expected to heal kindly and promptly if care is taken to avoid their subsequent infection from without and to keep the Avounded part at rest while repair is taking place. In view of the impossibility of adequately disin- fecting such a Avound by mere applications to the surface at the time of the dress- ing, as a general rule it should be freely laid open to the bottom by additional incisions, and there should be thorough disinfection of the wound and the adjacent integument. It should then be covered Avith an abundant antiseptic dressing, which should be supplemented by any posture or by the application of Avhatever apparatus that may be required to keep the part at rest. If, notAvithstanding this, inflammation of the deeper part of the wound develops, immediate resort should be had to additional free incisions to give vent to pent-up effusions and for subsequent disinfection and drainage. The more deep and narroAv the wound- track, the more important that free and early incisions should be made. Still more important, if possible, are such early incisions Avhen the puncture has involved strong fasciae, the thecae of tendons, or joint-cavities. Delay in resort- ing to such incisions is not only sure to produce extensive local damage, but may even prove dangerous to life. Not infrequently portions of puncturing bodies are broken off and left imbedded in the tissues. In some cases such imbedded substances may remain innocuous for an indefinite period of time. In yet other instances their presence provokes irritative symptoms of a marked character. Foreign bodies in the neighborhood of joints, or piercing nerves, tendons, or blood- vessels, are sure to be followed by excessive pain, muscular spasm, or hemor- rhage. Diligent effort should be made to detect and remove foreign bodies at the bottom of punctured wounds whenever there is reason to suppose from the nature of the body or the nature of the tissues wounded that they Avill become a source of peril or discomfort if allowed to remain, or in any case when the conditions are favorable to making such a search Avithout an unduly extended or dangerous dissection. The instrument inflict- ing the Avound should always be inspected to determine Avhether any of it has been broken off and left in the tissues. For the removal of such bodies the enlargement of the original wound may suffice, or possibly counter-openings at distant points may be required, so as to give more ready access to the body sought for. Such counter-openings may be of additional value in pro- viding means for thorough drainage. In attempting the removal of minute bodies, such as the fragment of a needle or a small bit of glass, the search may often be facilitated by raising a triangular flap in the centre of the base of which is the original point of puncture, the apex of the flap lying in the direc- tion toward which the body has penetrated. This flap should include the skin and superficial fascia, and Avhen raised gives more easy access to the deeper tissues, and permits a more free and thorough search for any small body which may be imbedded among them. To make such an operation bloodless, Es- march's bandage is often of the greatest use. The removal of a puncturing body when it projects from the surface, or lies so near the surface that it can be readily seized, is usually easy, but in some cases, by reason of the irreg- ularity of its surface or its being barbed, as a fish-hook or arrow-head, its removal is difficult. Whenever the location of such an entano-led body permits it to be easily pushed through to the other side, such a course should be adopted. When this manoeuvre is not feasible, whatever incisions may be CONTUSIONS AND WOUNDS. 109 required to free the body from entanglement and allow it to be easily plucked out should be made. The hemorrhage in punctured Avounds is usually slight and requires no special attention. Should it be at all free, the possibility of the Avounding of a large vessel should suggest itself, and a careful revieAv of the anatomical relations of the puncture should be made. Should the hemorrhage not be easily controlled by pressure, the Avound should be enlarged, the bleeding point identified, and a ligature applied. A false aneurysm is the not infrequent result of partial divisions of arteries in punctured wounds. Punctured Avounds impaling a vein and an artery lying in -contact Avith each other are occasionally the cause of arterio-venous aneurysms. Such sequelae call in many cases for free incisions and for exposure of the wounded vessels and ligature above and below the point of Avound. GUNSHOT AVOUNDS. The term " gunshot Avound " is applied generically to injuries inflicted by missiles, Avhatever their character, wmose force is derived from the explosive power of gunpowder. This definition, therefore, includes every grade of mis- sile, from the smallest bird shot to the immense projectile fired from mammoth pieces of heavy ordnance, and every grade of injury, from the mere peppering of the surface of the skin Avith grains of gunpoAvder or minute-shot to the laceration and comminution of extensive portions of the body. The character of the injury produced A\Then the missile has penetrated the tissues, which is usually the case, is that of a contused, lacerated, punctured wound; Avhen the surface is merely grazed, it partakes of the nature of the brush burn, as already described. In occasional instances a large missile mov- ing with slight momentum fails to break the skin, but produces extensive damage to the subcutaneous tissue. The missiles Avhich are more frequently met with in gunshot wounds are («) the shot used in fowling-pieces, which are of various sizes, from that of a buck shot, Avhich Aveighs 133 grains, to that of the smallest bird shot, one of Avhich weighs only l of a grain; (b) pistol bul- lets, varying in size from about ^ of an inch to |- of an inch in diameter, and weighing from 20 grains to 240 grains. The size of a pistol bullet is usually designated according to the decimal part of an inch Avhich makes its diameter ; thus a 22-caliber bullet is one whose diameter is 22 hundredths of an inch. (c) The rifle bullet, which is the missile of the modern arm of precision, long and generally conoidal, and weighing from f to 1J ounces. For military use yet larger missiles have been devised which hardly arrive at the dignity of can- non shot, and yet are heavier than the rifle balls of the infantryman, such as the projectiles ^hroAvn by the mitrailleuse, Gatling, and Hotchkiss guns. The repair of gunshot Avounds is often disturbed by foreign matter carried into the wound by the projectile, such as portions of clothing, gun-Avadding, buttons, pieces of coin, splinters of wood, etc. The mere explosion of powder from a gun fired at short range may produce a serious injury which combines the characters of a burn with those of contusion and laceration. Gunshot wounds derive especial significance from—1. The special tissue or organ injured; 2. The conditions under which the AA-ound Avas inflicted; 3. The presence or absence of septic infection. Injuries to Special Tissues.—The Skin.—The effects of grazing the skin and of contusion Avithout penetration have already been referred to. V> hen a penetrating Avound has been inflicted, the Avound of entrance is gener- ally small and less in diameter than that of the missile itself, owing to the 110 AN AMERICAN TENT-BOOK OF SURGERY. elasticity of the skin, which has been stretched by the ball before being pene- trated by it. It is also apt to be dirty, both from the powder if the wound Avas at short range, and from Aviping the dirt from the ball as it enters. Such a Avound will appear insignificant to one unfamiliar Avith its real gravity. Should other foreign matter be carried in Avith the ball, the Avound of entrance will be correspondingly increased in size. Should the ball pass clear through the body or limb, the wound of exit will be larger and more ragged than that of entrance, the difference being determined by the lessened momentum of the ball and the want of support to the tissues at the point of exit, as a nail driven through a board splinters largely the under side or point of exit. Conical bullets, having greater penetrating poAver than round, produce in the skin-Avounds Avhich they make much less difference in size than formerly resulted from the use of round bullets. By subsequent sloughing of the con- tused margins of the Avound of entrance it often becomes after a few days of greater magnitude than that of exit. Fasciae.—Especial interest attending Avounds of fasciae arises from the fact that their interlacing fibers are often to a considerable degree split and croAvded aside by the ball as it passes through them, so that the orifice that they present is much less free than is found in the softer tissues on either side, and tends to interfere materially with the drainage of the deeper parts of the wound. Dense fasciae again frequently present sufficient resistance to a ball, especially if it is a round one, to deflect it from its original course. Muscles Avhen involved are subjected to widespread damage through con- tusion and laceration of their substance and extensive infiltrations of blood. Tendons, by reason of the resisting nature of their structure and their roundness and mobility, are more frequently either pushed out of the way or deflect the bullet. Blood-vessels, especially arteries, Avhose Avails are more resistent and elastic than those of veins, are not infrequently pushed aside. Even in such cases, however, such contusion of their structure is often inflicted as to determine subsequent sloughing and secondary hemorrhage. Both partial and complete division of large blood-vessels is a frequent concomitant of gunshot wounds, and is also the most frequent cause of immediate death by reason of the hemor- rhage following. Traumatic aneurysm and arterio-venous aneurysm may result in certain cases, as has already been noted in ordinary punctured wounds. Nerves.—Large nerve-trunks when Avounded present no special symptoms that call for extended notice here. The functional disability resulting from such Avounds will depend upon the special function of the particular nerve, and may be more or less complex and important. Severe pain may result primarily from inflammatory processes in the injured nerve, or later from its being involved in a contracting cicatrix or by development upon its end of a neuroma. Trophic changes of every degree are among the ultimate results of nerve-injuries. (See Injuries of Nerves.) Bones.—A ball striking upon a bone usually inflicts much damage upon it, splitting and comminuting it, often producing fissures that extend into neighboring joints. The bullet may become lodged in the bone, remaining as a source of irritation, and often of suppurative inflammation, until removed. The Great Cavities of the Body.—Balls penetrating the cranial cavity will produce symptoms according to the region of the brain injured ; though ahvays serious, the Avounds they inflict are not necessarily fatal. Penetrating Avounds of the thorax may involve the lungs, the heart, or the great vessels, and, if not immediately fatal, present special difficulties in the inflammatory complica- tions or in the resulting extensive pleural or pericardial effusions." Penetrat- CONTUSIONS AND WOUNDS. Ill ing Avounds of the abdominal cavity, in addition to the dangers from hemor- rhage and from ordinary inflammatory complications, have the special dangers incident to possible Avounds of the stomach, intestines, bladder, and the various other abdominal viscera. (See Wounds of the Abdomen and its Viscera.) The Conditions under avhich the Wound is Inflicted.—Gunshot wounds differ especially from the ordinary operative wounds inflicted by a sur-. geon in the special conditions incident to Avarfare which make it difficult, often impossible, to give to the patients the full degree of care Avhich they require, and Avhich often expose them to further injury that greatly aggravates the original severity of the wounds. In dealing Avith these conditions is found the special field of military surgery. In civil life, hoAvever, it often happens that gunshot wounds are sustained under conditions that resemble those of military campaigning, as in the case of accidental wounds occurring among hunting-parties in regions remote from help. The frequent absence of skilled help and of the materials for the proper dressings for such wounds adds greatly to the dangers which attend them. The necessary transportation of wounded men for long distances, often with the most crude resources for their comfort, is another fruitful source of evil, and has many times demanded the sacrifice of a limb or has occasioned the loss of a life Avhich under more favorable circumstances could have been saved. In the accidental gunshot wounds of civil life also it is by no means the rule that adequate surgical skill and proper dressing materials are at once attainable. The Presence or Absence of Septic Infection.—This is a factor of the highest importance in determining the favorable or unfavorable course of a gunshot wound. If such a Avound is preserved from septic infection, the Avound of entrance is quickly closed and its remaining track, however long it may be, or hoAvever much lined by contused necrotic tissue, or Avhatever organ it may have traversed or bones it may have shivered, is reduced to the condition of a subcutaneous injury, and is thereby saved from a thousand dangers that might otherwise complicate its healing. Fortunately, experience has shown that in many instances a penetrating bullet does not carry with it septic material, and that if a wound Avhich has been thus made is preserved from subsequent infec- tion, an aseptic course of healing will take place. The question of the removal of the bullet itself in such cases becomes a secondary matter, depending entirely upon the importance of the later symptoms of disturbance Avhich its presence in the tissues might occasion. On the other hand, the introduction of sepsis into a gunshot Avound is sure to determine inflammatory and suppurative symptoms of the most pronounced type, and to call for the most energetic and thor- ough interference on the part of the surgeon. Secondary hemorrhages are to be feared; necrotic debris and the pent-up products of septic inflamma- tion will require to be evacuated; increased dangers to life and limb yvill be incurred; and in the most favorable event a prolonged convalescence Avill result. Diagnosis.—The circumstances attending the infliction of a gunshot wound Avill usually be sufficiently clear to settle the fact that a given wound is due to the penetration of the tissues by a projectile driven by the explosive force of gunpoAvder; but the surgeon in investigating the case may find it important to determine the course Avhich the missile has taken, the organs injured, and the final resting-place of the missile, provided it has not already escaped by an aperture of exit. The external marks of injury may give no clue whatever to the character and extent of the deeper injuries A\rhich have been received. In forming any conclusion as to the extent and 112 AN AMERICAN TENT-BOOK OF SURGERY. nature of the wound which has been received, a careful investigation, there- fore, must be made into all the symptoms attending the injury, such as shock, hemorrhage, functional disturbance, local pain, and tenderness, as well as an inspection of the external signs of wounding. All such investigations should be made with the most scrupulous care to avoid touching the wound itself unless under the most rigid antiseptic precautions. When it is possible to ascertain the direction from which the missile came and the position of the body or limb at the time the wound Avas received, valuable information as to the course which the missile has taken through the tissues may sometimes be gained by putting the parts again into the same position. The possible deflection of the bullet by bone or fasciae is not to be forgotten, and must be given due Aveight in explaining otherwise confusing symptoms. The slight differences which have already been remarked upon as existing betAveen the orifices of entrance and exit should be borne in mind in determining the point of primary penetration when tAvo apertures exist. The amount of pain attending the reception of a gunshot wound varies much, and is of little value as a diagnostic symptom. In the excitement of the moment many wounds are received with no consciousness of the fact on the part of the injured person, who discovers it later only through the hemorrhage or the functional disability which results. In other cases a sharp stinging pain or a dull, numb sensation indicates to the person that he has been wounded. Sometimes the shock of even slight wounds is very great. Probing a Wound.—When the circumstances of the case or the symptoms which are present make it important that the deeper recesses of the AAOund should be searched, this is to be accomplished by the insertion of the finger of the surgeon if possible, or by the use of suitable probes, and all the steps of the process of search should be conducted Avith most careful regard to the requirements of rigid antisepsis. Such probings are not to be done as a mat- ter of routine, but only when some distinct indication is present. Free enlarge- ment of the external wound should be made without hesitation whenever it will facilitate the prosecution of the search, and as far as possible reliance should be placed upon the finger of the surgeon for gaining the desired information to the exclusion of metallic or other probes. When it is necessary to pursue the investigation into depths Avhich are beyond the reach of the finger, a metallic probe of suitable length and having a bulbous tip of considerable size may be used. Such a probe having the tip made of porcelain biscuit, and known as Nelaton's probe, has the special value that when the tip comes in contact with the bullet at the bottom of the wound it retains the mark of the lead upon it, and thus gives an absolute demonstration that it has been in contact Avith the bullet or a fragment of it. Before using it its freedom from any similar prior stain must be ascertained. The stem of an ordinary clay pipe has been used extemporaneously for the same purpose. The "telephonic probe" of Girdner is an ingenious application of the telephone which may occasionally assist in identifying the location of a bullet in the tissues. This device may be extemporized Avhenever an ordinary telephone receiver is accessible: one of the wires of the telephone having been attached to the probe, the other is made fast to a metallic plate, which is placed upon any portion of the surface of the body previously moistened. The probe is noAv inserted into the Avound for the purpose of the search, while the telephone receiver is held to the ear of an assistant; whenever the probe comes in contact Avith the bullet a distinct click is heard in the telephone—a click Avhich is not elicited except by contact with metal. Other methods for utilizing the electric current for detecting and locating a bullet imbedded in the tissues have been devised ; some of these CONTUSIONS AND WOUNDS. 113 are ingenious and successful as experiments, but none are susceptible of being utilized in general practice. Probing should be done Avith gentleness and care. It cannot be too strongly impressed on the mind of the surgeon that all probing should be abstained from until such time as the final, thorough examination and dressing of the wound can be done, when once for all the probe may be resorted to in accordance Avith the restricted indications for its use hereafter mentioned. Treatment.—Shock is to be combated in accordance with general princi- ples. Persistent hemorrhage of sufficient extent to require special interference for its arrest indicates a Avound of a vessel of considerable size. In such cases the rule is imperative to enlarge the wound sufficiently to expose freely the bleeding vessel and to ligate it upon both the proximal and distal sides. Should the vessel not have already been completely severed by the ball, it should be divided between the ligatures after their application. Hemorrhage occurring secondarily during the after-history of the wound demands the same treatment, and often involves an extensive dissection in the necrotic tissue. When, by reason of its anatomical position or the difficulty of finding it in the sloughing tissues, it is not practicable to expose the Avounded vessel in this way, ligation of the main artery of supply in its continuity must be resorted to, but only after a most determined effort has been made to ligate it in the wound itself. From the standpoint of treatment gunshot wounds are divisible into two classes—first, those which are capable of primary occlusion of the external wound and of conversion into practically subcutaneous wounds; and secondly, those which must be treated as open Avounds throughout. A large proportion of gunshot wounds are capable of being kept within the first of these two classes. First class.—The first effort of the surgeon, therefore, should ahvays be scrupulously to protect the wound from contamination from without. The one exception to this rule is found when necessity for interference for the arrest of hemorrhage is so great that its urgency may compel the disregard of every other precaution. The external wound may be of such extent as to be manifestly incapable of being sealed up by primary occlusion, but such a condition gives no warrant for the neglect of every possible effort at antisepsis from the beginning. The mere lodgment of a bullet in the tissues is not of itself an indication for the introduction of an exploring finger or probe, nor is it justifiable to disturb the wound by the new traumatism of an exploration until distinct evidence has appeared that the missile is seriously interfering with the repair of the Avound by its presence, or unless there is good reason to believe that there has been car- ried into the wound with the bullet septic material, such as fragments of cloth- ing. That exploration of a gunshot wound which is called for by reason of such manifest extensive laceration and destruction of tissue that the questions of excision and amputation require to be decided, is of an entirely different character from that which has as its end the quest for a bullet and its removal. Such explorations are made on general surgical principles, and become a part of the more formal and extensive operative procedures to Avhich they lead. It is not infrequent, in cases where the foreign body has been allowed to remain undisturbed in its neAv position among the tissues, and satisfactory and rapid healing of the original wound has been secured, that the body subse- quently becomes a source of irritation, so that its extraction is necessitated. A late operation of this kind, when it can be surrounded by every precaution, and is done among tissues which are no longer infiltrated and from which all 8 114 AN AMERICAN TENT-BOOK OF SURGERY. bloody extravasation has long been absorbed, is attended with much less dan- ger than a primary operation would have been. A gunshot Avound from the time that it is received until adequate antiseptic cleansing and dressings can be applied should be left exposed to the air Avithout any covering Avhatever, inasmuch as the air is less likely to be septic than any ordinary dressing which could be applied. By such exposure desiccation of the secretions about the Avound-aperture is favored and a protective crust is formed. As early as possible after the infliction of the wound the external aperture and the surrounding area of skin for a number of inches should be thoroughly cleansed with soap and water and sterilized by the free application of a solution of corrosive sublimate, 1 : 1000, or of carbolic acid, 1 : 30. It should then be covered with an abundant dressing of absorbent antiseptic material. Almost anywhere ordinary linen or other similar dressings can be used after being made aseptic by heating in an oven to a point just short of burning. The Avound-opening itself should by preference be covered by a bit of oiled silk or rubber protective previously sterilized, but this is not absolutely essential; the part should noAV be immobilized, if it is a limb that has been injured, by an adequate splint, which should extend sufficiently far above and below the wound to keep at rest all the muscular tissue of the part from origin to insertion. The Avound should not be disturbed until definite healing has been accomplished, unless symptoms of septic infection should declare themselves, especially by a rise of temperature, thus converting the wound into one of the second class, next to be considered. The second class of cases, which must be treated as open wounds, include those in which the extent of the wound is too great to give any hope from the first of securing its primary occlusion ; those in Avhich these attempts have been made, but have failed; and those in which such attempts have been deferred or omitted until the wound has become manifestly septic by reason of its exposure, its having been subjected to uncleanly and premature explorations, or the application to it of contaminated dressings. Even in this second class of cases all explorations and other operative measures should be deferred, if possible, until they can be done with the necessary disinfection, and can be accompanied by adequate protective dressing. Treatment should be conducted Avith scrupu- lous attention to the thorough disinfection of every accessible recess of the wound and to perfect freedom of drainage. The appearance of high fever, inflammatory swelling, progressive infiltration, gangrene, and other evidence of progressive septic contamination calls for the energetic and thorough application of all the resources for the control of sepsis Avhich are within the command of the surgeon. The primary examination and cleansing of the wound should be conducted with the view of making it aseptic if possible. Frequent partial cleansings should be avoided; repeated probings, cuttings, irrigations, and squeezing for the purpose of evacuating the Avound-secretions and debris, which keep up a continued irritation of the wound, should be replaced by one thorough primary examination and cleansing. This should be conducted under an anesthetic, with deliberation and minute attention to the ultimate object in vieAv—the destruction and prevention of sepsis. The external wound should be freely enlarged Avhen necessary, so as to permit the introduction of a cleansed and disinfected finger for purposes of exploration. Bullets, splinters of bone entirely detached, pieces of clothing, and other foreign bodies Avhich are found during the examination should be carefully extracted. A bullet, after having in the early part of its course inflicted injuries Avhich require to be treated by the open method, not infrequently continues its course in such a manner that CONTUSIONS AND WOUNDS. 115 the second part of its track may heal primarily behind it, and the bullet remain shut off from the first part of the Avound, and there, becoming encysted, remain permanently Avithout inducing further mischief. The treatment of such a deep Avound-track should be conducted on the same principles as those Avhich control the more superficial Avounds; it should not be probed nor irrigated, nor in any manner interfered with, unless evidences of inflammatory disturbances of its Avails appear; no search should be made along it for the bullet; much less should the presence of the bullet at its bottom be considered an indication for an attempt at its removal, unless easily accessible from the opposite side, Avhen it should be removed antiseptically. The dis- infection and drainage of the superficial portion of the Avound should be conducted with all care and thoroughness. Should deeper disturbances manifest themselves, the exploration, cleansing, and drainage of that portion of the Avound would then be required. Enlargement of the aperture of com- munication Avith the superficial AvOund, and free counter-incisions to the extent required for its easy and perfect drainage and for the removal of any foreign and irritating bodies along its track, -will be necessary. A certain proportion of these injuries will require primary resections of joints, partial or complete, and amputations, as a part of the care required in the pri- mary dressing. The necessity for these more important operative procedures will have become revealed in the course of the explorations Avhich have been made. The judgment and experience of the surgeon as to his ability to Avard off the dangers AA'hich threaten badly shattered joints and bones and exten- sively-mangled soft tissues, and to conduct the wound to a satisfactory healing so as to preserve a useful limb, must influence the decision in many cases as to Avhether a conservative method of treatment or the opposite should be adopted. In yet other cases, when, in addition to extensive injury to a bone or penetra- tion of a joint, the main vessels or nerves of the limb are injured, or when extensive loss of the soft tissues has taken place, or Avhen a part of the limb has been carried aAvay, no alternative is left to the surgeon but amputation. When the necessity of amputation is unquestionable, it should be done as soon after the shock from the primary Avound has passed aAvay as is practicable, provided this is before septic infection, inflammatory infiltration, and secondary traumatic fever have developed. This is the period characterized by old authors as the primary period; which, in pre-antiseptic days, extended over the first thirty-six to forty-eight hours. This is folloAved by a period extending over a variable time, during which there is progressive local inflammatory infiltration and general fever. This period is termed the intermediary period. During this period no operative interference is to be attempted other than that required for the removal of necrotic tissues or for affording adequate drainage, unless spreading gangrene of the wound develop, when distant amputation through tissues yet sound should be done as quickly as possible. When the primary inflammatory infiltration has become limited and begins to subside, and free suppuration from the Avound-surfaces has become established, another period is said to have been reached, known as the secondary period. When the secondary period has been reached, amputation through tissues yet sound should be clone Avithout further delay. The prolongation of the primary stage by antiseptic treatment—continuous antiseptic irrigation being the method which in general is best adapted to these cases—makes it possible for the surgeon to delay amputation until such time as, in his judgment, the patient Avill be in the most favorable condition to bear the operation. In some cases it will happily have served to demonstrate the possibility of recovery Avithout amputation, for in not a few instances the 116 AN AMERICAN TENT-BOOK OF SURGERY. possibility of saving a limb Avill depend entirely upon the success of the efforts to prevent the Avound from being invaded by septic infection. As soon as it is evident that these efforts have not been successful, amputation should be pro- ceeded with, before the full local and constitutional symptoms of sepsis have developed. Point of Amputation.—The choice of the point at which the amputa- tion shall be made may be greatly influenced by the facilities at the command of the surgeon for keeping the Avound aseptic. If these be adequate for the purpose, the section may be made at Avhatever point may be desirable to give the patient the most useful stump, even though bruised and lacerated parts be included in the flaps. These are preserved from inflammatory disturbance, their full vitality is regained, and they participate in the formation of the stump without disaster from sloughing. When, for any reason, the wound cannot receive adequate antiseptic treatment, amputation, if possible, should be made at a point sufficiently far above the injury to exclude all bruised and lacerated tissues from the flaps. A blind groping for a bullet at the bottom of a deep sinus should never be attempted. The enlargement of the external aperture and the dilatation of the deeper track, as required for the purposes of the cleansing and drainage of the wound or the counter-incisions made when the length of the track and the location of the ball demand it, should be ample enough to permit the sufficient exposure and ready seizure of the bullet if it is to be removed at all. For the purpose of facilitating the removal of a bullet when exposed many styles of forceps have been devised; it is not necessary that mention of any special one should be made. Any pair of forceps Avith slender and firm jaAvs, with slightly projecting teeth or Avith roughened points to increase the security of the grasp upon the bullet, will answer. The bullet will commonly be found to be somewhat battered and misshapen and entangled in interlacing strands of fibrous tissue that hold it closely, so that some little difficulty is often experienced in freeing the bullet so that it can be removed after it has once been exposed. If the bullet is firmly impacted in bone, it must be first loosened by the chisel or elevator, and then removed. Gunpoivder grains imbedded in the skin may be picked out by a sharp- pointed bistoury and a fine curette, or be left to spontaneous discharge by suppuration. In any event, a permanent tattooing will remain as a mark of the wound. Arrow-wounds.—The wound made by an arrow is a punctured incised wound. Such wounds demand special mention only in connection Avith the question of the treatment of the arrow Avhen any portion of it is lodged in the wound. The barbed head of the arrow, by becoming entangled in the tissues which close over it after it has penetrated them, forms a condition that is espe- cially difficult to overcome if the arrow has penetrated to any depth. The general principles of surgery which are applicable to the search for and removal of all foreign bodies imbedded in the tissues are equally applicable to imbedded arrow-heads. If the shaft of the arrow is still attached to the head, it affords a valuable guide along which the dissection of the surgeon may be made for adequate exposure and disentanglement of the arrow-head. It should never be pulled upon for the purpose of removing the arroAv, for the effort will certainly be futile, and if the shaft becomes separated from the head its further service as a guide is lost. If, however, the arrow has so far penetrated the tissues as to make it feasible to push it clear through and out on the other side, that treat- ment should be adopted; and in that case the shaft should be used to push out the head, the exit of which through the skin should be helped by the proper use of the knife. The head and the ribbon Avhich attaches it to the shaft being CONTUSIONS AND WOUNDS. 117 then removed, the shaft itself can be AvithdraAvn. ArroAv-heads do not become encysted like bullets. The experience of military surgeons is uniform that an arroAv-head lodged in the soft tissues invariably produces serious results. Hence the rule is Avithout exception that an arrow-head left behind and lodged in the tissues must be removed as soon as possible, even if this removal should require the severest and most dangerous operation (Bill). POISONED AVOUNDS. Certain Avounds remain to be considered which are associated with the inoculation of special hurtful substances. They have long been classed together as poisoned wounds, although in some the poison injected is of a chemical character, while in others it is microbic. A distinction, hoAvever, should be made betAveen Avounds that are subjected to microbic and those subjected to chemical influences. The former constitute the general class of infected Avounds, in Avhich are to be grouped not only all those heretofore described as subject to the usual septic infection, but also those which are infected by special microbes, as rabies,-glanders, anthrax, actinomycosis, etc. Chemical poisons differ from microbic poisons in that they are incapable of self-reproduction, and that their deleterious effects are proportionate to the amount of the poison at first introduced into the body. In this class are to be grouped the bites and stings of insects and of reptiles. It is not be overlooked that in ordinary infected Avounds the local and general symptoms Avhich are produced are due largely to the action of the chemical poisons or ptomaines which are generated by the micro-organisms that infest the Avound, and not to the presence of the micro-organisms themselves. Such Avounds are there- fore of a double nature. In all cases Avhere there is a tendency to spreading gangrene this mixed character of the poison is especially marked. The acrid ptomaine by its chemical effect upon the tissues Avith Avhich it comes in contact produces their death and converts them into a fertile soil for the rapid multipli- cation of the invading micro-organisms, Avhich, again, as they multiply, produce a renewed supply of the ptomaine, that attacks a fresh layer of tissue: and thus the vicious circle is completed and the progressively destructive process is maintained. There are, therefore, three great classes of poisoned Avounds: First, that of mixed or bio-chemical infection, Avhich includes all the ordinary septic wounds that have been treated of in the preceding pages, and likewise those special AA'ounds Avhich are at times accompanied Avith marked tendencies to spreading inflammation and gangrene, such as those received in the dissecting-room, during post-mortem examinations, by butchers and fish- dealers from tainted meat and fish, and those resulting in that rapidly-extend- ing gangrenous process known as "malignant oedema.-' Second, chemical poisons alone—the bites of insects and reptiles. Third, microbic infection alone—rabies, glanders, etc. This latter class differs so Avidely and materially in every respect from the first two as to deserve an entirely separate consideration. We shall accordingly group the first tAvo under the one head of Poisoned Wounds proper, Avhile the latter class Ave shall treat under the designation Surgical Diseases due to Microbic Infection. A number of these are usually derived from animals. POISONED AVOUNDS PROPER. Dissection Wounds.—The term " dissection wounds " is applied to septic wounds of special virulence contracted in the dissection of dead bodies, both in 118 AN AMERICAN TENT-BOOK OF SURGERY. the dissecting-room and especially in post-mortem examinations. It is applica- ble also to a similar class of injuries sustained by surgeons in operating on the living; similar wounds occur also in butchers,"fish-dealers, cooks, and other persons whose vocations may demand their handling putrefying animal material. Only a very small proportion of the pricks inflicted upon themselves by medi- cal students and surgeons in dissecting the bodies of the dead or in operating upon the living are followed by any serious consequences. For the develop- ment of the more grave results it is necessary that there shall be some special virulence in the tissues or fluids by Avhich the wound is inoculated, or that the individual who receives the wound should be in a condition of general consti- tutional depression, so that the natural resisting power of his tissues is greatly diminished. The Avorst cases occur Avhen both these conditions happen to be combined. Experience has shoAvn that the tissues of the recently dead are more frequently capable of communicating serious infection than those in which the process of decomposition is well advanced. The dissection of bodies in which death has been caused by virulent infective processes, as puerperal fever, ery- sipelas, or pyemia, is especially dangerous. Occasionally the Avetting of the hands, on Avhich there is no perceptible scratch or breach of surface, by the acrid fluids of a body dead of virulent infective disease may be attended with all the results for which the presence of a prick or scratch or abraded surface of some kind is usually necessary. Symptoms.—The symptoms presented by a dissection Avound may be those of any grade of septic infection, from that of slight local inflammation and suppuration to that of rapid, progressive gangrenous inflammation, with extreme general prostration from septic absorption, the development of pyemic foci in other parts of the body, and death. A not uncommon form is that in which the inflammation extends especially along the lymphatics, which appear as red lines, and produces marked SAvelling of the axillary glands. Treatment.—The treatment of these AA'ounds differs in no way from that which has been laid doAvn for a septic Avound in general. When an individual is conscious of the reception of the Avound at the time, energetic local antiseptic treatment should be immediately instituted; thorough scrubbing and cleansing of the Avound and the surrounding integument over a Avide area should be made; the wound itself, if a puncture, should be enlarged sufficiently to permit of the certain introduction to its deepest point of the antiseptic to be used. The wound should then be thoroughly SAvabbed out with some such strong antiseptic agent as pure carbolic acid, solution of corrosive sublimate, 1: 500, or solution of chloride of zinc, 8 per cent.; the part should be covered with an abundant dressing of absorbent material, Avhich should be kept Avet Avith a solution of corrosive sublimate, 1 : 2000, for three or four days; that is to say, until suffi- cient time has elapsed to demonstrate Avhether or not the disinfection of the Avound has been successful. When this has been assured, any simple emollient protective dressing may be substituted until complete healing of the wound has taken place. When, through the neglect or inefficiency of primary antiseptic care, advancing phlegmonous inflammation or lymphatic irritation and glandu- lar enlargement begin to develop, the surgeon should not wait until suppuration and sloughing of tissue have taken place before incising the inflamed and infil- trated regions, but should at once make sufficiently free incisions to open up thoroughly every infected district and to permit the free exit of the inflamma- tory secretions with Avhich the tissues are infiltrated. The early resort to free incisions of this character will prevent much destruction of tissue and serious impairment of function, will relieve pain, and greatly abbreviate the course of the attack. Abundant antiseptic irrigations should be practised upon all the CONTUSIONS AND WOUNDS. 119 tissue-spaces opened up by these incisions; the incisions themselves should be kept open by tents of iodoform gauze until all tendency to spreading inflam- mation has subsided and a healthy granulating process has developed. Mean- while, the whole limb should be kept enveloped in Avet bichloride dressings. Abscesses, whenever and Avherever formed, should be opened as soon as possible and treated after the general manner already described. The constitutional treatment required will be conducted on general principles, and will include stimulants in large doses, opiates, and tonics. Malignant (Edema, known also as Gangrenous Emphysema and Gan- grene Foudroyante, is a rapidly-spreading gangrenous inflammation in which the affected tissues become distended with the gaseous products of decomposition, due to infection by a special micro-organism. (PL III, Fig. 6). This micro-organism was identified by Koch in 1882, and is a rod-like bacillus, resembling in form and size that of anthrax, but somewhat smaller, with rounded ends. The bacilli are joined together in threads after a peculiar fashion. ITnlike the anthrax bacillus, they have the property of spontaneous motion and of spore-formation in the living body; they groAV only in the absence of oxygen; they only rarely enter the animal body Avith any activity; they abound in garden soil, and may be met Avith in any kind of soil or dust. The gangrenous and putre- factive phenomena which are marked features of the disease in question are said not to be primarily produced by the bacillus, but to be due to the admixture Avith it of the ordinary putrefactive forms. According to Park (Mutter Lectures on Surgical Pathology, 1890 and 1891), when a pure culture of these specific bacilli is injected there results an extensive hemorrhagic oedema of the sub- cutaneous cellular tissue, without any appearance of putrefactive action and quite free from gas-formation; but Avhen an impure culture is injected or when garden earth is used for inoculation, the distinctive oedema of the previous instance becomes a mixture of emphysemic oedema and gangrene. These organ- isms must be planted subcutaneously in the areolar tissues in order to produce the typical results. Inoculations upon abrasions or open Avounds are harmless, owing to the free access of the inhibiting oxygen of the atmosphere. Symptoms.—The local symptoms of the disease are those of a rapidly- extending gangrene surrounded by an extensive ever-spreading area of SAvollen, livid tissue, infiltrated by foul-smelling, acrid secretion and the gaseous prod- ucts of decomposition. The oedematous tissues emit a fine crepitus Avhen pressed by the finger; the overlying cuticle is raised into blebs filled with red- dish offensive serum; the sloughing tissues are bathed in a thin putrid fluid. The general state of the patient is one of great prostration and profound septicemia, accompanied by apathy and sometimes by delirium. Death super- venes usually within from one to tAvo days ; after death putrefaction goes on with great rapidity. Examination of the viscera shoAvs them to be congested and oedematous and the subject of multiple hemorrhagic infarcts. The diagnosis of malignant oedema is simple. The clinical picture which it presents is clear and not likely to be mistaken for anything else. The first symptom is hemorrhagic oedema of the subcutaneous cellular tissue, to Avhich is added infection Avith ordinary putrefactive organisms ; a rapidly-spreading gangrene results. Avith the addition of an emphysemic element to the previously existing oedema from the gases of putrefaction. This mixture of emphysemic oedema and gangrene is the pathognomonic clinical feature of the disease. Microscopic examination of the oedema fluid will shoAv numerous bacilli of the disease. The prognosis is ahvays grave; Avith rare exceptions the disease marches rapidly to a fatal termination. Treatment.—The treatment must be heroic and radical from the moment 120 AN AMERICAN TENT-BOOK OF SURGERY. of the recognition of the disease. If a limb is attacked, immediate amputa- tion should be done at a point Avell above the line to Avhich the disease has extended. When amputation is not feasible, a radical excision of the affected tissues should be done, Avith the most thorough, continuous, subsequent antiseptic treatment. The general strength should be sustained by vigorous stimulation and by other tonic and supporting treatment. BITES AND STINGS OF INSECTS AND REPTILES. These are minute punctured Avounds into AAhich has been injected some poisonous secretion from distinct poison-glands or from modified salivary glands of the animal inflicting the bite. Insect-bites and Stings.—In the case of insects the poison inoculated is acid in its nature; the results of its injection present every degree of variation in severity, from that of the simple local irritation produced by the minor and more common insects, such as the flea, the mosquito, bedbug, various forms of mites, etc., to the greater local reaction and considerable constitutional disturbance following the stings of the more aggressive and venomous hymenoptera, such as bees, Avasps, hornets, and yelloAv-jackets, and the still more virulent and dangerous centipedes, spiders, tarantulae, and scorpions. As a rule, the stings of even the most venomous of insects are unattended with dan- ger to life, but where many have been inflicted or Avhen the person is weak and feeble severe constitutional disturbance, marked by chills, fever, and great prostration, and even ultimate death, may result, the severity of the symptoms depending upon the amount of the poison Avhich has been absorbed into the general circulation. The wounds inflicted even by spiders and scor- pions of the largest size rarely prove fatal. Treatment.—Alkaline local applications should be used, such as dilute aqua ammonias or solution of bicarbonate of sodium. Ordinary loam mixed with water to form a mud poultice is useful as an extemporaneous application. Local inflammatory disturbances must be treated upon general principles; constitutional symptoms must also be combated according to the special indica- tions of the particular case. Serpent-bites.—In the United States naturalists have discovered tAventy- seven species of poisonous serpents and one poisonous lizard; eighteen species of these are true rattlesnakes; the remaining are divided betAveen varieties of the moccasin or copperhead and of the viper. The poisonous lizard is the Texan reptile knoAvn as the " Gila monster." In all these serpents the poison fluid is secreted in a gland which lies against the side of the skull beloAv and behind the eye, from Avhich a duct leads to the base of a holloAV tooth or fang, one on each side of the upper jaw; which fang, except in the case of the vipers, is movable and susceptible of erection and depression. When not in use, the fang hugs the upper jaAv and is ensheathed in a fold of mucous membrane. In the vipers the fang is permanently erect. In the act of biting the contents of the poison-sac are forcibly ejected through the hol- low fang. In India venomous snakes abound, of which the chief are the hooded cobra, the viper, and the bungarus. In Europe the most dreaded serpent is the common viper, while Africa, South America, and Australia and the islands of the Pacific are not wanting in many varieties of venomous serpents. The physical appearances of all serpent-venom are nearly alike: it is a viscid fluid, varying in color from a pale amber to a deep yellow, and containing in solution certain albuminoid principles Avhich are the toxic elements, the nature of which has not yet been made out. According to the researches of Mitchell and CONTUSIONS AND WOUNDS. 121 Reichert, venom induces rapid necrotic changes in living tissues with which it is brought in contact. It renders the blood incoagulable, disintegrates the red blood-corpuscles, and produces such a change in the capillary blood-vessels that their walls are unable to resist the normal blood-pressure, and wide and rapid blood-extravasation results. Profound depression of the respiratory nerve- centers is the most common cause of death from serpent-venom, although cardiac paralysis, hemorrhages into the medulla, and general disorganiza- tion of the red blood-corpuscles may likeAvise each be a sufficient cause of death. Symptoms.—Much similarity characterizes the effects which follow bites of all varieties of poisonous serpents. The amount of the venom injected and the rapidity with Avhich it enters the circulation govern the intensity and the rapidity of the symptoms produced. The local symptoms are pain—at first slight, but later becoming more severe—with rapid tumefaction and ecchymotic discoloration in the vicinity of the AAOund. Symptoms of cardiac and respira- tory depression soon manifest themselves by feeble and fluttering pulse, faint- ness, cold perspirations, mental distress, nausea and vomiting, and labored respiration. In the more intense cases of poisoning death may result in a short time by the paralyzing effect of the venom upon the heart, but more frequently the struggle extends over a number of hours. When life is pro- longed over forty-eight hours, the special symptoms of venom-poisoning give place to those Avhich are due to the disintegrating effect of the venom upon the blood and the tissues; that is to say, a sapremia of intense form remains, which may prove fatal by exhaustion or may be slowly recovered from. When death takes place from the primary effects of the venom, it is ushered in by delirium and coma, with intensification of all the primary symptoms. The post-mortem appearances are those Avhich Avould folloAV the blood-changes and the visceral disturbances that have been described. In the neighborhood of the bite the tissues are infiltrated Avith hemorrhages and with the results of rapidly-extending gangrene, the right heart is engorged, the general blood-mass is fluid, and all the internal organs, especially the brain, spinal cord, and kid- neys, are congested and present multiple ecchymoses. Treatment.—When a bite by a venomous serpent has been received, instantaneous and energetic efforts must be made to prevent the entrance of the venom into the general circulation. When the bite has been upon any portion of a limb, a ligature should at once be thrown around the limb aboAre the Avound, and by tAvisting be draAvn so tightly as absolutely to check the circu- lation of blood in the part. This ligature should be a broad one, so as to diminish later pressure-effects; then free excision of the wounded part should be done. When the bite is upon a part of the body other than a limb, imme- diate excision should be practised, and, Avhen this is impracticable, vigorous suction of the wound should be made, which can be done Avithout fear if no cracks or abrasions of the lips or mouth are present, for the poison is harmless Avhen taken into the mouth. Should a hot iron be accessible, its vigorous and free application Avithin the Avound might safel}7 replace excision or suction. When none of these procedures are practicable or have been only imperfectly applied, there remains the device of permitting the poison to be admitted into the gene- ral circulation in instalments by slackening the ligature a little at intervals, and then tightening it again, Avhile constitutional treatment is being resorted to for the purpose of antidoting the poison thus sloAvly admitted into the circulation. Permanganate of potassium, in 1 per cent, aqueous solution, freely injected by means of a hypodermatic syringe into a serpent's bite, Avithout especial regard to the amount used, is asserted by Lacerda of Rio Janeiro to 122 AN AMERICAN TENT-BOOK OF SURGERY. be an absolute antidote to serpent-venom, and whenever practicable should be given a trial. Hypodermatic injections of ammonia have also proved useful. The constitutional treatment available in cases of serpent-bite is limited to the use of cardiac stimulants, especially alcohol, which is to be combined when possible with digitalis; both are to be given freely by the mouth and hypoder- matically. The state of the pulse is to be taken as the guide to indicate Avhen the proper amount of stimulation has been reached, it being remembered that alcohol does not act as an antidote to the poison, but simply sustains the vascular and nervous systems Avhile the poison is being eliminated through the natural emunctories. The toxic sequelae in cases that survive are to be treated upon general principles. SURGICAL DISEASES DUE TO MICEOBIC INFECTION. As the result of bacteriological investigation, the number of surgical affections which have been demonstrated to be due to infection by a specific microbe has become quite considerable. The processes of suppuration and the general septic disturbances of infected wounds have already received full attention as respects their bacteriological relation. To these must be added a series of distinct surgical diseases in the causation of each of which a specific micro-organism has been demonstrated to be the active agent. This list includes the following diseases: Anthrax, Babies, Glanders, Actinomycosis, Erysipelas, Tetanus, Gonorrhea, Tuberculosis, and Leprosy. Of these the last five are described elsewhere. The first four it seems proper to consider along with " Poisoned Wounds." They are usually derived from animals. Rabies is generally admitted to belong to this class, and is accordingly included in the present study, although a satisfactory demonstration of its specific micro-organism has not yet been made. There is much evidence to show that syphilis also should be included in this list, but the complete and indisputable evidences of its microbic origin are still wranting. ANTHRAX, Malignant Pustule, Wool-sorter's Disease, Charbon, or Milzbrand.—A disease caused by infection Avith a peculiar rod-like bacillus, and characterized by an acute inflammatory primary local lesion, Avith subsequent general infection of the fluids and tissues of the body, with tendency to rapidly fatal ending. The bacillus of anthrax is the largest of the pathogenic organisms, and Avas the first to be detected, having been identified as early as 1849 by Pollender in the blood of cattle suffering from the disease. The organism is a straight rod, from 5 to 10 micro-millimeters in length and 1 to 1.25 micro-millimeters in breadth ; it is devoid of motion, and in the bodies of living animals multiplies exclusively by segmentation. Under certain conditions in dead nutrient media spore-production also occurs. The disease, according to Pasteur, is spread among animals by germinating spores, which, having become attached to plants and grass, are taken in with the food and develop the primary lesion in the mouth or in the walls of the intestines. The tenacity of life of these spores is very great. Among animals the herbivora are especially susceptible to the disease, less so the omnivora, and least so the carnivora. The disease occurs in all latitudes and in any portion of the world. It is most widely spread in Russia and Siberia, and is particularly common in Hungary and in certain parts of France and Germany. The disease in man is ahvays acquired from affected animals CONTUSIONS AND WOUNDS. 123 or from the products of such animals. Any part or tissue of an animal dead from anthrax is capable of communicating the disease. In its dried state the bacillus is able to preserve its virulence for many years, and through anv substance to which it may become attached the disease may be communicated"; even the feet and probosces of flies which have alighted upon the diseased animal or upon the infected product may carry the disease, and earth-Avorms carry it from the buried animals to the grass above. Persons Avho work in industrial establishments where the products of diseased animals may be among the objects of their labor, as hides, horse-hair, and avooI, are peculiarly subject to the disease; hence one of the names by which it has been knoAvn, Wool- sorter's disease. Infection may occur equally from inoculation with the bacillus or with spores. When the skin is the site of the primary lesion, some minute scratch, abrasion, or insect-bite may suffice for the inoculation; the unbroken skin affords ample protection from the virus, but the spores Avhen inhaled or swal- loAved may reach the circulation through a healthy mucous surface. Symptoms and Course.—The attention of the surgeon is required only in those cases in Avhich the primary lesion is external; cases in Avhich the bacillus enters the organism through the gastro-intestinal canal or the respi- ratory passages fall under the domain of internal pathology, and for their description the student is referred to text-books on general medicine. The character of the primary lesion Avhen external infection has taken place depends upon the anatomical structure of the part affected. If it is dense and vascular, a circumscribed carbuncular inflammation develops—anthrax carbuncle, malignant pustule; if the infection is in the midst of loose connective tissue with comparatively scanty blood-supply, a diffused inflam- matory infiltration manifests itself—anthrax oedema. In either case after infection a variable period of incubation intervenes before the manifestation of special symptoms. This period may be from a feAv hours to three days; in rare instances a longer period, even of ten to fourteen days, has occurred. Anthrax Carbuncle.—A slight burning and itching at the point of infection, Avith the rapid development of a papule surmounted by a small vesicle, which, bursting, discloses a central eschar, are the first manifestations of the disease. The inflammatory infiltration at the base and circumference of this primary papule rapidly increases, with development of a ring of secondary vesicles around the margin of the primary eschar, and Avith gradual extension of the tissue-necrosis. In rare instances the progress of the disease becomes spontaneously limited at this point; a gradual subsidence of the swelling takes place; the slough becomes detached by suppurative inflammation, and the ulcer heals by granulation. More commonly, the oedema and infiltration .continue to spread, the eschar extends, phlebitis and lymphangitis develop, and symptoms of general intoxication folloAv, terminating speedily in death. Anthrax GEdema manifests itself by the appearance at the point of infection of a livid diffuse oedema Avhich rapidly spreads in all directions; the swelling may become enormous in its extent and size, and at different points local gangrene of the skin and subcutaneous tissue may occur, preceded by the formation of blebs upon the surface, filled Avith bloody serum. In rare instances spontaneous recovery from this variety of anthrax takes place. The local pain is slight, and, as long as the diseased process is limited, there is but little general elevation of temperature, the patient often continuing to be about and manifesting simply slight chills and mild fever. General infection is shoAvn by Avell-marked rigors, high fever, with great Aveakness, delirium, feeble pulse, sAveating, diarrhea, and acute pains in many portions of 124 AX AMERICAX TEXT-BOOK OF SURGERY. the body. Cough, rapid respiration, and cyanosis indicate pulmonary disturb- ance. Collapse, often sudden in its development, closes the scene. Pathology.—The tissue-changes Avhich are discernible in cases of anthrax are dependent upon the multiplication and diffusion of the bacilli in the capil- laries and lymphatics. The local changes of oedema and necrosis are due to the blocking up of the capillaries by the bacilli and to their irritating effect upon the capillary walls, which produces such abundant inflammatory exuda- tion into the paravascular and connective-tissue spaces that acute ischemia results. When general infection has taken place, the capillaries in every part of the body teem with bacilli, Avhich accumulate in largest numbers at points where the blood-current is slowest. In the most vascular organs, like the spleen, liver, and kidneys, the bacilli especially abound. They form thrombi in the capillaries and lymphatics, from Avhich multiple and more or less exten- sive extravasations into all the tissues result, and transudations into the various serous cavities are produced. Diagnosis.—The typical anthrax carbuncle is not likely to be confounded with any other affection. The early superficial depressed eschar, the tough slough closely attached to the surrounding tissues, the lack of sensitiveness of the SAvelling, the Avidely-extending infiltration, the absence of suppuration, and the general symptoms which attend its later course form a picture distinct from that Avhich characterizes simple inflammatory carbuncle with its prominent cen- ter, its multiple soft, suppurating, sloughing foci, its local pain, and indolent inflammatory course. The multiple small carbuncles of glanders have little in common with the carbuncle of anthrax. Anthrax oedema at its outset may be confounded with acute phlegmonous inflammation or with malignant oedema. Phlegmonous inflammation is characterized by its tendency to suppuration, which at once distinguishes it from anthrax. In malignant oedema the necrosis is attended with rapid disintegration and liquefaction of the dead tissue, in marked contrast with the tough and adherent sloughs of anthrax. In all cases of suspected anthrax microscopic examination of the fluids of the affected part should be made. The anthrax bacillus can be readily stained and identified under the microscope. Microscopic findings may be made still more positive by inoculation experiments. Prognosis.—External anthrax Avhich is alloAved to take its own course, or in Avhich the treatment is too long delayed, is very grave, but Avhen an early diagnosis is made and energetic, rational treatment is at once instituted, the prognosis is usually favorable. When general infection of the system has occurred, the result is uniformly fatal. The prognosis of the oedematous vari- ety is more grave than that of the carbuncular, in consequence of the greater liability to general infection Avhich attends the former. In either case the fatal termination is due, probably, as indicated by the most recent researches of bacteriologists (Bollinger), to toxic ptomaines formed in the body by the bacilli as the products of their groAvth. Treatment.—All treatment must be conducted upon antiseptic lines, and should be energetic, and instituted at the earliest possible moment. Excision of the infected area should, if possible, be done, the incisions being carried wide of the disease, through healthy tissue if possible; special care must be taken to prevent infection of the operative Avound from the diseased mass that is excised. To guard against the results of possible infection, the exposed sur- face remaining after the excision should be thoroughly mopped over Avith a strong solution of carbolic acid, 1 : 10, or even Avith the pure acid, or of chlo- ride of zinc, 1 : 8, or the actual cautery may be applied. The immediate appli- cation of the actual cautery at the seat of inoculation, whenever such an inocu- CONTUSIONS AXD WOUNDS. 125 lation is recognized as having taken place, will destroy the virus and prevent subsequent evil. When excision of the entire infected area is impracticable, multiple deep crucial incisions should be made into it, accompanied by injec- tions of carbolic acid, 1 : 10, by means of a hypodermatic syringe, systemati- cally administered so as to diffuse the carbolic solution throughout the entire extent of the base of the affected tissue and through the surrounding healthy tissue. The punctures should be made just outside the borders of infiltration, the needle passed to the center of the infected area, and the solution slowly expelled as the needle is withdrawn. The carbolic solution should be mopped freely into the cuts, and injections should also be made into the substance of the diseased mass, so as to thoroughly saturate it with the antiseptic, while at the same time an ice-bag should be" kept applied upon its surface, and the Avhole part should be enveloped in compresses saturated with sublimate solution, 1:1000. The carbolic injections may be repeated every six hours until the disease is manifestly under control or until symptoms of carbolic-acid poisoning are developed. The treatment of the subsequent slough is to be conducted on general antiseptic principles. The constitutional symptoms of prostration and threatening collapse are to be met by stimulant, tonic, and supporting measures. HYDROPHOBIA (RABIES, LYSSa). Hydrophobia in man is an infectious disease resulting from the inoculation of a specific virus from an animal suffering from rabies. After a variable period of incubation following the primary inoculation, the disease declares itself by certain spasmodic muscular phenomena, followed by great general prostration and ultimate rapidly-ascending paralysis, significant of lesions of the spinal cord, in which organ, especially the medulla oblongata, the effects of the virus are chiefly centered. Etiology.—Hydrophobia in man is always the result of inoculations with the virus of a rabid animal, most frequently the dog (90 per cent.), less fre- quently cats, Avolves, and foxes. There is no proof that even among animals there is any spontaneous development of rabies: among them, as in man, it is ahvays caused by direct inoculation from an already rabid animal. There is reason to believe that the bite of an infected dog even during the period of incubation of the disease may produce hydrophobia in man (Bollin- ger). The lack of disposition to bite upon the part of a dog during this period, however, renders the danger of such an occurrence comparatively small. Instances are recorded where the disease has resulted from accidental wounds sustained during the post-mortem examination of rabid dogs and in laboratory experiments. Not all persons bitten by rabid animals develop hydrophobia. In the nature of the case it is impossible to secure reliable statistics on this point. In many cases, certainly, bites are inflicted by dogs supposed to be rabid, but that are in fact not so ; in other cases bites have been inflicted by dogs really rabid in Avhich the infecting saliva Avas wiped off by the clothing through which the teeth passed, and the Avounds were thus preserved from infection. In yet other cases wounds that Avere really infected have been subjected to adequate immediate cauterization, and thus the later development of the disease prevented. There is, however, sufficient experience to warrant the general statement that about 12 to 14 per cent, of those who are bitten develop the dis- ease (Roux), and of these all die. As regards immunity, no relation is trace- able either to age or sex. While the ordinary medium of infection is the saliva of a rabid animal, the 120 AN AMERICAN TENT-BOOK OF SURGERY. disease can also be produced by inoculation with other fluids and tissues of such an animal. All the conditions relating to the propagation, development, and course of the disease indicate that it is due to a specific micro-organism, Avhich, by its multiplication within the body, finally causes the ultimate ovenvhelming symptoms of the disease. This micro-organism, however, has not as yet been satisfactorily demonstrated. Pathology.—No Avell-defined, gross pathological changes attend hydro- phobia. Microscopic examination of the medulla oblongata and the spinal cord shoAvs irritative lesions, marked by an infiltration of the perivascular sheaths with leucocytes, Avhich at points may be accumulated in considerable number. Hyperemia and moderate oedema of the brain and spinal cord and their membranes as a rule are present. The pharynx, fauces, and neighboring lymphatic glands are usually congested, as is also the mucous membrane of the stomach and intestinal canal; the lungs and kidneys present general dif- fused, congestive conditions, the Avhole condition indicating the presence in the circulating fluid of an intense irritant. The heart, spleen and liver are, as a rule, normal. Symptoms.—Stage of Incubation.—A period varying greatly in length intervenes betAveen the time of inoculation and the appearance of any constitu- tional disturbance. The average period of incubation is about six weeks; it is seldom less than fourteen days, and may be protracted to some months. There is credible evidence that in extremely rare cases this period has been prolonged to between one and tAvo years. During this time the persons bitten feel well and present no symptoms whatever of the dormant disease; the local wound heals kindly. In the young the period of incubation averages less than in the old. Premonitory Stage.—The outbreak of general symptoms is usually pre- ceded by a brief period, generally not more than twenty-four hours, rarely* extended to two or three days, during which ill-defined premonitory symptoms manifest themselves ; some uneasiness or pain is felt in the region of'the wound, the cicatrix of which may become congested and tender ; in other cases all such local symptoms are absent. Symptoms of constitutional disturbance declare themselves with headache, loss of appetite, sleeplessness, and much mental depression and irritability, with tendency to aimless wandering about, accom- panied by great anxiety and apprehension, especially if the patient recalls the fact that he has been bitten. A general hyperesthesia soon shows itself, as evinced by sensitiveness to currents of air and to light. The stage of the full development of the disease is now ushered in by noticeable spasms of the mus- cles of deglutition, causing a sense of tightness and choking about the pharynx, producing difficulty in speaking and in swallowing, and hence dread of fluids, although there is intense thirst. Examination of the pharynx will show that its mucous membrane is congested and that there is an abundant secretion of viscid saliva, which, since it cannot be swallowed, causes frequent hawking and spitting to get rid of it. Occasionally the precursory symptoms are absent, and the first manifestations of the disease are spasmodic contractions of the pharynx occurring while attempting to drink or precipitated by some mental agitation ; at other times some oppression of breathing is first noticed, culmi- nating in marked suffocative attacks from spasmodic contractions of the upper respiratory muscles, combined usually with the already described pharyngeal symptoms. Stage of Excitement.—The disease has now fully declared itself. The spasms of the muscles of deglutition and respiration are more marked and more easily excited; swalloAving becomes impossible; the mere suggestion of CONTUSIONS AND WOUNDS. 127 it suffices to bring on spasm. Currents of air, an unexpected touch, the slightest source of agitation, will suffice to provoke the convulsion. The embarrassment of the breathing caused by the spasms of the respiratory mus- cles is often great, producing a sensation of impending suffocation; frequently the entire muscular system Avill share in the convulsive attacks. These suc- cessive muscular spasms are separated by periods of complete relaxation, there being no tonic spasms, as in tetanus. The mental faculties remain for the most part unimpaired, though excite- ment, anxiety, and terror occupy the mind. Intervals during AA'hich hallu- cinations develop are common. The duration of the convulsive paroxysms is variable; they rarely continue longer than from one-half to three-quarters of an hour, and usually for a much shorter period. During the paroxysms the excitability and restlessness of the patient, combined with dyspnea and Avith hallucinations, may produce a condition similar to mania. In the intervals betAveen the attacks the mind appears clear: these intervals are likeAvise of variable length, very brief at times, at others prolonged for several hours. In rare instances the convulsive paroxysms are completely absent, the patient complaining merely of great anxiety and difficulty in breathing. In excep- tional cases the patient is able to SAvallow food during the entire course of the disease, although the act is accompanied by pain. As a rule, the taking of solid food is impossible, but in exceptional cases such food is SAvalloAved Avithout difficulty. The pulse at the beginning of the attack is normal in character, but, as the disease progresses, grows gradually weaker and quicker, until as death approaches it is no longer perceptible. The body-temperature is some- what increased, ranging from 100° to 103° F., seldom rising as high as 105°. The urine is scanty, free from albumen, and frequently contains an appreciable amount of sugar. This stage of excitement may prevail from thirty-six to seventy-tAvo hours; during its course death may occur amid the convulsions from exhaustion or from asphyxia; more frequently there is a gradual transition to a state of comparative tranquillity—the last stage of the disease, the stage of paralysis. There is then a gradual remission of the severe symptoms; the reflex nervous excitability diminishes, resulting in freer respiration and the recovery of the ability to swalloAv, Avhile the general debility and prostration rapidly increase. The convulsions become feebler and cease entirely. If life is sufficiently prolonged, a condition of rapidly-ascending paralysis supervenes, and symptoms of respiratory and cardiac failure develop, terminating in death. The duration of the final stage of hydrophobia is brief, being, as a rule, between tAvo and eighteen hours. Diagnosis.—Hydrophobia is to be distinguished from tetanus, from the effects of mental agitation and fear simulating hydrophobia (hydrophobia imaginaria, lyssophobia), and from certain forms of hysteria and epilepsy in which symptoms affecting the organs of deglutition are manifested analogous to those observed in genuine rabies. The positive history of a bite from a prob- ably rabid animal, the prolonged period of incubation in hydrophobia, the fact that in this disease the spasms affect the muscles of deglutition, and not those of mastication, as in tetanus, and are not tonic in their character, and that the respi- ratory embarrassment is due to spasm of the laryngeal muscles, and not to those of the chest, will suffice to distinguish between these affections if any doubt should otherwise exist. The pseudo-hydrophobic symptoms AAThich are sometimes manifested in the course of other affections of the nervous system are distin- guished, as a rule, by the absence of the general reflex excitability which is a marked feature of genuine hydrophobia. The development of symptoms closely 128 AN A MERIC A N TENT-B O OK OF S UR GER Y. simulating genuine hydrophobia, through the effects of fear and anxiety, in persons of highly excitable and imaginative temperament AAho have been bitten by animals which Avere not rabid, is Avell authenticated. Such cases may even proceed to a fatal termination, although, as a rule, under appropriate treatment recovery takes place; which fact is sufficient to demonstrate that the case was not one of true hydrophobia. Upon the result of an examination of all the circumstances that surround the case must depend the conclusion as to the real character of such an attack. Prognosis.—The prognosis is absolutely hopeless in genuine hydrophobia when once the symptoms of the disease have declared themselves. Treatment.—Palliative treatment is all that any case admits of, but the utmost importance attaches to prophylaxis. The patient should be kept in a dark and quiet room, and as absolutely free from every source of agitation as possible. Morphia should be administered hypodermatically in amounts suf- ficient to relieve pain. The severity of the spasmodic paroxysms should be mitigated by inhalations of chloroform. Thirst should be relieved as far as possible by rectal enemata. Prophylaxis.—Every wound inflicted by a possibly rabid animal should be subjected as soon as possible either to free excision or to thorough cauteriza- tion. In any interval that must elapse until this can be done constriction should be applied upon the proximal side of the Avound if possible. If the part bitten is one in w7hich the knife can be used freely, excision is preferable, the cuts being made wide of the bitten part, the resultant wound being thoroughly disinfected and sutured or treated openly as its special conditions may require. If cauterization is more feasible, it should be done with the actual cautery if possible, which should be applied deeply and thoroughly. Of chemical caustics, caustic potash or fuming nitric acid is to be preferred. Prophylactic inoculations with emulsions of the dried spinal cords of rab- bits infected Avith hydrophobia, after the method of Pasteur, have certainly been proved to be of value in establishing absolute immunity against the strongest hydrophobic infection if the series of inoculations is completed a sufficient time before the actual development of constitutional symptoms. The earlier the inoculations are begun after the infection has been received, the greater the certainty of the immunity conferred by them. The practical appli- cation of the method depends upon the discovery that the virulence of such infected spinal cords may be reduced progressively from the highest degree to nothing, according to the length of time during Avhich the cord is preserved in a dry and pure atmosphere, fourteen days' drying being sufficient to destroy all virulence. Injections are made, beginning Avith emulsions of the weakest virulence and passing gradually to the strongest. The duration of treatment varies slightly according to the severity of the bites. In bites about the head the incubation period is often very short; in such cases, therefore, promptness of action is especially necessary, and in order to save time the number of injections made during the earlier days of the treatment is increased. Institutions for carrying on this method of treatment have been established in various parts of the Avorld. The result of these inoculations, made at the institute of Pasteur during the five years 1886-1890, is, that of 7925 persons who had been bitten by animals either proven by experiment to have been suffering from rabies or recognized by veterinary surgeons as suffering from that disease, and who had then submitted to the inoculations, only 73 had died, a mortality of but 0.92 per cent. In yieAv, therefore, of these results, and in vieAV of the great danger of the possible development of hydrophobic symp- toms in a person bitten by an animal suffering from rabies, and the utter hope- CONTUSIONS AND WOUNDS. 129 lessness attending the progress of such an attack, it Avould be the part of wisdom in all cases of bites from presumably rabid animals to subject such patients to the Pasteur treatment if possible. GLANDERS (FARCY ; EQUINIA). Glanders is a contagious, eruptive, ulcerative disease, primarily of horses and their congeners, asses and mules, caused by their infection with a specific micro-organism, the bacillus mallei (p. 9). It is capable of being transmitted to men, as well as to many of the lower animals, by inoculation. The special manifestations and course of the disease vary much, being dependent upon the location and character of the tissues first inoculated and the amount and viru- lence of the inoculating material. The bacillus of glanders is a small rod, someAvhat shorter and broader than the tubercle bacillus ; it is either straight or slightly curved, rounded at its ends, and is usually found in pairs, the tAvo lying parallel Avith each other and held together by a delicate pellicle. The existence of spores is in doubt. The bacilli may be killed by exposure for ten minutes to a temperature of 131° F. (oo° C). Carbolic acid in o per cent, solution destroys them in five minutes, and corrosive sublimate in 1 : 5000 solution in tAvo minutes. Their tenacity of life under ordinary circumstances is great, so that virus that has been in the dried condition for many months may be effective. Etiology.—Infection occurs usually through some abrasion or wound; the possibility, hoAvever, of infection through an unbroken skin by rubbing the virus into the hair-follicles has been demonstrated. Inoculation through an unbroken surface along the mucous lining of the nasal and respiratory pas- sages, or the conjunctiva, is not rare through the lodgment thereon of par- ticles of infected muco-pus deposited there by the snortings of infected animals. As a rule, diseased horses are the source of infection in the human subject; in rare instances the disease has been transmitted from man to man. But a small proportion of the persons Avho are exposed to infection develop the disease. Pathological Anatomy.—The histological changes determined by the presence of the bacillus in the tissues consist of a Ioav grade of inflammation, resulting in the formation of nodules of embryonal or granulation-tissue, AAhich speedily break down into pus, forming more or less extensive abscesses, which, when they open upon free surfaces, degenerate into ill-conditioned phagedenic ulcers with undermined edges, surrounded by extensive areas of inflammation. Dissemination of this series of diseased processes may take place throughout all the organs and regions of the body by continuous exten- sion, by transmission along lymphatic channels, and by emboli carried in the blood-stream. The lesions of glanders appear first in the skin and the subcu- taneous cellular tissue, and upon the mucous membrane of the nares and respi- ratory passages. Post-mortem examinations shoAV similar lesions in the lungs, many of the muscles, the larger joints, and the great viscera. The cartilages and bones are likeAvise involved, sometimes primarily, but more frequently secondarily through contiguity. The lesions of ordinary pyemia are super- added to the specific lesions of glanders as soon as the suppurative processes become at all general. Symptoms.—The symptoms that follow infection with glanders maybe rapid in their course, manifesting a high grade of malignancy, and terminating in death Avithin two or three Aveeks. or they may be slower in their develop- ment and progress, extending over a period of many months; hence the classi- fication Avhich has been made into Acute and Chronic Glanders. When the 9 130 AN AMERICAN TENT-BOOK OF SURGERY. lesions are Avell marked and abundant in the skin, the special term Farcy has been applied, more particularly to the disease among horses. After infection a stage of incubation of varying length elapses, usually of but a feAv days, but possibly prolonged to two or three Aveeks. Arague symptoms of general malaise usher in the special symptoms of the disease; an inflammatory nodule appears at the point of inoculation, attended with pain and an extend- ing zone of inflammatory congestion, involving especially the lymphatic trunks; fever develops; the primary nodule suppurates and breaks doAvn into an ill- conditioned phagedenic ulcer. If the primary lesion is in the mucous mem- brane of the nose, the progressive ulceration soon destroys the soft parts and attacks the bones, the neighboring tissues of the face, pharynx, and palate become involved, and the whole of the face and neck becomes swollen and inflamed. In the further course of the disease, Avithout regard to the seat of the primary lesion, multiple nodules develop on different parts of the skin; these quickly suppurate and degenerate into offensive ulcers, or larger sAvellings and abscesses are formed which become converted into extensive and deeply- burrowing ulcers. These diffused skin lesions may appear Avithin one or tAvo days from the onset of the attack, or their appearance may be delayed some weeks. In the second or third week of the attack an outbreak occurs upon the mucous surfaces, primarily that of the nose if it has not been the seat of the original lesion. Other mucous surfaces—of the eye, mouth, fauces, respiratory and gastro-intestinal tracts—rapidly take on the same conditions. If the infection has been an internal one, the gastro-intestinal disturbance, the fever, and the general prostration may cause the case to simulate for a time typhoid fever. The due development of external manifestations suffices in time to correct the error. In cases running an acute course febrile exacerba- tions become marked. The emaciation and prostration increase, all the symp- toms of profound septic infection develop, Avith delirium, terminating in stupor and final death in collapse. In some cases the fatal result is accelerated by the disturbances consequent upon bronchial and pulmonary conditions. In those cases which pursue a chronic course the development of the lesions is more gradual and less generalized. The constitutional symptoms depend upon the number, size, and situation of the local lesions, and upon the amount of general septic infection which is present. Often, cases after pursu- ing a chronic course for a time take on an acute character and rapidly hasten to a fatal termination; in other cases death occurs from exhaustion and septicemia or from pulmonary and bronchial complications. Many chronic cases, hoAvever, ultimately display a gradual amelioration of all the symptoms; cicatrization of the ulcers and healing of the abscesses slowly take place, and eventual recovery is secured, more or less perfect, but the patient is ahvays seriously crippled. The average duration of the chronic form is about four months. Diagnosis.—The acute form in its earlier stages is liable to be confounded with acute suppurative lesions, and even, in some of its manifestations. Avith rheumatism and typhoid fever. Its later manifestations may be referred to pyemia, which usually complicates it, but when the local phenomena are' once fully developed the diagnosis is free from uncertainty; the knoAvledge that a patient has had to do Avith horses Avill aid in forming a diagnosis. The chronic form is more likely to be confounded Avith syphilis or tuberculosis. Where doubt exists search should be made for the specific micro-organisms in the nodules or the discharges; their detection Avill render the diagnosis positive. Inoculation experiments on animals may also be resorted to. Prognosis.—The acute form of glanders is always fatal. When it man- CONTl \SIONS A ND 11 'O UNDS. 131 ifests a tendency to run a chronic course the prognosis is relatively favorable, for about one-half such cases ultimately recover. As long as the lesions remain limited to regions accessible to direct surgical treatment hope may be enter- tained of securing a cure. Treatment.—Prophylaxis is of the utmost importance. This consists simply in the immediate destruction of all animals affected or suspected; the burning of all substances soiled with the infecting discharges; and the utmost carefulness on the part of all persons having to do with infected animals to guard against the possibility of inoculation. When a point of inoculation has occurred, immediate thorough disinfection and cauterization should be done. If nodules and abscesses develop, they should be at once thoroughly laid open, curetted, and disinfected. Chloride of zinc in solution, 1 : 8, is to be recommended for such disinfection. All sur- faces that have been affected should be subjected to continuous antiseptic applications. The general treatment must consist of tonics, nutrients, and stimulants freely administered. Fi.j. 13a. ACTINOMYCOSIS. Actinomycosis is an infectious disease due to the presence in the tissues of a peculiar fungus, termed actinomyces (ray fungus), and characterized by the development of tumor-like masses at the points of infection, Avhich readily undergo softening and suppuration, Avith continuous extension of the original process into adjacent tissue (Fig. 13a). Etiology.—The source from Avhich the infecting fungus is derived has not been determined. The disease has as yet been found only among herbivor- ous and omnivorous animals, including man. The medium of infection is probably some article of food. The recognition of the disease as a specific one is of recent origin. Bollinger first, in 1877, described the relation of the fungus to certain swellings of the loAver jaw in cattle. Its recognition in man is due to the labors of Israel and Pon- fick, especially the latter, the results of whose researches Avere published in 1882. Since at- tention was called to it many cases, not a feAv of Avhich have occurred in the United States, have been identified by different observers. The disease has heretofore been confounded with sarcoma, since the granulation-tissue which composes the greater mass of the tumors has the microscopical structure of the round- cell sarcoma. Section through the tumor, hoAV- ever, Avill show many soft, sulphur-yellow col- ored spots in strong contrast Avith the general reddish tissue of the growth. If the tumor has already- fallen into suppuration, the pus will be found to contain numbers of sulphur-yelloAv miliary ■ bodies; these are frequently united together in clusters, and have a soft consist- ence and an unctuous feel. By pressure these clusters are easily separated into smaller gran- ules. These little granules, Avhen vieAved under the microscope, are found to consist of intertAvined mycelia, the single threads of Avhich have bulbous ter- mini. In many cases a single filament Avill terminate in a mass of bulbs Actinomycosis. 132 AX AMERICAN TENT-BOOK OF SURGERY. branching in various directions. A frequent, and apparently the highest, type of development is when the granule is composed of a multitude of filaments radiating from a common center, their bulbous termini presenting upon the periphery. That this ray fungus is the specific cause of the disease has been established by cultivation and inoculation experiments. Pathological Anatomy.—The primary effect of the lodgment of the fungus in the tissues is to excite a Ioav grade of chronic inflammation, resulting in the accumulation of a mass of granulation-tissue, in the midst of which the fungus is imbedded. By the continued formation and accumulation of such masses sAvellings of considerable size result. The disease may remain stationary in this stage for an indefinite time, though, as a rule, degenerative processes begin early, the breaking down of the tumor resulting from a process of sup- purative inflammation. The fungus is probably not itself pyogenic ; the sup- puration that occurs is due to secondary infection Avith pus-microbes. Symptoms.—In cattle the disease occurs most frequently in the lower jaw, hence the name "lumpy jaAv" by Avhich it has been characterized; in man, likeAvise, the lower jaAv is most frequently affected, and in a very large propor- tion of cases the disease has its site in some tissue adjacent to the mouth (of 73 cases reported by Moosbruegger, in 41 the jaAvs, mouth, throat, tongue, or oesophagus Avere involved; in 14, the respiratory tract; in 11, the intestines; in the remaining 7 the point of infection was not ascertained). Wherever the disease is, the symptoms are those of an ill-defined, slowly-increasing swelling. The lymphatics are not involved, and there are no glandular enlargements until secondary infection has occurred; suppuration sets in early when the growth is in regions most likely to be infected Avith pus-microbes. A chronic abscess is noAV inaugurated, and the local and constitutional symp- toms which follow are due to the activity of the secondary infective pro- cess and the extent of the septic infection Avhich results. Diffusion of the actinomyces, Avith the development of the disease in distant organs and parts of the body, may occur when the fungus or its spores have obtained entrance into the general circulation through an opening in a vein-Avail Avhich may have occurred during the process of ulceration : such general dissemination is of rare occurrence. In general, the disease remains localized, and extends steadily from the original point of infection into adjacent tissues, invading every tissue with which it comes in contact, irrespective of its anatomical structure. Before suppuration takes place the swelling is quite firm on pressure and free from pain and tenderness; the condition of suppurative inflammation, once established, favors the growth and extension of the specific disease by setting free and dif- fusing the actinomyces. The pus discharging from actinomycotic abscesses always contains the actinomyces, Avhich can usually be detected by the naked eye as minute yellowish granules. Diagnosis.—The presence of the specific fungus in the granulation-tissue or mingled Avith the pus is the one diagnostic feature of actinomycosis. It has been most frequently confounded Avith sarcoma; in some of its manifestations it may be mistaken for syphiloma or tuberculosis; sarcoma does not suppurate and break <1oavii as early as the actinomycotic granuloma. Tuberculosis is attended with glandular infection, actinomycosis, previous to secondary infec- tion, not at all; in suspected syphiloma adequate specific treatment will suffice to establish its presence or absence Avithin a few weeks. In any case, resort to the microscope should be made as early as possible, and the detection of the fungus will positively establish the diagnosis. Prognosis.—The clinical course of actinomycosis is that of a malignant tumor. Without radical surgical treatment it tends to indefinite extension, and SYPHILIS. 133 ultimate death by exhaustion, sepsis, or pyemia. When the disease is early recognized and the affected part is susceptible of thorough extirpation, a cure may be obtained. Treatment.—Absolute extirpation of all infected tissue is the only treat- ment Avhich can avail. This should be done by the knife, as far as possible by incisions carried through sound tissues at some distance from the visibly infected part. If this is impracticable, the abscess-cavity should be freely laid open, the fistula? and overlying infected tissues excised as far as possible, and the remaining cavity thoroughly curetted; and, finally, the actual cautery should be applied to the surface remaining. The wound should be kept open and the curetting and cauterization repeated as often as any suspicious points show themselves. CHAPTER XVII. SYPHILIS. Syphilis1 is an infectious, contagious, and inoculable disease, transmissible also by heredity. It first manifests itself by an indurated or infecting chancre, folloAved by general lymphatic enlargement, afterward by eruptions of the skin, usually symmetrical and at first superficial, and by allied conditions of the mucous membranes, later by chronic inflammation and infiltration of the cellulo-vascu- lar tissue and bones and periosteum, and finally by special productions in the form of small swellings, which may invade any tissue or organ of the body, but chiefly involve the connective tissue, and are known as gummata. During all the acute symptoms, and for a period extending over several years, the patient has acquired an immunity against fresh infection. The dis- ease is probably caused by the entrance of a specific microbe into the system, and although the final and conclusive evidence, consisting of the isolation, cul- ture, propagation, and re-inoculation of the micro-organism, is still lacking, the clinical facts alone are sufficient, in the light of our present knowledge of the microbic diseases, to place syphilis in that class. Considered in this man- ner, as has been done by Finger, the various symptoms and stages of syphilis are to be explained as folloAvs : The general symptoms in the primary stage of syphilis—the languor, fever, malaise, pain, etc.—are due to intoxication by the ptomaines produced by the virus, as these symptoms are too ephemeral and changing to be ascribed to localizations of the virus. In the secondary stage the various eruptions on the skin and mucous membranes are caused by local deposits of the virus. Their virulence proves this; but a great many of the so-called secondary symptoms are of intoxicative character, being due to tissue-products passing into the cir- culation, and causing a general, often severe, nutritive derangement. After the second stage comes a long stage of latency—for many a period of cure; for others, only an interval between the second and third stages. That the virus still exists in the body is shown in many cases by its hereditary transmis- sion. The general health is not perfect. The immunity against fresh infection 1 The histology and pathology of syphilis will doubtless before long have to be rewritten from the bacteriological standpoint. At present the observations of Cornil are the most accu- rate and reliable in our possession, and have been closely followed in this work. (See Cornil On Syphilis, American edition.) 134 AX AMERICAN TENT-BOOK OF SURGERY. is the chief characteristic of the above latent period. We do not know how long it lasts, but its duration is certainly limited, in some cases at least, as the undoubted cases of re-infection show. The immunity, as mentioned, began even in the primary period. It is an immunity only against fresh virus. The first virus which caused the infection may still cause relapses. The immunity in the primary stage is due to tissue-products of the virus in the circulation, the infected foci being still strictly localized. In support of this there is the undeniable fact that, under certain conditions, persons may acquire immunity against syphilis without passing through its stages. Heredi- tary syphilis teaches us this. The specific products of syphilis have been taken into account in explaining the following tAvo kinds of immunity from syphilis : 1. Colles's immunity ; 2. Profeta's immunity. By Colles's immunity is meant that which is shoAvn by those healthy mothers who, owing to syphilis in the father, have borne syphilitic children, but have themselves apparently escaped infection. This immunity has been proved in thousands of cases, and there is no longer any doubt that it may exist. Caspary and Neumann even inoculated without result, and Finger has done so three times. The immunity in such cases is due to the tissue-products of the syphilitic virus Avhich have passed from the foetus, by diffusion, into the maternal circulation, causing immunity from syphilis without the symptoms of syphilis. It is true exceptions are pub- lished, .but they are feAv and uncertain. Profeta's immunity (" la hi de Pro- feta," Fournier) is the immunity of the children of syphilitic parents, either or both being syphilitic. The children in many such cases are born healthy and remain healthy, but some of them are proof against the contagion of syphilis just as if they had had the disease. This immunity also is due to tissue-products of the virus passing into the foetal blood, and not to the entrance of the virus itself. In fact, all immunity from syphilis (and the same holds with all other infec- tious diseases) is due to the "tissue-products" of its organized virus passing into the circulation; for (1) this immunity occurs even in the primary period; (2) it outlasts the period of activity, and even that of the presence of the virus in the body; (3) it can be transferred independently of the virus itself. How this immunity is to be explained essentially is, however, still an open question. Tertiary symptoms are not due to the syphilitic virus per se, but to its tissue- products. A moderate amount of tissue-products of the virus (or only slight virulence or greater resistance of the body) causes simple immunity; an increased amount or greater virulence of morbid products of the virus causes tertiary syphilis. It has frequently been asserted that there is no relation between the vari- ous stages of syphilis, as there is none betAveen the character of the syphilis of the person who supplies the poison and that of the one aa^o receives the infec- tion. Certain cases, hoAvever, will be grave or "malignant" from the earliest period, and the dosage of virus or a feeble power of resistance in normal cells may Avell be factors in determining this gravity. The definition given above includes all the periods of the disease, which are as folloAvs: First. Period of primary incubation, or that intervening betAveen the exposure to contagion and the appearance of the chancre, on an average about three Aveeks. Second. Period of primary symptoms (chancre and adenitis). Third. Period of secondary incubation, or that between the appear- ance of the chancre and the development of secondary symptoms, on an aver- age about six Aveeks. SYPHILIS. 135 Fourth. Period of secondary symptoms (syphilides of the skin and mucous membranes, mucous patches, roseola, papules, pustules, etc.). This period may last from one to three years. Fifth. Intermediate period, during Avhich there may be no symptoms, or irregular, slight, and less-symmetrical and less-generalized manifestations. The patient is protected as regards fresh contagion, but if he begets children they are likely to suffer. This period is very variable, lasting from two to four years and ending in complete recovery or in Sixth. Period of tertiary symptoms (tuberculo-ulcerous syphilides, periostitis, osteitis, gummata, etc.). The duration of this period is unlimited. This separation of syphilis into periods is, to a certain extent, artificial, but it corresponds, however, to the course of most cases, and is desirable fof pur- poses of dogmatic description. In considering the methods of transmission of syphilis, it must never be forgotten that it is not necessarily a venereal disease. While it most fre- quently has its origin in sexual connection, yet it quite often occurs from the- contact of the buccal mucous membrane of a nursing child with the nipple of its nurse, or vice versa, or by the common use of the same drinking-glasses, etc., or midwives and physicians may be infected in practising the vaginal touch. It is the secretionfrom a chancre or mucous patch which most frequently determines the disease : the result is always an infecting chancre. The theory of the trans- mission of syphilis from all the lesions of venereal disease—i. e. the doctrine of the identity of gonorrhea and chancres—prevailed Avithout opposition dur- ing several centuries. At the present time it is entirely abandoned. When a person is exposed to impure connection, the lesions do not imme- diately intervene; there occurs a period of from tAvo to four Aveeks, an aver- age of tAventy-one to twenty-five days, before any symptoms appear, and some- times a longer time elapses—six Aveeks or tAvo months. This period of incubation, Avhich precedes the appearance of the indurated chancre, is knoAvn as the period of primary incubation. Whenever an inoculation, Avhether intentional (as in some unjustifiable experiments Avhich have been made) or accidental, Avith the secretion or pus of a secondary lesion or Avith the blood, is successful, it produces a chancre, preceded by this long period of incubation, and the symptoms of syphilis are then developed in their regular evolution and successively appear. Mucous patches and moist papules not only have the poAver of causing a chancre and syphilis by contact, but are probably the most frequent source of its transmission. Syphilis transmitted by a syphilitic nursing infant suffering with mucous patches of the lips is seen as a chancre upon the nipple of the nurse, provided the latter is not its mother and has never had syphilis. Again, syphilitic papules of the nipples of a syph- ilitic nurse occasion a chancre upon the lip of a healthy infant. Secondary lesions of syphilis may extend over a long time. Syphilis may thus be communicated by a syphilitic person for several years after the begin- ning of the disease. In marrying during this period there is danger of com- municating the disease to the Avife and of having syphilitic children. There has been, as far as Ave knoAV, not one trustAvorthy case of the trans- mission of syphilis by means of any of the normal secretions, even Avhere the most careful and persistent attempts at inoculation have been made. Thus there are no reliable cases of syphilitic contagion by the spermatic fluid or of inoc- ulation by this liquid. The tears and saliva obtained from syphilitic persons have been inoculated upon healthy persons Avithout producing the disease. As the blood itself is undoubtedly contagious and inoculable, while the fluids of the various secretions do not possess these properties, it is very probable that 136 A A AMERICAN TENT-BOOK OF SURGERY. the passage of the serum of the blood through the glandular membranes and cells arrests the contagious particles and renders the secreted fluids harmless. Whatever may be the lesion or fluid or organism which determines the trans- mission of syphilis, it appears that except in cases of hereditary syphilis the result is always the same, and is an infecting chancre, preceded by a period of incubation. SECTION I.—PEIMAEY SYPHILIS. The Chancre.—We are not in possession of absolutely conclusive evi- dence as to whether or not the virus of syphilis remains localized during the period of primary incubation, but it is probable that when inserted under the skin it remains there a certain length of time Avithout any other action than gradually to prepare the cells Avhich are in immediate relation with it for the hyperplasia which soon constitutes the chancre. The chancre always appears at the point of inoculation. If we suppose that the syphilitic poison is from the first carried everywhere in the economy, it is difficult to understand Avhy there is not, during one or two months, any other lesion elsewhere than at the point of entrance. The primary lesion is invariably met with at the point inoculated, never elsewhere; and secondarily, a neighboring gland is swollen after the appearance of the chancre, then sev- eral glands; such glands, as we know from our study of other diseases, arrest for some time the diffusion or generalization of morbid products and tumors. This conception of the localization of the virus at the beginning of the con- tamination is very important in a practical point of view. It would indicate that the destruction of the chancre at the moment of its appearance would pre- vent syphilis. While there is great difference of opinion among syphilogra- phers upon this point, the weight of authority is against the probability of the abortion of syphilis by excising or otherwise destroying the chancre. Most authorities are agreed, hoAvever, that cauterization or excision of an abraded or absorbing surface soon after exposure, and before the development of the chancre, is strongly indicated, and has probably in several cases prevented constitutional infection. The infecting chancre has a period of incubation varying from ten days to six weeks, the average being about three weeks. It is an excellent general rule for prognosis in cases of suspicious ulcers upon the genitals to assume that if an interval of ten days or more has elapsed between the last exposure to contagion and the development of the sore, the latter is probably the initial lesion of syphilis. It begins sometimes by a superficial papule, which generally extends in circumference and depth; sometimes by an excoriation or a superficial fissure, often very slight. As it spreads upon the skin there are seen accompanying redness and desquamation of the epidermis; upon the mucous membranes a superficial abrasion or an ulceration covered by a grayish or yellowish false membrane ; there is also observed an induration, sometimes giving the sensation of a hard nodule, fibrous or cartilaginous; at other times, that of a thin plate like parchment or paper. There may be no absolute loss of epidermis over the surface of a chancre, but merely a gradual thinning of the epidermic layers from the margins of the sore toward its center. Ulceration, when it exists, is a simple cup-shaped depression ; its surface is smooth and the margins are not abrupt. At the center of the chancre there is found a false membrane, beneath which is a raAV vascular layer, bleeding readily. Section of a chancre shows, in addition to the usual lesions of cutaneous SYPHILIS. 137 inflammation, a special and characteristic change—a sclerosis or thickening of the coats of the venules and arterioles, affecting chiefly the tunica adven- titia. This thickening of the arterioles and venules is very important. In con- nection with the preservation of the firm trabecuhe of the derm and of most of the fasciculi of the connective tissue and of the elastic tissue, it gives to the infecting chancre its most essential clinical character—the induration. The induration may be either superficial or deep, depending upon the arrangement of the vessels, which form on the skin two horizontal networks— one beneath the papilhe. the other deeper at the base of the derm. When the former is affected Ave have a superficial induration. If the sclerosis has involved at the same time both sets of vessels, the intermediate branches being equally affected, we have a more extensive nodule, varying in thickness according to the region of the skin involved. In the first case the induration is foliaceous or parchment-like; in the sec- ond it is woody and gives the sensation of cartilage. Almost always the sclero- sis is continued along the coats of the vessels farther than the induration itself. These lesions do not develop very rapidly; which fact, taken in connection with the changes of the tissues involved, explains the long duration of a chan- cre and the persistence of the indurated nodule. The induration of a chancre usually occurs at the end of the first Aveek, dating from its appearance ; it may not show itself until much later. The indu- ration is progressively developed from the surface—that is, from the papillary network—to the deep cutaneous and subcutaneous layers. The variations in thickness of the affected part give rise to different degrees of induration. Laminated induration is thinner and less distinct than the parchment variety, and gives to the fingers the sensation of a piece of paper. Parchment induration is that which gives to the fingers applied to the cir- cumference of the chancre the sensation of a piece of parchment forming the base of the erosion. Nodular induration is that in which the base of the chancre is hard and thick, feeling betAveen the fingers like a nodule of cartilage or Avood; it is the most characteristic. Annular induration is that in Avhich only the margins of the chancre are indurated and form a hard ring, the tissue in the center retaining its normal elasticity. The most readily recognized and the most characteristic chancre has the shape of a cup-like depression seated upon the indurated and elevated skin. The histological relations of the connective tissue and vessels beneath the chancre Avill explain the anatomical reasons for these several forms of indura- tion. The laminated or parchment induration corresponds to a sclerosis limited to the papillae of the derm and to the vascular netAvork of the papillae; deeper or nodular induration corresponds to a sclerosis of the cutaneous and sub- cutaneous connective tissue and of the vascular network of these parts, Avhich latter is much larger than the superficial network, and is therefore slower in forming and in disappearing than a similar lesion of small vessels. Traces of induration have been observed four or five years after the begin- ning of the chancre. Ricord has found remains of the induration ten and fifteen years subsequent to the primary lesion. The induration and its extent are best appreciated by seizing the chancre at its margin betAveen the thumb and finger, draAving it upAvard, so that it may move upon the subcutaneous tissue, and then using slight pressure in a direc- tion parallel to the surface of the chancre. The degree of induration varies very much according to the seat or region 138 AX AMERICAN TENT-BOOK OF SURGERY. of the primary lesion. When occurring upon the glans penis, upon the mucous membrane of the prepuce, or in the fossa glandis, the chancre is generally very distinctly indurated ; upon the skin of the penis and upon the general integu- ments the induration is not so marked or so extensive. In women the indura- tion of the chancre is greater upon the labia majora than upon the labia minora and fourchette. The induration of an infecting chancre is not only variable, but, in rare cases, it may be absent. Therefore it is not positive and constant, and Cornil believes that induration is a symptom less important in infecting chancre than the characters of the erosion and the condition of the surface of the chancre, especially if, in addition to these, Ave take cognizance of the several indurated, movable, painless, and hypertrophied lymphatic glands, which never suppurate unless the chancre has been irritated by caustic or other applications folloAved by infection with pyogenic microbes. The induration generally does not remain at its height longer than three or four Aveeks, and the chancre heals entirely in five or six weeks; but the indu- rated nodule, if it Avere primarily large and cartilaginous, may persist and be still recognizable for years. According to Fournier, three times in four the indurated chancre is single. Multiple infecting chancres all begin at the same time, for the primary lesion of syphilis is not, as a rule, auto-inoculable, and therefore it has no tendency to be reproduced alongside of the primary sore, as is the case with chancroid. The appearance of infecting chancre is varied. BetAveen an erosion or slight abrasion situated upon a parchment-like base that may be readily over- looked, and an ulceration Avith a nodular cartilaginous base of considerable size, as large as a quarter of a dollar, there are found several intermediate degrees. The most frequent seat of chancres is the genital region; they are very seldom met Avith upon other parts of the body ; this is especially true with men, less so in the case of Avomen. The usual seat of chancres of the genital organs Avith men is the glans penis, the internal surface of the prepuce, and especially the fossa glandis and frenum. Three-fourths of all chancres are found in these localities. At times they are found upon the skin of the penis, at the meatus urinarius, upon the scrotum, in the urethra, or upon the groin. In women the labia majora are the most common seat of genital chancres; then folloAV the fourchette, the labia minora, the clitoris, the skin of the pubes or groin, the neck of the uterus, etc. It is doubtful if an infecting chancre has in a single instance been found upon the vagina, and yet this canal is certainly the part most exposed to con- tagion. This immunity may possibly be due to the structure of the vaginal mucous membrane, which is covered with thick layers of pavement epithelial cells, and to the absence of glandular orifices over its entire surface ; the vaginal mucous membrane possessing papillae and prominent villi, but no glands. Extra-genital chancres, particularly those of the anus, are very much more common in Avomen than in men. Yet all chancres of the anus in women do not indicate unnatural sexual relations: the anal orifice is so situated that in dorsal decubitus the fluids from the vulva Aoav over and often contami- nate it. Anal chancres are usually situated at the margin of the anus, at the bottom of one of the radiating folds of skin produced by the contraction of the external sphincter. The ulceration is apt to follow the lines of these folds, and thus to assume an elongated or linear character. They are hard, and do not give rise SYPHILIS. 139 to the painful symptoms of fissures of the anus. They have been observed as high as the upper margin of the internal sphincter. The seats of extra-genital chancres are the anus, mouth, lips, tongue, uvula, palatine arches, tonsils, cheek, nipple, etc. A cephalic chancre is almost ahvays infecting. Chancroid is scarcely ever seen upon the lips or face. Chancroid.—The form of sore variously knoAvn as soft sore, soft chancre, simple chancre, non-infecting chancre, and chancroid is variously ascribed to the inoculation of a specific virus (the chancroidal), to infection Avith pus- microbes, and to a mixed (syphilitic and purulent) infection. There is, Iioav- ever, every reason to think that there is no peculiar nor specific virus for chan- croid, the older vieAArs to the contrary being noAV nearly if not totally disproved and abandoned. No final conclusion can yet be stated, though bacteriology Avill doubtless definitely settle the matter at no distant period. In the mean time, avc may be content to consider chancroid as a sore Avhich has a very different appearance and runs a very different course from an infecting chancre. In the case of a chancroid there are observed from the first certain phe- nomena. The first day avc see a small red point, which on the second day becomes a papule, and is converted into a pustule by the end of the second or third day, especially in a region Avhere the skin is delicate. The pustule soon breaks, and beneath the lowest epidermic layers we,find a deep suppurating ulcer, Avhich rapidly extends in circumference and depth, becoming at the end of the first Aveek deep and crater-like with perpendicular or undermined edges; its surface is granulating, irregular, and infiltrated with pus, Avhich is abundant and gives it a grayish color. The serum upon the surface of an indurated chancre, on the contrary, is small in amount and transparent. In the chancroid there is no sclerosis of the vascular Avails : we meet Avith the phenomena of inflammation, but there is no induration or thickening of the Avail and no narroAving of the caliber of the vessels. The fibrous trabeculse of the derm of the region involved are not preserved intact. The fibrils sepa- rated by the lymph-cells are themselves destroyed by the softening of the tissue and by the suppuration. These changes upon the surface of a chancroid result in the fibrous tissue losing its firmness and elasticity ; its fibrous trabecular have a tendency to disappear. The lymph-cells, Avhich collect in great numbers in the granulations and neighboring connective tissue, are large, turgid, and become free by softening the fibrils betAveen Avhich they are placed. The absence of specific induration comparable to that of the indurated chancre, and also a tendency to a progressive destructive involvement of neigh- boring tissues, result from this anatomical arrangement of elements. From this it will be seen that between chancre and chancroid there is a marked histological difference, one being essentially a prominent papule or new groAvth, the other an ulcer. A chancroid is apt to be painful and itching; the pus, Avhich is secreted in large amount, is inoculable upon the patient, Avho frequently inoculates himself inadvertently or from uncleanliness, so that it is often multiple. When the lymphatic glands are affected there may occur a true suppurating bubo, especially if the patient be broken doAvn in health or if he has been negligent of treatment. In this case an inguinal gland is swollen, fixed, and becomes very large ; the skin reddens upon its surface, and Ave soon feel a super- ficial fluctuation, due to pus formed in the cellulo-adipose tissue surrounding the gland. When this abscess is opened the gland in some cases suppurates, and there is formed an irregular cavity Avhich secretes sanious pus ; the skin consti- tuting its borders is red, inflamed, and separated from the tissue beneath. These glandular abscesses, like the chancroid, sometimes become phagedenic. 140 AX AMERICAX TEXT-BOOK OF SURGERY. • Chancroid is variable in its duration, Avhich is sometimes quite short, last- ing three, four, or five weeks ; at other times it continues several months, and sometimes, if it is phagedenic, one or more years. The diagnosis of chancre is a matter of such great practical import- ance that it may be well, even at the risk of repetition, to enter into it some- what fully :l 1. In dealing with lesions apparently non-venereal in their origin and character Ave should consider carefully the following points: (a) The anatomical situation and the course of the lesion. Among those particularly to be viewed with suspicion may be mentioned herpetiform erosions of the lips, papules on the tip of the tongue, squamous or "scabby" ulcera- tions of the skin, scratches which obstinately refuse to heal, chronic inflamma- tions at the tip of the fingers resembling felons, etc. (b) Indolence, absence of suppurative tendencies, and persistence in spite of treatment are negative signs which should lead us to believe that any cutaneous or mucous lesion is not of a simple nature. (c) If the morbid products are slight, rather serous than purulent, tend to form into crusts or to assume a pseudo-membranous form upon an eroded sur- face, syphilis should be suspected. (d) The consistence of the base upon Avhich the lesion is situated is one of the most important diagnostic points, and should always be carefully investi- gated. If, upon palpation, instead of the usual inflammatory swelling and thickening, shading off into the surrounding tissue, we meet Avith a cartilaginous, elastic, sharply-circumscribed resistance, we may immediately suspect very strongly that Ave are dealing -with a syphilitic lesion, although even this symp- tom cannot be considered as infallible. (e) If the lymphatics of the groin become slightly SAvollen and painful and progress no farther, or if these symptoms occurring in a single gland subside spontaneously, it is probable that they are due to a sympathetic adenitis, such as folloAvs many irritations of the skin or mucous membrane. If, on the con- trary, they steadily augment in size and hardness, are almost painless, and constitute a chain of little tumors including several or all the inguinal glands, it may be considered strong presumptive evidence of specific disease, though even yet not conclusive. In addition to these points the history of the case must carefully be inquired into—the probabilities of infection, in regard to which Ave should not be misled by the beliefs of the patient—and the period of incubation, Avhich, Avhen it can be clearly established, is of great value. Confrontation—i. e. examination of the person from Avhom the disease has probably been contracted—will often, not invariably, decide the matter, but, in this country at least, is rarely obtainable. Difficulties of diagnosis are greatest during the first Aveek or ten days, and steadily diminish Avith the age of the lesion, AA'hich, if syphilitic, is almost cer- tain to assume in time a definite character. The chief points among those mentioned are the period of incubation, the presence or absence of induration, and the condition of the nearest lymphatic glands. If, however, all of these seem to point to syphilis, the experienced observer Avill still refrain from giving a positive opinion, no symptom or group of symptoms being absolutely conclu- sive as to the specific character of any primary lesion; certainty only being attained by the development of some of those general or constitutional phenomena which in from six to eight weeks folloAv the infecting chancre. 1 In doing so we shall follow closely the paper of Ch. Mauriac, which is the best resume" of this subject with which we are acquainted. SYPHILIS. 141 2. The region occupied by a chancre may cause errors or difficulties in diagnosis. (a) In the cephalic region chancres of the hairy scedp, of the supraorbital prominences, and of the chin and cheeks are the most deceptive. They always assume an ecthvmatous form, and are so concealed by the hair that it is impossible to judge of the character of their surface. In all such cases the hair must be carefully shaved, and if Ave then find that Ave are dealing with an ulceration lacking the ordinary characteristics of ecthyma, and glazed, flat, or even elevated, our suspicions should be aroused, and after eight or ten davs will usually be confirmed, if the sore is syphilitic, by the development of induration and of neighboring lymphatic enlargement. Razor-cuts on the chin, cheeks, or lips Avhich, after having healed, reopen and become covered Avith a crust, should on a priori grounds be suspected. This is equally true of pseudo-furuncles, acneiform pustules, cracks around the circumference of the nostrils, etc., Avhich persist Avithout giving rise to pain, and become bloody, encrusted, and surrounded by an area of subinflammatorv, oedematous SAvelling. We should then carefully examine the preauricular, parotidean, and submaxillary lymphatic glands. A stye Avhich behaves in an unaccustomed manner or is accompanied by hyperplasia of the lid, or a conjunctivitis Avhich becomes localized and causes an isolated swelling, should be attentively watched. In the neighborhood of the mouth errors of diagnosis should be less frequent than in other portions of the cephalic region, because it has been shoAvn so often that the lips, tongue, and fauces are frequently brought into contact with syphilitic discharges and constitute one of the principal channels of infection. Here, hoAvever, as elsewhere, the chancre assumes at the very outset the appearance of ordinary lesions. Thus, upon the lips the chap, crack, or fissure often found in the median line, the little aphthous erosions, herpetic ulcerations, and cigar or cigarette burns, simulate very closely the characters of the initial lesion, and, as the latter will almost invariably be attributed by patients to some such ordinary cause, may give rise to serious error. At the end of the first week, however, the specific characters of labial chancre are usually so distinct as to render diagnosis easy. In several instances these chancres have been mistaken for epithelioma, and have been excised. The diagnostic differences may be indicated as follows: Labial Chancre. No marked difference between the sexes. The ulcer may involve either lip. Occurs at any age. Patient often strong and robust. Is insensitive. Regular in outline, smooth surface, elevated. Indurated and sharply circumscribed base. Evolution of sore usually occupies a few weeks at the most. Glandular involvement follows closely on appearance of sore. Xo marked odor from secretion of sore. History of exposure to syphilitic inoculation often obtainable. Heals rapidly or disappears under mercurial treatment. Epithelioma. Twenty times more common in males than in females. Almost invariably situated upon the lower lip. Rarely occurs before middle life. Patient usually in impaired health. Often sharp, burning, lancinating pains. Irregular in outline, ragged, filled with fungous granulations, bleeding easily. Induration less cartilaginous, unequal, not clearly circumscribed, and more extensive. Sore may be months in developing after its first appearance. Glands are not implicated for three or four months, often not until later. Odor often extremely offensive. Frequently no such history. Xot affected or rendered worse by such treatment. 142 AX AMERICAX TENT-BOOK OF SURGERY. While there is a possibility of error in diagnosis between a chancre and an epitheliomatous ulcer Avhen a macroscopical examination alone is made, there is, on the contrary, no such apprehension when a microscopical examination of the lesions is instituted. The histological structure and arrangement are so very distinct and unlike in these lesions that a mistake cannot Avell occur. In the epithelioma we have the ingrowing of the interpapillary layers of epithelial cells, the branching or budding outgrowths from the sebaceous glands Avhich consti- tute the very characteristic epitheliomatous pegs, and the formation of the cell-nests or pearls upon these pegs, which are all so strikingly different, Avhen contrasted with the histological structure of a chancre, that no doubt as to diagnosis remains. Upon the. sides of the tongue ulcerations, produced by the continual contact of that organ Avith rough and carious teeth, have been mistaken for chancres. This error should be guarded against, but is not so serious in its results as the failure to recognize the specific lesion Avhen it is situated at the point of the tongue, the possibility of its communication to innocent people being, in such cases, an element of unusual importance.1 In the first five or six days it is impossible to diagnosticate it, but if the original little inflamed papule enlarges and extends, becoming elevated above the surrounding parts; if its epithelial covering drops off and its surface becomes diphtheritic; if superficial cauteri- zation Avith crayons of nitrate of silver, Avhich so rapidly cure the common small painful papule of the tongue, have no effect upon it,—there is a strong presump- tion that it is chancre. This Avill be confirmed later by the appearance of submaxillary glandular enlargement and induration of the sore. Of all the chancres of the cephalic region, hoAvever, that of the tonsils or of the isthmus of the fauces presents the greatest diagnostic difficulties, on account of the effacement of its characteristics by the surrounding inflam- mation. If in a case of prolonged sore throat there be an appearance resembling a single mucous patch, and there be no history of antecedent syphilitic poison- ing, it becomes probable that the trouble is chancrous; and this probability is greatly increased if any induration can be felt by palpation Avith one finger in the pharynx and another external to its Avails; if enlargement of the glands above the angle of the jaw occurs; or, of course, if the patient confesses to having been peculiarly exposed to contamination. The sore is much more common in this region in females than in males, Mackenzie noting the fact that out of 7 cases of primary syphilis of the ton- sils Avhich he had met Avith, 6 Avere AAromen. (b) Superior and Inferior Extremities.—Chancres of the hands are often seated at the margin of the nail and closely resemble simple AA'hitloAAS. They may be diagnosed by their long duration, their abrupt limitation, the hardness of the tissues around and beneath them, and the consecutive engorgement of the epitrochlear ganglion. Upon the dorsal face of the phalanges the initial lesion at first simulates an inflamed papule or boil, but is less painful, dis- charges no "core," and is elevated, not excavated. The anterior face of the forearm in both sexes, the anterior surface of the thigh in men and the posterior surface in Avomen, are the parts most exposed to contagion. The chancre of vaccino-syphilis occurs after the evolution of the vaccine sore. It can only be confounded with the ulcerations described by Blot under the name of '' vaccinal phagedenism," which are rounded with abrupt borders and indurated bases, and are often accompanied Avith engorgement of the axil- 1 The same remark applies to mucous patches of the tongue and lips with even more force, as they are so much more frequent than primary sores. SYPHILIS. 143 lary lymphatic glands. The diagnosis from appearances is difficult, but may be made by noticing the fact that these sores run an acute course, and are read- ily cured by poultices or emollient applications, Avhich, of course, have no effect on chancre. (c) Upon the trunk the mammary and hypogastric regions are those most frequently involved. In the former locality the initial lesion is most likely to be mistaken for eczematous excoriations, fissures, and small furuncular or papil- lary tumors. The diagnosis rests upon the presence of the characteristic indu- ration, elevation, etc., and upon the poly ganglionic axillary enlargement. In cases where syphilis has been transmitted during suckling confrontation is almost invariably possible and furnishes the most satisfactory guide. Chancres of the hypogastrium are generally large and ulcerating, and are most liable to be mistaken for chancroids. (d) Genital Organs.—The diagnosis of sores situated in this locality is chiefly betAveen chancre, chancroid, and herpetic ulceration. The diagnostic table given beloAv expresses the main points of difference. Chancre. Origin : Due to contagion from a chan- cre, a syphilitic lesion, or blood or pus from a person having syphilis. Incubation: Not less than ten days ; often three weeks ; very rarely six to eight Aveeks. Situation: Most frequent upon the geni- tals. Often seen on the hands, nipples, lips, etc. Commencement: Begins as an erosion, papule, tubercle, or ulcer. May remain without ulceration through its entire course. Number: Single or simultaneously mul- tiple; occasionally, but rare- ly, successively multiple. Shape: Round, oval, or cally irregular. symmetri- Depth : Usually superficial — cup- shaped or saucer-shaped —or may be elevated. Surface: Smooth, shining, red, glazed; diphtheritic membrane or scab. Chancroid. Usually due to contact with pus from a similar sore, or to accidental inoculation of the secretion of a chan- croid upon a person already affected .with syphilis ; of- ten to the irritation of pus from other sources. None. Almost always upon the glans penis or prepuce; rare upon other portions of the genitals; scarcely ever seen elsewhere. Begins as a pustule or ulcer. Often multiple, frequently by auto-inoculation. Round, oval, or unsymmetri- cally irregular, with bor- der described by segments of large circles. Herpetic Ulceration. Mechanical irritation ; fric- tion, as in sexual inter- course ; chemical irritation, as of acrid discharges ; un- cleanliness. Occasionally follows cold or fever ; may be a neurosis. None. Glans penis and inner layer of prepuce. Begins as a group of vesi- cles, which may coalesce or may ulcerate singly. Multiple ent. apt to be conflu- Irregular ; edges serrated or described by segments of small circles. Hollow, excavated, or Superficial. "punched out." Rough, uneven, " worm-eat- Same as local ulcer, but more en,'- warty, whitish-gray- superficial. ish, pultaceous. 144 AN AMERICAN TENT-BOOK OF SURGERY. Secretion: Scanty, serous, auto-inocula- ble with great difficulty, producing either a chan- croidal sore or, in rare cases, a second sore like the first. Induration: Almost always present; firm, • cartilaginous, or parch- ment-like ; circumscribed, terminating abruptly; movable upon subjacent parts ; skin not adherent; usually persistent: disap- pears under specific treat- ment. Sensibility: Very little or no pain. Course: Usually regularly progressive toward health, the sore often healing spontaneous- ly. Phagedena uncommon. Second attack also very rare. Histology: A new cell-growth. Very little destruction of tissue. Bubo: Constant, painless, multiple. Prognosis: Good locally; constitutional syphilis will follow in the great majority of cases, but in a few may not ap- pear or may be prevented by treatment. Treatment: Excision when seen early; other local treatment of minor importance. Abundant, purulent; readily auto-inoculated Only exceptionally present; may be caused by caustics or other irritants, or by simple inflammation ; bog- gy, inelastic, shades off into surrounding parts, to which it is adherent; dis- appears soon after cicatri- zation. Painful. Irregular ; may cicatrize rap- idly or may extend, taking on phagedenic action. No protection against a second attack. An ulceration, with more or less loss of substance. In one-third of the cases; painful, inflammatory, sin- gle. More serious, locally, on ac- count of loss of tissue; occasional refusal to heal, and possibility of phage- dena. Very rarely is fol- lowed by syphilis. Local treatment curative. Moderate secretion; auto-in- oculated with difficulty. Same as local ulcer. Painful. May spread, in exceptional cases, by the appearance of successive crops of vesicles. Usually heals promptly under mild local treatment. Likely to recur, especially in uncleanly patients with long fore- skins. Originally an elevation of the epidermis in spots by an effusion of serum. Rare. When it does occur, painful, single, inflamma- tory. Always good if the diagnosis be absolute. Should be guarded when there is the least doubt as to the her- petic character of the affection. Local treatment curative. Chancres of the meatus are more often syphilitic than simple in their cha- racter. In the former case they are attended Avith little or no ulceration, are confined to one lip of the meatus, are accompanied by the usual induration and glandular involvement, and are often, indeed usually, not discovered by the patient, Avho imagines he has a gonorrhea. Chancroid of the meatus is irreg- ular in shape, ulcerated, involves both lips, is painful, and does not have the characteristic induration. The diagnosis betAveen infecting urethral chancre and gonorrhea may be tabulated as follows: SYPHILIS. 145 Urethral Chancre. Symptoms appear after a period of incuba- tion rarely less than ten days, often two or three weeks. Confined to meatus or its immediate neigh- borhood. Ardor urinae felt only at lips ; no chordee. Discharge moderate, never purulent, often bloody. Induration perceptible to touch, usually in- volving only one lip of meatus. Invariable enlargement of chain of inguinal lymphatics, which are painless and freely movable, and almost never suppurate. Sore can almost always be seen as a loss of continuity of mucous membrane. Constitutional symptoms follow after from six to eight weeks. Use of syringe painful at meatus. Urethritis. Symptoms folloAV suspicious intercourse in from twenty-four hours to a week, rarely at a longer interval. Begins at meatus, but extends some distance backward. Ardor urinae felt along the urethra; chordee often present. Discharge more profuse, decidedly purulent, not so often or so largely stained with blood. No induration. If lymphatics are involved at all, only one is affected, which often goes on to sup- puration. No loss of continuity perceptible. No constitutional symptoms. Use of syringe not usually painful. The small hard tumors which occasionally appear or may be felt along the under surface of the penis during an attack of gonorrhea, and which are due to inflammation and enlargement of the follicles, should not be confused Avith chancre. They usually feel like grains of sand or small peas directly beneath the skin, are situated behind the fossa navicularis, have no characteristic induration, and subside spontaneously or go on to suppuration. When phimosis exists the diagnosis betAveen subpreputial chancres and chancroidal, herpetic, or balanitic ulcerations is often one of great difficulty. It should be founded on the following considerations: Subpreputial Chancre. The incubation is that of chancres, ten to twenty-one days or more. If the site of the original trouble can be felt or can be described by the patient, it will be found to be single. Inflammatory phenomena comparatively slight. Swelling hard, dry, indurated character- istically. The discharge from the preputial orifice is moderate, thin, serous or bloody, not readily inoculable. The margins of the preputial orifice are not markedly inflamed or ulcerated. At some point the induration can probably be isolated from the surrounding tissues and raised and felt between the thumb and finger. Syphilitic buboes are invariably present. Subpreputial Ulceration (non-syph- ilitic). The interval between the exposure and the subsequent ulceration, swelling, etc. is much shorter. Several points of ulceration, abrasion, or pustulation will usually be found or de- scribed. Inflammatory phenomena—heat, pain, red- ness, swelling—very marked. Swelling oedematous. sero-purulent, like that of phlegmonous erysipelas. Discharge profuse, purulent, usually very irritating, and apt to be inoculable, both accidentally and experimentally. Almost invariably ulcerated. This is usually not possible, no distinct dividing line existing. Buboes, if present at all, are of an inflam- matory character. The diagnosis betAveen a new indurated chancre and an ulceration occupy- ing the site of an old chancre, the induration of which has never entirely dis- appeared—''relapsing chancre"—is extremely difficult, and, unless a clear history of the case can be obtained, is impossible. The latter cases are often reported as instances of a second syphilitic infection. The opinion must be 10 146 AN AMERICAN TENT-BOOK OF SURGERY. based upon the presence or absence of a syphilitic history and the circumstances of the exposure, incubation, etc. The possible effect of local irritation on an old indurated mass should ahvays be taken into account. The prognosis of syphilitic chancre, considered as a local affection, depends chiefly upon the seat of the lesion. A chancre of the conjunctiva may give rise to a grave ophthalmia; a chancre of the tongue or of the fauces may cause great debility through interference Avith mastication, deglutition, and digestion. As regards the genital organs, however, the prognosis is almost uniformly favorable. Phagedenic or gangrenous processes are rare, ulceration even is usually very slight, or, if seemingly extensive, is apt to be at the expense of the neoplasm, and not of the normal tissues. The relation betAveen the constitutional disease of which the chancre is the precursor and the sore itself is a question of great interest. It may be at once acknowledged, however, that our information upon this point is deficient. We are able neither to predict the form of local lesion from the character of the source of infection, nor, on the other hand, can we, Avith any accuracy, fore- cast the constitutional condition which will result from any given sore. The varieties of the chancre in form, extent, etc. depend more upon local causes or upon the idiosyncrasies of the patient than upon any special source or pecu- liarity of the virus. Every syphilographer of experience has seen the most Avidely-differing forms of initial lesion derived from the same individual, and a similar diversity exists in the forms of constitutional disease arising from a given focus of infection. The amount of glandular implication is also an entirely unreliable guide and presents all sorts of variable phenomena. The Treatment of Chancre.—Every surgeon whose work has brought him in contact with large numbers of cases of venereal sores must recognize the fact that betAveen the typical soft, suppurating local sore and the distinctly indurated chancre there are large numbers of doubtful ulcers which partake of the characteristics of both : local sores with deceptive inflammatory hardening, and true chancres with equally deceptive inflammatory softening, suppuration, and even loss of substance. Nearly every specialist who has Avritten upon the subject has recognized and been influenced by this avell-known fact. Fournier, perhaps the most eminent living syphilographer, has recorded a case which bears most strongly upon the question under consideration: A female child, six years old, Avas said to have been infected with syphilis during an attempt at rape. She had marked vulvitis, and upon the labia three grayish, shalloAv, indolent, indurated ulcers covered with a diphtheritic- looking membrane and raised a little above the general surface. In both groins there Avere enlarged, multiple lymphatic glands. He positively diag- nosticated chancre, but, conforming to his custom in medico-legal cases, declined to testify for a few days. During this time, under a simple dressing, the symptoms disappeared, and the patient, Avho Avas carefully observed for several months, never showed any subsequent signs of infection. Fournier believes that the case demonstrates that small inflammatory lesions may so closely resemble chancres as to deceive the most experienced surgeon, and adds that in medico-legal cases the diagnosis should not be made upon the local lesions alone, but should depend upon the development of constitutional symptoms. The surgeon who is daily called upon to give an opinion in cases AA'hich involve the whole future of the individual, his relations to the other sex, his determination toAvard celibacy or matrimony, his matrimonial relations if he should be already married, the question of the influence of paternity, the institution of a course of treatment extending over years, the diagnosis of any SYPHILIS. 147 obscure visceral troubles which he may develop later in life, the profoundly depressing mental effect Avhich a knoAvledge of syphilitic infection usually has upon intelligent people,—the surgeon who remembers these facts and recalls the vieAVS above cited as to the possibility of error should surely hesitate about beginning a course of treatment Avhich will possibly obscure or render altogether impossible the diagnosis. While there is no positive advantage in delay as regards the subsequent course of the case, yet, on the other hand, the gain from the immediate treat- ment during the primary sore is not sufficient to counterbalance the doubt and uncertainty Avhich that treatment often throws about the future life of the patient. Certainly the cases are comparatively rare in Avhich a careful surgeon Avould be willing to make an absolute diagnosis of syphilis during the existence of the primary sore alone. A feAv necessary exceptions to this rule may be included under the folloAving heads : 1. Where confrontation is possible and the sore is distinctly a typical one. 2. Where with a typical sore its continued existence Avould destroy or imperil the conjugal relations of tAvo people or possibly the happiness of an entire family. 3. Sores with characteristic induration, but Avith marked tendency to spread and involve important regions. 4. Sores in such conspicuous positions, as upon the lips or the nose, that their continuance would involve a general knoAvledge of the patient's condition. With these exceptions it is the part of Avisdom to Avait until the development of glandular enlargement at some point removed from the initial lesion, and not, therefore, by any possibility a result of simple adenitis, demonstrates the constitutional character of the trouble. It is to be hoped—and, indeed, may be confidently expected—that the progress of bacterial investigation Avill in the near future enable us to make a very early and positive diagnosis, but Ave cannot do so as yet. It is not necessary, hoAvever, to Avait for the syphilo- dermata. Treatment may be safely begun when, after a suspicious sore upon the genitals, consecutive enlargement of the epitrochlear or post-cervical lym- phatic glands takes place. The argument above used against the mercurial treatment of chancre applies Avith equal force to the local abortive measures Avhich have from time to time been recommended. These include excision ; cauterization ; antiseptic measures ; and various local applications of mercurial preparations by means of ointments, hypodermatic injections, or othenvise. Taking them in the order mentioned, their relative advantages and disadvantages seem to be as folloAvs: As to excision, it appears unquestionable that it can be of service in but a very small proportion of venereal sores as they usually come under the notice of the practitioner. The opinions of syphilographers, however, vary greatly in regard to the value of this form of treatment, and in the light of the opposing vieAvs a safe general rule for practice is to assume that a sore seen Avithin a feAv days after its appearance, and as yet unaccompanied by any enlargement of the inguinal glands, is still a localized lesion. If favorably situated—i. e. upon the skin of the prepuce or of the genitals—it may be removed, the surgeon picking up the sore and surrounding tissue with a pair of toothed forceps, and removing it by a single SAveep of the knife or by means of scissors curved on the flat, aftenvard dressing the wound with iodoform or boracic poAvder. By this plan of treatment Ave give our patients Avhatever small chance there may be of avoiding constitutional disease, Avhile at the same time Ave expose them to the minimum degree of local pain and disturbance. When the patient refuses this treatment, or Avhen the sore is so situated that its removal would cause considerable pain, hemorrhage, or deformity, 148 AN AMERICAN TENT-BOOK OF SURGERY. destructive cauterization with fuming nitric acid may be employed. In all cases (and these comprise the majority Avhich come for treatment) in Avhich a week or more has elapsed since the development of the sore, and in which involvement of the dorsal lymphatics of the penis and the inguinal lymphatic glands is observable, cauterization as a routine method of treatment should be rejected, on account of its undoubted uselessness at that stage in preventing constitutional disease; the pain Avhich it causes ; the inflammatory action which follows it, and which often produces enough oedema and swelling to cause phimosis, and thus convert an open sore into a hidden one; the sub- sequent effusion of lymph, Avhich simulates true induration and confuses the diagnosis; and, finally, the greater liability to the production of suppurative action in the ordinarily indolent bubo of syphilis. The so-called antiseptic treatment of the initial lesion of syphilis is a mis- nomer, so far as the essential character of the sore is concerned, unless it be meant to include only the thorough destructive cauterization of all portions of the infected tissue. Applied simply to superficial dressings placed over the chancre, it can refer only to the prevention of the development of pyogenic organisms upon the surface of the sore. As the tendency of infecting chancres to suppuration is generally unimportant, we can hardly expect advantages from the employment of aseptic or antiseptic methods Avhich are at all commensurate with those obtained by the same methods in ordinary surgical conditions. The local treatment by hypodermatic injection of mercurials beneath the base of the initial lesion and into the mass of indurated lymphatic glands rests upon the view that mercury acts as an antidote Avhen brought directly into con- tact with the syphilitic germs, and that this influence would probably be espe- cially active if the drug Avere brought to bear directly upon the local lesions Avhich are the foci of infection during primary syphilis. If we believe that the virus remains localized for a time after inoculation, and is not disseminated through the general system, and that mercury acts by its germicidal influence, this treatment is not unphilosophical, but seems inferior to the more thorough plan of excising both the chancre and the enlarged lymphatics of the groin. The latter procedure would be less likely to result in local troubles, such as abscess or cellulitis, and would certainly be more effective. The rules as to the treatment of chancre may accordingly be expressed as follows: 1. While it is unquestionably desirable to begin mercurial treatment at the earliest proper moment, and while that treatment undoubtedly either suppresses or renders milder the subsequent secondary manifestations, and while there is every reason to believe that in this way the liability to later or tertiary lesions is somewhat lessened, nevertheless the sum-total of these advantages does not warrant the employment of mercury one moment before the diagnosis of con- stitutional disease is absolutely assured. 2. While in many cases that diagnosis can be made with a high degree of probability from the appearance of the primary sore alone, yet it cannot be said that all possibility of error is excluded until some general symptom, such as the enlargement of distant lymphatic glands, has shown itself. 3. The administration of mercury during the existence of the primary sore, unaccompanied by general symptoms, for the purpose of suppressing or "abort- ing" syphilis, is not, therefore, justifiable, unless by confrontation the diagnosis can be confirmed, or unless there are urgent and unquestionable reasons for securing rapid cicatrization of the chancre. 4. It is proper to employ cauterization or excision, according to the site of the chancre, in cases in Avhich it is seen very soon after its appearance, and SYPHILIS. 149 especially when it is knoAvn to have folloAved intercourse Avith a syphilitic per- son. The chances of preventing constitutional infection in this way, while slight, may yet be considered sufficient in such cases to counterbalance the dis- advantages of the method, such as pain, SAvelling, the production of phimosis or of suppurating bubo, and the obscuring of the diagnosis by the resulting inflammatory exudation. 5. Aseptic or antiseptic measures, while harmless, cannot be considered especially indicated in the local treatment of chancre, and in all probability can have no true abortive influence. 6. The local use of mercurials, hypodermatically or by inunction, is perhaps worth a trial, but it is probably inferior to the more radical methods based essentially upon the same principles—namely, excision and cauterization. The treatment of chancroid may be described in this connection. While it has been for many years the custom to cauterize freely all soft or sup- purating venereal ulcers—i. e. all sores diagnosticated as chancroids, Avhether situated in the genital regions or elseAvhere—the introduction into surgery of the principles of antisepsis, and with them of such drugs as iodoform, has greatly modified this routine treatment. It is safe to say that chancroids are neither so frequent nor so severe as they were years ago, and that by the appli- cation of antiseptic methods to their treatment a great advance has been made in the ease and certainty with which they can be cured. In a large majority of cases daily irrigation Avith sublimate solution of 1: 500 or 1 : 1000, folloAved by free dusting Avith iodoform or by the applica- tion of an ointment consisting of one and one-half drams of iodoform to one ounce of carbolated cosmoline, will be folloAved by speedy cicatrization. If these fail, the continuous application by means of pledgets of cotton or lint of a lotion containing sublimate, boric acid, and peroxide of hydrogen will often cure. If, in spite of this, the sore deepens and extends, destructive cauterization with fuming nitric acid or the acid nitrate of mercury is at once the safest and speediest method of cure. The objections to the cauterization of chancroids are as follows, and are similar to those mentioned in relation to chancres: First. The pain to Avhich it gives rise. Second. The inflammatory action Avhich follows, and Avhich often in the case of the male produces enough oedema and SAvelling to cause phimosis, and thus to conceal the sore and prevent the proper application of remedies. Third. The subsequent effusion of lymph, which is apt to cause an induration closely resembling that of the true chancre, and thus greatly to obscure the diagnosis. The general rule may be followed of meeting indications—that is, of using sedative lotions, lead-water, or lead-water and laudanum, or sulphate of zinc and opium—in the acutely inflamed, painful sores; and of using stimulat- ing washes—sulphate of copper, strong zinc solutions, nitrate of silver, etc.— upon indolent, pale, and flabby ulcers. Special indications having been met, iodoform will generally complete the cure. SYPHILITIC BUBOES. Almost at the same time that the chancre becomes indurated the lymphatic glands, connected with it by means of the lymphatic vessels, undergo hyper- trophy. The glands nearest to an infecting chancre become enlarged and hard; they roll readily beneath the skin ; they are painless and do not suppurate. These clinical characters are unvarying. They are found in the groin when the chancre is upon the external genitals ; in the submaxillary glands when the chancre is upon the lips; in the axilla when the chancre is upon the nipple or hand. 150 AX AMERICAX TEXT-BOOK OF SURGERY. The glands of the groin, in connection with a chancre upon the genital organs, are successively involved, the gland first affected being the most inferior of the group upon the diseased side. When the chancre is situated at one side of the frenum, it is not uncommon to find the buboes in both groins, a cer- tain amount of decussation occurring betAveen the lymphatics of the former region. The inguinal glands are all hypertrophied, but are distinct one from another, the skin remaining healthy. About a month and a half after this enlargement of the glands near- est to the chancre all the lymphatic glands of the body are successively invaded, at least all those Avhich are visible. They appear a little inflamed before or at the same time with the eruption of the cutaneous syphilides. Prob- ably all the glands of the economy are affected, and cases of enlargement of the glands in front of the sacral, lumbar, and dorsal vertebras have been reported. The subcutaneous glands affected by syphilis are the cervical, maxillary, occipital, etc. Among the most important glands for diagnostic purposes are the post-cervical, which do not enlarge from local causes so fre- quently as the anterior chains of cervical lymphatics (glandular concatenate), and which are therefore almost pathognomonic Avhen they undergo painless mul- tiple enlargement at about the period for the appearance of the early secondaries. In syphilitic lymphatic glands the follicles of the delicate reticulated tissue are hypertrophied, and occasion small lobulated projections upon their surface when the capsule is removed. These glands remain more or less enlarged, not only during the active period of the secondary lesions, but frequently after the syphilides have disappeared. The folloAving tables will serve to contrast the buboes and lymphangitis characteristic of the tAvo chief forms of venereal sores: Syphilitic Bubo. Inflammatory Bubo. Always accompanies or follows infecting Occurs in only one-third of the cases of chancre. chancroid; occasionally, but more rarely, in herpetic or balanitic ulceration or in gonorrhea; may follow an infected wound of the lower extremity. Several glands involved, making a group or One gland implicated, rarely bilateral. chain of small, movable glands in one groin or often in both. Appears soon after chancre. No definite time of appearance. Slight enlargement. Great enlargement. Cartilaginous induration. Inflammatory hardness. No inflammatory symptoms. Always present. Glands freely movable. Gland fixed (periadenitis). Skin normal, not adherent. Skin red, adherent. Painless. Painful. Indolent, slow. Runs an acute course. Terminates by resolution, rarely by suppura- Usually suppurates, rarely undergoes resolu- tion, tion. No marked tendency to phagedena. Phagedena not very uncommon. No local treatment effective. Local treatment required. Mercurial treatment hastens resolution. Mercury has no influence upon the condition. Syphilitic Lymphangitis. Inflammatory Lymphangitis. Lymphatic vessels feel hard, like the vas Same, but less hardness. deferens ; size of a knitting-needle. Painless to touch. Painful. No pain on erection. Erection gives rise to pain. Skin normal. Skin red over inflamed vessel. Terminates by resolution. Resolution or suppuration. Local treatment unnecessary and ineffective. Local treatment of great use. SYPHILIS. 151 SECTION II. : GENERAL SYPHILIS. At about the time of the general lymphatic enlargement—and coincident with <>r preceding the earliest eruption—Ave have a characteristic group of symptoms—viz.: 1. Fever, varying from 100° F. to 101° F., coming on toward evening and associated Avith moderate anorexia and malaise. 2. Muscular and articular pains, chiefly affecting the muscles and joints of the chest, back, and upper extremities, but sometimes very general and quite severe. 3. Alopecia, not confined to the scalp, but involving the hairs of the whole body, distin- guished from ordinary baldness by that fact, by the concomitant symptoms of syphilis, and by the irregular, moth-eaten character of the bald spots. Constitutional syphilis may be diagnosticated when an indurated genital chancre is folloAved by a painless, hard SAvelling of the inguinal glands and of others like the post-cervical, Avhich are remote from the spot of local irritation. The change of the lymphatic gland is so characteristic that from it alone the diagnosis of syphilis is possible Avhen the cervical, maxillary, supratrochlear, and other lymphatic glands are invaded, as well as those in the inguinal region, and still more easily when the fever, pains, and alopecia are present. SECONDARY SYPHILIS. The eruptions of the skin and mucous membranes soon make their appearance, and constitute the first manifestations of the secondary stage of syphilis. These syphilides usually appear about six Aveeks after the beginning of the infecting chancre, sometimes sooner; at other times later, even tAvo or two and a half months from the date of the chancre. They are seldom as late as three or four months, yet in rare cases they have occurred after five months have elapsed. The mercurial treatment, Avhen given during the existence of the chancre, has been accused of causing this retardation of syphilides, and doubtless does so, but it must not be forgotten that the evolution of the disease is very variable. Cutaneous and mucous syphilides are more superficial when they are more recent, and grow deeper as they groAv older. Thus the syphilides of the first period of secondary lesions affect only the papillary surface and epidermic lay- ers. These are erythemata, or superficial spots, as roseola; or limited, slight, and temporary inflammations of the papillary and epidermic layers, as papules. The older syphilides, on the contrary, belonging to the later secondary period, appear as pustules or tubercles,1 Avhich affect the deep cutaneous and subcuta- neous layers in connection Avith the papillary network and epidermis; they are destructive and are folloAved by cicatrices. A classification of syphilides similar to that adopted by Cornil and based on their pathological histology is both useful and practical. It is as folloAvs: 1st. Erythematous syphilides—erythema; macules; roseola. 2d. Papular syphilides—conical, lichen-like syphilide; large papules. —Patches of papulo-lenticular syphilide ; papulo-squamous. 3d. Pustular syphilides—acneiform; impetiginous; ecthymatous; rupial. 4th. Gummatous and tubercular syphilides. In this classification there is indicated the gradual passage of the superficial lesions of the early period of secondary symptoms into the deeper and later 1 The word " tubercle " is often used to designate one of the eruptions of syphilis. It refers simply to its visible characteristics, and does not mean that there is any infection with the bacilli of tuberculosis. 152 AX AMERICAN TEXT-BOOK OF SURGERY. lesions of the second period, and finally into the rupia, tubercles, and gum- mata of the third period. Syphilides of the first period are almost always polymorphous ; that is, the eruptions present at the same time the different varieties of roseola, papules, and small pustules or squamous papules. In ordinary eczema or impetigo we have the same elementary lesion of the skin at all points, and the same appear- ance of all the regions affected; but, on the contrary, there are found in syph- ilis varied elementary lesions, spots of erythema alongside of papules and vesico-pustules, and other lesions modified according to their location. In other cases there will be seen a papular syphilide in a someAvhat chronic state; the papules when upon the skin of the limbs appear dry, their epidermis desqua- mating. In those regions Avhere the skin is in folds, as upon a dependent mammary gland, the papule, instead of being dry, is moist; upon the palm of the hand, where the epidermis is corneous and thick, the epidermic layers over the papule form hard scales, which have incorrectly been compared with psoriasis. This polymorphous condition and the blending together of the elementary lesions are among the best diagnostic characteristics of syphilides. Syphilides of the late secondary period frequently involve all the layers of the derm and epiderm, and are given compound names, as papulo-vesicular, papulo- pustular, tuberculo-pustular, etc.—names which define themselves. The syphilides have a color which is said to resemble that of copper or of ham ; this is owing particularly to extravasations of red blood-corpuscles, and is marked in the eruptions of the first period. The copper color is not seen in lesions of the mucous membranes. Another distinctive characteristic of syph- ilides, except diffused erythematous roseola, is that they all have a regularly round shape, whether isolated or in groups. They form small circles, figures-of-8, etc. Finally, the lymphatic glands are often affected in the region invaded by the eruptions, and the action of mercury upon these eruptions is to cause their rapid disappearance. The earliest cutaneous symptom in syphilis is almost equally apt to be an erythema or a roseola, the former a diffused mottling of the surface, affecting chiefly the trunk and abdomen and Avithout appreciable elevation: the latter, somewhat darker in color and apt to show a tendency to become papular. Roseola may indeed be considered as an eruption intermediate between the erythematous and papular syphilides. The diagnosis is usually easy, and can readily be made from simple roseola, the roseola caused by copaiba, by expo- sure to the atmosphere, by measles, by bites of insects, etc., if the patient be examined with care, if enlarged lymphatic glands and mucous patches are looked for, and, finally, if the special color of the papules and the history of the case be remembered. The papular syphilides may be small or large, and may be associated with such an accumulation of epidermic scales as to receive the name of the papulo-squamous syphilides. The first variety (small papules) has received the name of lichen-like or miliary syphilide. The color of the papule is very cha- racteristic. The elevation of the skin is due to a thickening of the papillae and epidermic layers; but at the summit of the papule and over all the surface forming it the most superficial layers of the corneous epidermis have desqua- mated, while those at the margin of the papule are continuous Avith the normal skin of the periphery. The papules remain a varying length of time; they usually disappear in three or four Aveeks when mercurial treatment has been employed ; at other times they continue for two and three months. They are modified according to their location. The mucous patches corresponding to this variety may be small and acuminated. Upon the scalp the eruption appears SYPHILIS. 153 as small pustules or papules covered Avith a yelloAvish or brown scab ; upon the palmar surface of the hands the papules are covered Avith hard epidermic scales or they are depressed and surrounded by a corneous epidermis. The second variety of papular syphilides is characterized by large papules, having a diameter of from half an inch to an inch, or even larger. In its beginning a pimple is noticed Avith regular edges and pink surface, Avhich soon assumes the characteristic color, and upon Avhich the most superficial layers of the epidermis are desquamating; at the periphery of the papule the desquama- tion is arrested, and here is seen a thickened epidermic border. The surface of the papule is smooth and circular. In the papular eruptions generalized over the entire body the skin Avhere they are situated often becomes so thick as to warrant the term papulo-tuber- culous; they unite and form large bands; for example, upon the forehead— corona veneris—or surround the mouth and ahe of the nose; they also form circles upon the shoulders, neck, and trunk, and extend over the surface of the limbs. Often, during the period of acme, they are covered Avith thick scales, Avhich may be removed in irregular fragments by scratching; this form is termed papulosquamous. Their color is ahvays very distinct, intense, deep copper-red. The essential histological changes Avhich enter into the formation of a syphilitic papule are a hypertrophy of the papilloe of the skin, an increase in the number of epithelial layers which form the epidermis, and a proliferation of the cells of the rete mucosum. The blood-vessels are congested, and there occurs an extravasation of the blood-elements into the tissue of the derm Avhich gives the characteristic coloration to the lesion. Desquamation of the superficial layers of the skin is one of the features of the papule. The changes are not limited to the papilhe and superficial corium, but in some varieties extend to the subcutaneous adipose tissue. There is no vascular sclerosis comparable to that met with in the chancre. These changes are modified by situation, duration, etc. The diagnosis of a large papular syphilide is never very difficult. The special color and the arrangement of the papules, the involvement of the palms of the hands and soles of the feet, also of the palmar surface of the fingers and plantar surface of the toes, the enlargement of the lymphatic glands, the frequent existence of mucous patches, are all characteristic. The papular syphilide is indeed the most distinctive of all, and the most common after rose- ola. It is seldom that a syphilide Avith large papules continues less than tAvo months, and frequently it remains three, four, or five months, especially if mercurial treatment has not been employed at all or too timidly. There is no form of medical treatment in Avhich the curative power of a remedy is so evi- dent and so admirable as in the use of mercury in cutaneous syphilides, and particularly in the severe forms of papulo-squamous eruption. Mucous Patches.—A transformation of a syphilitic papule into a mucous patch takes place whenever it is under the continuous influence of warmth. moisture, and friction, as on a mucous membrane at a muco-cutaneous junction or in the creases or folds of skin. Under these circumstances the overlying epidermis or epithelium is macerated and disappears; the papule, originally small, rapidly extends in superficial area; it becomes grayish or opalescent in appearance if seated on a mucous surface: red, smooth, and polished if on the skin. In either case it is moist and has a free secretion, often offensive, and ahvays highly contagious. The most common seats of mucous patches are, first, in the order of their frequency, the genital organs and region of the anus. Their location varies according to the sex. With women mucous patches of the labia and of the 154 AX AMERICAN TEXT-BOOK OF SURGERY. vulva are almost constant; with men, on the contrary, they are not very frequently met with on the prepuce or glans, the most common seats being the scrotum and anus. With women the anus is also frequently the seat of mucous patches. The histological structure of mucous patches consists in a thickening of the epidermic layers and an increase in the size of the papillae of the skin by a development of the elements entering into their structure. This increase in size of the papillae causes a corresponding increase in the length of the inter- papillary prolongations of cells of the rete mucosum. The blood-vessels of the papillae are distended with blood. The tissue of the derm is found prolifer- ating. Diagnosis of Mucous Patches.—It is almost impossible to mistake a mucous patch after a number have been seen. They are formed upon a papule—that is, an inflammatory swelling of the corium and papillae; their surface is oozing, and the epidermis or epithelium Avhich covers them is satu- rated or desquamated. Thus, upon the labia majora and minora there are seen Avhitish patches or small points which resemble moist or pulpy paper, and consist of epidermic cells or changed superficial epithelium; upon a mucous membrane, as on the lips or palate, the epithelium is Avhitish, opaline, resem- bling a surface which has been touched with nitrate of silver. The mucous patch, if eroded, has a surface which is red and smooth after the superficial epithelium has desquamated; the shape of the patch is always circular or regularly oval, and the derm is thickened upon its surface. The patches of the vulva and labia majora, likewise of the anus and of the scrotum and scroto- femoral folds, even when in process of healing are very distinct; as the epider- mis forms, the derm remains a little papular and the surface dull red. The syphilitic papules, covered Avith thick superficial layers of corneous epidermis—that is, Avith scales—are termed papulo-squamous syphilides. They are generally very obstinate, since the layers of the epidermis repose upon the thickened and chronically inflamed derm. These squamous papules, covered with or deprived of their epidermic layers, Avhen situated upon the palms of the hands and soles of the feet, are called palmar or plantar syphilides. The papules are modified simply on account of their seat and the structure of the skin of the hands and feet. Here the corneous epidermis attains considerable thickness and resistance; it forms a layer Avhich at times measures a millimeter in thickness and is dense and hard like parchment. Thus it offers more or less resistance to the development of the papules, especially at their beginning. Later, however, the epidermis covering the papule is raised, cracked, and partly or completely eliminated, or it forms hard and irregular stratifications. With syphilitic papules, and at the same time with secondary syphilides, there occurs a lesion allied to the lesions of the epidermis—viz. the changes of the nails. Syphilitic Onychia is a disease of the nails, the peculiarities of which result from the anatomical structure of the matrix of the nail and of the peri- and subungual papillo-epidermic tissue. There are described two varieties— the dry and the moist. The dry variety of onychia generally accompanies the papular and papulo- squamous eruptions situated upon the fingers and toes, the ends of which are attacked by papules, Avhich pass around their extremities or may be seated at the roots and edges of the nails or under them. Sometimes the nail is cracked and readily broken ; it is dry and separated from the skin. Sometimes, when the papules exist at the ungual matrix, there is a SAvelling of the skin at this region, SYPHILIS. 155 and the formation of the epidermic layers of the nail is very much interfered with. At times there is an irregular thickening of the nail by hard scabs, Avhich are stratified and occasion a dense, irregular elevation. The moist variety of onychia occurs Avith vesiculo-pustular or pustular syphilides. Sometimes true AvhitloAv is met Avith. These conditions often terminate in the destruction of the nail, and neces- sitate rest, antiseptic fomentations, and aftenvard some simple dressing. Pustular Syphilides.—The pustular syphilide is found in the form of acne, of impetigo, or of ecthyma. Syphilitic acne is ahvays early and super- ficial. Impetigo and ecthyma may also occur in the first stages and Avithout any element of gravity, but in other cases, Avhere they appear very early, may be of graver import; during the later eruptions they assume a still more serious aspect, and tend to rapid extension both in depth and superficial area, resulting in pustulo-crustaceous ulcers, of long duration and of extent corresponding to the amount of suppuration and the tendency to confluence of the lesions, which are often accompanied by symptoms of general cachexia, and in exceptional cases even terminate in death. Syphilitic acne is as much a papule as a pustule in its structure and evolution. It forms a small conical projection, upon the top of Avhich appears a very slight epidermic elevation, caused by a small quantity of serous effusion, Avhich rapidly becomes purulent. The pustule is of short duration, and is soon replaced by a little crust, and then by scales, leaving only a stain, Avithout cicatrix. This eruption appears in successive crops upon the face, the shoulders, the trunk, and thighs, in Avhich latter situation the pustules are often confluent. There are generally at least as many papules or papulo-squamous spots as well- formed pustules, the papular elevation remaining after all traces of the pustule have disappeared from its summit. It is an eruption of the early stages, and behaves like the papular syphilide. It is distinguished from acne vulgaris by its distribution—for it especially affects the belly and thighs, while acne vulgaris is found on the face and shoulders—by its copper color and its greater dryness, and by the absence of Avhite permanent cicatrices. Syphilitic impetigo appears in the form of little pustules covered by crusts and resembling isolated pimples, or as patches formed by the union of many pustules. The pustulo-crustaceous form is commonly found upon the scalp at the same time that a syphilitic roseola or mucous patches have invaded the general integumental surface. The impetigo may be the predominant eruption, the scalp, face, and fore- head being the points of election. The reason for the transformation of a papular syphilide into the pustulo-crustaceous form upon the face and scalp is found in the abundance of sebaceous glands Avith Avhich those parts are supplied. These glands, Avhen involved in the inflammatory action, produce a papule; upon the cutaneous surface their secretion is modified, and consists then of a sebaceous liquid more or less intermingled with blood-corpuscles. As a result there is seen either a well-formed pustule, a sebaceous concretion, or a crust upon the surface of the papule. Usually the pustules are seated upon a reddish, copper-colored patch or papule. When the eruption is confluent it covers large surfaces with scabs. Syphilitic ecthyma may be superficial or deep. The former variety occurs usually on the loAver limbs, and appears as a large pustule Avith a thick dark crust. It leaves behind it ecchymotic stains. Deep ecthyma at first appears as a collection of pus under a large elevation of superficial epidermis, as occurs in the variety already described. The pus- tule is regularly circular; the contents inspissate by evaporation, and form a 156 AX AMERICAX TEXT-BOOK OF SURGERY. crust Avhich increases by the addition of successive layers. These crusts in superimposed strata, greenish or broAvn in hue, imbricated like the shell of an oyster, dry, resistant, are also met Avith in rupia, having the same configuration and immediately suggesting syphilis. Under this crust, Avhich continues to enlarge and thicken, the pustule itself extends in breadth and depth. The crust overlaps the border of the ulcer, or, Avhen the latter is the larger, is set within it like a watch-crystal in its case. When it falls off there is disclosed an ulceration extending to the papillae or even deeper into the skin. These pustules are sometimes spread singly over a large portion of the body, most frequently the inferior extremities; in other cases they are grouped in the form of circles or crescents. The diagnosis of syphilitic ecthyma from scrofulous ecthyma is frequently difficult. The latter ulceration is often deep and Avith perpendicular borders, as in the syphilides; the crusts, however, in syphilis are drier, darker, and more imbricated, the cachectic lesion suppurating earlier and more freely, con- sequently permitting of less adhesion of the crusts. This is not an invariable distinction, as in certain cases syphilitic ulcerations are attended Avith the formation of large quantities of pus. When the eruption is distributed upon the face and body as well as upon the limbs, the diagnosis of syphilis should be made, as the ecthyma due to scrofula is observed only upon the inferior extremities. The history and concomitant symptoms almost ahvays lead to a recognition of the disease, as it is a persistent eruption, lasting for months or even for a year, and often reappearing with all its original characteristics. It necessitates a guarded prognosis on account of its persistence and of the continual suppura- tion caused by it, especially Avhen it is widespread. It is formidable also because it indicates a grave form of syphilis, particularly when it appears soon after the initial lesion. Rupia manifests itself at first by large elevations of the epidermis filled with a clear or bloodstained serum, soon becoming turbid and purulent. The bulla bursts, alloAvs some of the liquid to escape, and as it desiccates is covered Avith a crust, Avhich dries, accumulates neAv layers, and becomes imbricated with brown and greenish strata, as in the variety of ecthyma just described. Rupia is, of all the syphilides, the one attended Avith the largest, thickest, darkest, and most characteristic crusts, as it is also the one presenting the most exten- sive ulcerations. Under these crusts the papillary layer and the entire derm are undergoing suppuration, as in the last two eruptions considered. In the tubercles and gummata of the skin are seen the latest and deepest manifestations of cutaneous syphilis. Syphilitic tubercles and gummata have striking analogies. They appear at the same stage of syphilis, are of the same clinical import, and are caused by the same pathological changes; the chief distinction being that the tuber- cles are more superficial, only involve the derm, do not extend into the sub- cutaneous tissue, and give rise to a less abundant cellular infiltration. Tubercular syphilides represent deep and enormously SAvollen papules, and are intermediate pathologically betAveen the papule and the gumma. They appear as single, flattened pimples, attended with an induration of the entire skin, from the superficial epidermis to the deepest layer of the derm ; they are sometimes solitary, sometimes in groups, and may be scanty or may be widely extended. Their favorite situation is upon the face, at the mucous outlets, upon the nose, ears, forehead, back, neck, and inferior extremities, especially the legs. There are tAvo varieties, the dry and the ulcerating. The dry tubercular SYPHILIS. 157 syphilide is usually copper-colored and covered with thick scales, almost crusts; there may be no ulceration, and healing may occur, Avith the production of a white or pigmented cicatrix, Avithout any ulcerative process having taken place. The ulcerative tubercular syphilides are more grave on account of the abundant suppuration caused by them. They may be isolated, but are usually in groups, often very extensive. Histologically, gummata and tubercles consist essentially in the forma- tion of embryonal cells, Avhich in the former, the gummata, occupy a position deep in the derm, infiltrating all the tissues, and in some instances even involv- ing the deeper structures, bone, cartilage, etc. The tubercles are similar in their histological structure, but are limited more particularly to the skin, not affecting the subcutaneous tissues. The disease for Avhich an ulcerating tubercular syphilide is most likely to be mistaken is lupus vulgaris, which is a cellular neAv-growth due to infection with the bacillus of tuberculosis, and results in various papular or tubercular patches Avhich are usually followed by ulceration. It has no relation with syphilis, and should be carefully distinguished from it, as the treatment bene- ficial in one case is useless or absolutely harmful in the other. The main diagnostic points may be tabulated as follows: Tubercular Syphilide. Lupus Vulgaris. Occurs chiefly among adults. Occurs commonly in young persons; when in adults there is often a history of a similar eruption in childhood. Considerable infiltration of skin. Not so marked. Tubercles opacpue and of a deep brownish- Tubercles often translucent and lighter in red color. color. The characteristic ulcer produced in a month The same amount of ulceration would require or two. several months or even years for its devel- opment. Ulcers usually distinct. Ulcers apt to be confluent. Ulcers deep and extensive. More superficial and involving smaller area. Ulcers small, circular, punched out. No regular form or perpendicular edges. Secretion copious, sometimes offensive. Secretion slight, inoffensive. Crusts bulky, greenish. Crusts thin and dark-colored. i Scales irregular in shape and attachment. Scales arranged more regularly, attached in the centre and loosened at the edges. Cicatrices soft, white, circular. Cicatrices distorted, irregular, puckered. History and concomitant symptoms of syph- No such history except as a coincidence. ilis. Local treatment ineffective. Internal spe- Eruption disappears only under very active cific treatment effects a cure. local treatment, as curetting, or under the influence of tuberculin. Gummata of the skin make their appearance at variable intervals after the contraction of syphilis; sometimes very late—twenty or thirty years after the chancre—sometimes, on the contrary, very early, during the first year, or even in the first four or five months; this occurs in the grave and abnormal varieties of the disease; most frequently they develop three or four years after the chancre. The favorite localities are the face, scalp, shoulders, neck, arms, thighs, and legs, but they may appear in any region of the body. Cutaneous gummata are inflammatory tumors of the subcutaneous tissue— the cellulo-adipose connective tissue—Avhich terminate by discharging exter- nally : they cause a loss of substance to great depths, more considerable in extent at the bottom than at the cutaneous orifice, the disintegrated tissue being sloAvly throAvn off like the core of a furuncle. In the development of a gumma there are four periods, Avhich include the processes of formation, softening, idceration, and repair. The first period 158 AX AMERICAX TEXT-BOOK OF SURGERY. is of long duration, and. as the tumor is painless, the patient usually discovers it by chance as a rounded or slightly flattened nodule seated deeply beneath the "skin, Avhich latter is slightly raised. The nodule is movable in the sub- cutaneous tissue, is hard, consistent, and gives rise to no subjective symptoms. The tumor groAvs sloAvly until it acquires a volume varying from one centimeter in diameter to that of a hen's egg. Ordinarily it has a diameter of from one- half to three-quarters of an inch. The skin over the surface of the gumma remains normal, until suppuration begins. After a time the tumor softens, becomes doughy, and then fluctuation takes place. Soon the skin reddens, groAvs thin at the most prominent point, and is finally perforated. The small circular opening gives exit at first only to a small quantity of purulent or gummy liquid; an open gumma not resembling in the least a discharging abscess. The gumma does not at once empty itself AAhen it is opened. The inflamed connective tissue adheres by its deeper portions to the subcutaneous cellular tissue, Avhich is thrown off in the form of small sloughs. Granulations forming at the bottom soon fill the cavity, the solution of continuity is repaired. and cicatrization takes place. The resulting cicatrix is depressed, often adherent to the deeper tissues or to the bone itself. The clinical characteristics of the group of cutaneous syphilides may be stated as folloAvs : 1. General or constitutional symptoms are usually absent, with the excep- tion of the syphilitic fever Avhich precedes or accompanies the early eruptions. 2. Additional evidences of syphilis will usually be found, and should be carefully searched for—the chancre, its cicatrix or its induration, the buboes, sore throat, baldness, mucous patches, etc.—df an early eruption be in ques- tion ; osteocopic pains, nodes, and other bone-lesions in the later stages. 3. The eruptions, especially the early ones, are apt to be polymorphous, or to present at the same time a variety of forms of cutaneous lesion, macules, papules, and pustules being usually intermingled. This is due to the chronic, sIoav evolution of the disease, Avhich permits of the development of neAv symp- toms during the gradual fading of previous ones. 4. The patches of eruption are apt to have a rounded or crescentic form, due to the anatomical arrangement of the cutaneous capillaries, and Avhen seated upon the extremities occupy the side of flexion—the anterior surface of the forearm, the palm of the hand, the sole of the foot, etc. 5. The characteristic color of the syphilitic eruptions is a yellowish-red, usually described as " coppery." Its peculiar dusky tint is due to the absence of the active hyperemia and arterial excitement which usually exist in the non- specific eruptions, the color of syphilides being the result of slow changes in the coloring matter of the blood Avhich has exuded under pressure, and not the accompaniment of acute inflammation. 6. There is an absence of pain and itching AA-hich is very distinctive, and Avhich is also due to the non-inflammatory character of the eruption. It is quite common to find patients Avho are not aAvare of the presence of an extensive syphiloderm until their attention is directed to it by the surgeon. 7. The early eruptions are superficial, general, and symmetrical, indicating by these characters the infection of the blood to Avhich they are due. During their evolution the disease is transmissible by contagion. 8. The early eruptions are frequently scaly, the pressure of the cell-prolif- eration, Avhich is ahvays present, cutting off the supply of nutriment to the superficial epidermic layers, which accordingly dry, desiccate, and are exfoliated. 9. The scales are Avhitish, superficial, and usually not adherent, there being no plastic or inflammatory exudation to fasten them to the subjacent part. SYPHILIS. 159 10. The later eruptions are not contagious, are irregular in distribution, extend to the eutis vera or beneath it into the connective tissue, and are described as local lesions or as sequelae folloAving the acute or secondary stage, and due either to relapses in parts previously diseased or to neAV-groAvths result- ing from changes effected by syphilis. 11. The later eruptions have thick, irregular, or imbricated crusts, often occur in groups, and leave scars even if no ulceration has occurred. 12. Ulcers resulting from the breaking down of syphilitic deposits have rough, abrupt edges, are irregularly crescentic or circular in shape, covered with an unhealthy greenish-yelloAV secretion, and, as a rule, are painless. 13. The cicatrices caused by syphilis are at first pigmented, then Avhitish, shining, rounded, or radiating, and depressed beloAV the level of the surround- ing surface; they often show very small apertures, the sites of pre-existing follicles. 14. The therapeutic test in all very doubtful cases is an extremely valu- able one, although it should be necessary to resort to it only in extremely exceptional instances. The amenability of nearly all the cutaneous symp- toms to well-directed specific treatment often renders this test very conclusive. The tertiary lesions of the mucous membranes are characterized by growths occupying the deeper portion of the mucous membrane or extend- ing beyond it, and by gummata identified Avith those just described. They are nearly always ulcerative, but are not covered by crusts, owing to the facility with which the accumulated secretions are detached from the surface. Thus, in cases AAmere upon the skin there would be a scab, upon the mucous membrane there is found an ulcer discharging pus more or less freely. Like the deep syphilodermata, they are limited and localized, for, as the disease grows older, instead of being extended and superficial and symmetrical, it becomes limited to a special locality and deeply involves and destroys its tissues. The most important mucous membranes affected by tertiary lesions are the tongue, soft palate, and pharynx. Tertiary Syphilis of the Mouth.—The most important of the late man- ifestations of syphilis in this region are the gummata of the tongue, Avhich may be either submucous or muscular in their origin. The submucous gummata are of the size of a pea or a cherry-stone, single or multiple. They begin as small, hard tumors, and their softening, their dis- charge through a small aperture, their excavated appearance and characteristic base, do not differ from those of other gummata : this is also true of their dura- tion and of their mode of healing. The muscular gummata are larger: they may occupy either the lateral or median aspects of the tongue, or may affect its tip, its base, or its edges. They reach the size of a hazel-nut. They open by Avhat is first a very nar- roAV channel, Avhich enlarges or extends in the direction of the muscular fibers. In these affections of the tongue it is rare to find enlarged cervical or sub- maxillary lymphatic glands, and the same is true of gummata of the pharynx. The differential diagnosis of syphilitic diseases of the tongue is one of some importance, especially in regard to non-syphilitic affections which simulate them. Gummata of the tongue may be mistaken only for tubercular ulcers or for epithe- liomata. From tubercular ulcers it Avould be difficult, if not impossible, to make a diagnosis from the character of the ulcer alone. The sides and edges of ulcer- ating tubercles often show, hoAvever, a feAv small yelloAv points Avith opaque centers, which are tubercular granulations undergoing caseous degeneration. These latter are finally throAvn off by ulceration, and are never seen in syphilis. The evolution of tubercles of the tongue is entirely different from that of gum- 160 AX AMERICAX TEXT-BOOK OF SURGERY. mata. The gumma begins as a single mass, submucous or muscular in position, opening after a time by a contracted passage, ulcerating, and discharging like a furuncle and having a'sloughing base. The tubercles, on the contrary, begin on the surface as small nodules. By the union of many of these a large, irreg- ular ulcer is formed, slower in its evolution than a gumma. As it extends in depth there are successive eruptions of tubercles, too minute to be detected by the naked eye, and situated betAveen the muscular fibers. The ulcer has jagged edges and usually suppurates less than the gumma. In cases of doubt the chest should be carefully examined, as pulmonary tuberculosis often exists at the same time. The family history may also aid in the decision. Lingual epithelioma may ahvays be detected by microscopic examination of the fragments of tissue from the cancerous ulceration, large pavement-cells and epidermic nests being found. In addition, the epithelioma never becomes stationary or recedes, that of the tongue being especially grave and rapid, often running its course and terminating in death in a year or eighteen months. The diagnosis between ulcerating epithelioma of the tongue and ulcerating gumma of the tongue has been tabulated by Fournier, as follows: Epithelioma. Chiefly affects persons between fifty and sev- enty years of age. Often a history of cancer in near relatives or ancestors. No history of syphilis. The appearance which has been described as "lingual psoriasis" often precedes the cancerous disease. Is generally single and confined to one side. Is sometimes found on the under surface of the tongue. Begins as a hard swelling upon the surface of the organ, and ulcerates rapidly and superficially ; sometimes begins as a fissure or ulcer, without previous swelling or in- duration. Induration follows cancerous ulceration. No cavity resembling that of an abscess. Surface bleeds when touched or spontane- ously. Edges turned outward, with the border ele- vated, irregular. Secretion profuse, offensive, irritating. Lancinating pain, often darting toward the ear, thought to be pathognomonic. Great disturbance of deglutition, mastication, speech, etc. General cachexia supervenes. Microscopic examination shows the charac- teristic ingrowing of the interpapillary epithelium, the large squamous cells, pearly bodies, and other histological pecu- liarities of epithelioma. Submaxillary lymphatic glands progressively enlarged and indurated. Specific treatment useless or harmful. Gumma. Is apt to occur at an earlier period of life. No such history, as a rule. Such history almost always obtainable. Nothing Avhich resembles this has been seen. May be multiple and bilateral. Never seen except upon the dorsum or side of the tongue. Begins as a rounded mass beneath the sur- face, and then opens like a furuncle, leav- ing a hollow, deep ulcer. Induration precedes ulceration. An excavation like an abscess-cavity. Ulcer covered by an irregular slough which does not bleed. Edges abrupt,perpendicular, "punched out," sharply defined. Secretion moderate, not so apt to be offen- sive. Painless or nearly so. Tongue much more mobile ; functional trou- bles not so marked. No cachexia. The microscope shows an infiltration of the part by embryonal cells in various stages of granular degeneration. Glands not in\rolved, or, at the most, a little swollen and tender. Specific treatment curative. Gummata of the soft palate, or of the palatine arch, usually result in a perforation of the palatine bones, causing a communication between the oral and nasal cavities. These gummata are slow and insidious in their onset. SYPHILIS. 161 The patient experiences no pain or discomfort. The soft palate is red, thick- ened, and either nodular in its entirety or at one point. The induration and thickening may be felt Avith the finger. If the patient be asked to utter sounds requiring the assistance of the soft palate for their production—ah, for example—whilst the throat is being examined, it will be seen that the palate is elevated incompletely or not at all. The immobility of the palate is a valuable symptom, and, taken in conjunc- tion Avith the induration, the thickening, and the prominence often presented by the gumma itself, permits of an early diagnosis, Avhich it is especially import- ant to make as soon as possible in order to avoid perforation. If the patient be left Avithout treatment, the gumma ulcerates and discharges, and if it be of the kind above mentioned, involving both the anterior and posterior mucous surface, complete perforation of the palate will folloAV with great rapidity, often taking place in a single day or night. A gumma of the soft palate does not invariably give rise to perforation, especially if mixed treatment (see p. 170) be at once commenced. It may affect only one surface of the palate, and then it Avill heal Avithout interfering with function. There may be even a small but complete perforation at the moment of the evacuation of the gumma, which will entirely heal. Syphilis of Muscles.—Muscular syphilis is rare; it may manifest itself by contraction due to myositis, Avhich at first appears to be idiopathic, as it is not accompanied by tumors or changes in size or apparent lesions; in other cases gummata develop in the interior of the muscles. Syphilitic contracture of the muscles is chiefly an affection of the mus- cles of the arm, and more particularly of the biceps. It appears about six months to a year after the chancre. The first symptom is a stiffness of the elbow. Gradually extension becomes more and more limited, and the forearm remains flexed upon the arm at an angle varying from a large obtuse angle to one quite acute. No tumors or inequalities of surface are discoverable: if the muscle be examined during forced extension, it is found prominent and like a tightly-drawn cord. It has been denied that this affection has any essential relation to syphilis, and it has been attributed to rheumatism, to traumatism, and to other causes. The Aveight of evidence is, however, in favor of its syphilitic origin; nine out of ten cases observed by Mauriac had a distinct history of syphilis and were accompanied by unmistakable eruptions, chiefly papular and papulo-squamous. He believes it to be a subacute myositis. In every one of six cases reported by Notta syphilitic symptoms were present. In none of them Avas there any association with rheumatism. Gummata of muscles have a more important significance than these simple contractures. They consist of tumors, often of considerable size, which may discharge externally, may give rise in various ways to serious results, and may even invade the cardiac muscles. The tongue appears to be the muscle most frequently affected, and those of the sides and nape of the neck are often involved. Murchison has recorded a case of gumma of the diaphragm. Some- times, instead of distinct tumors, a general infiltration occurs. White has seen a case in Avhich all the posterior cervical muscles, including the trapezius, were thus infiltrated. Mixed treatment effected a rapid cure. Syphilis of the Bones.—Among the most important and most common late effects of syphilis are the osseous lesions, which are often of much gravity. Both in adults and in children affected with hereditary syphilis the order, the seat of the lesions, and even the anatomical condition of the diseased bones, n 162 AX AMERICAX TEXT-BOOK OF SURGERY. are so characteristic that the diagnosis of syphilis is rendered easy. Osseous syphilis is met Avith during any of the periods of the malady. The determining cause of the osseous lesion and of its seat, in tertiary as in secondary syphilis, is generally some form of traumatism, Avhich is usually slight, but frequently repeated at the same point. It is OAving to this fact that the superficial bones, as the frontal bone, clavicle, sternum, radius, tibia, etc., are the most common seats of the disease. Only the lesions of adults are here referred to. In cases of infantile syphilis traumatism is not the determining cause; the active development of the bones sufficiently accounts for the local- ization of the disease. The lesions of the bones from an anatomical point of view are very numerous, varying from simple periostitis and osteitis to gummata; their final consequences also vary from the development of exostoses to the formation of sequestrae in pus-cavities. The folloAving lesions may be successively described: 1. Simple osteo-periostitis. 2. Rarefying osteitis. 3. Intense rarefying osteo-myelitis or gummatous osteo-periostitis. Then the consecutive lesions of these different states, Avhich are: formative osteitis or eburnation, the exostoses, the necroses, and the sequestrae; and finally the osseous lesions of infantile syphilis. (See p. 178.) 1. Syphilitic osteo-periostitis does not differ materially from ordinary osteo-periostitis. Limited to the superficial layers of the bone and the perios- teum, it most frequently occurs at the end of the secondary or in the tertiary period, attacking the tibia, clavicle, sternum, bones of the head, etc. 2. When the inflammation is more intense there occurs a rarefying oste- itis. The subperiosteal inflammation extends into the Haversian canals; the subperiosteal tissue and the osseous marrow contain numerous small cells with transuded red blood-corpuscles. These elements are free, with a small amount of granular intercellular substance. The original bone is eroded or destroyed. This lesion, which is observed so often in diseases of the phalanges and short bones, is named spina ventosa. It is frequently a result of syphilis. 3. Gummatous osteo-myelitis and gummatous osteo-periostitis are nothing more than a rarefying osteitis in Avhich the abundant subperiosteal embryonal tissue or the medullary tissue assumes the arrangement that is observed in the gummata. The lesions are seen in the form of tumors, vary- ing in size and having a tendency to become caseous. Gumma of bone is thus merely a circumscribed osteo-periostitis Avith destruction of the osseous lamellae by a rarefying osteitis. It is the localization and form of the lesion which give it its distinctive characters. The histological changes of the osseous tissue, as met Avith in the various forms of syphilitic lesions of the bones, therefore resemble similar lesions due to other causes. In osteo-periostitis there is a proliferation of the cells within the Haversian canals or the medullary elements of the bone which causes an increase in the size of these canals, the marrow7 itself becoming embryonic in nature. A continuation of this same process in a more intense degree results in the absorption of the osseous tissue, an enlargement of the Haversian canals, an increase in the amount of embryonal marrow, or, in brief, a rarefying oste- itis, Avhich in syphilis constitutes a gumma; that is, a gumma of bone is a local- ized intense osteo-periostitis in Avhich there is a destruction of the osseous trabeculae by the formation of granulation or embryonal tissue, Avhich later undergoes retrograde metamorphosis and absorption. The bone in Avhich the gumma or rarefying osteitis has been developed after the absorption of the SYPHILIS. 163 gummatous tissue takes on reparative action, and there occurs a formative osteitis, in Avhich there is a neAv formation of osseous tissue, the process resembling that of the physiological development of bone. This process con- tinuing, there results a condensing osteitis of the part, in which the laminae surrounding the Haversian canals are increased to such an extent as finally to obliterate the lumina of the canals and cause a sclerosis or eburnation of the bone. An exostosis is nothing more than a slow formative osteitis, which results in the gradual addition of neAv osseous layers to the original bone; if the process becomes active there is produced an eburnation of the new-formed bone, or if very intense there occurs that form of osteitis known as rarefying, and if still more active there may even be a complete destruction of the nevv osseous tissue. It is thus seen that the several lesions occurring in bones, and due to syphilis, are, to a great extent, the continuation or stages°of one process Avhich varies in its intensity and results. Symptoms of Syphilitic Osseous Lesions.—The osseous lesions of syphilis are not always recognized during life, but in ordinary cases, when subcutaneous bones are involved, the symptoms are well marked. The essential symptoms of syphilitic osteo-periostitis are pain and swelling. The pain is peculiar in that it is more intense during the night than during the day. It is very acute at times. It prevents sleep, and by its persistence may become of considerable gravity. The slightest touch to the tumor causes exquisite suffering. After tAvo or three days' treatment with iodide of potassium it is usually relieved and often is entirely removed. The symptoms of syphilitic osteitis are very variable, depending upon the bone affected and its connections. They differ, of course, very much with the variations in form of the lesions, Avhich, as has been explained, may vary from a simple swelling of the periosteum and bone to the suppuration and necrosis Avith fistulous tracts met Avith in intense gummatous osteo-periostitis. The most simple and most frequent cases are those of osteo-periosteal tumors of the superficial bones—the tibia, clavicle, sternum, frontal bone, etc. The nodular SAvelling, the single or multiple nodes of differing size, and the special pain upon firm pressure or upon percussion, are all characteristic. The pain occurs spontaneously during the early part of the night, before retiring. The periostoses of the clavicle are readily seen on account of the position of the bone, and most frequently are oval in shape, Avith their long axes parallel to the long axis of the bone. Osteo-periostitis of the anterior surface of the sternum and of the bones of the cranium, Avhen recent, generally appears as a flattened swelling, varying in size and of the shape of the segment of a sphere. It is then elastic to the touch, and may disappear under mixed treatment. Later, when an osseous formation is developed around its circumference, it feels hard at the margins, while its central part is relatively soft. As regards bones in general, the differences between syphilitic and tuber- cular inflammations may be stated as follows: Syphilitic Osteitis. Syphilitic osteitis occurs in persons in vary- ing physical conditions. Begins most frequently in the periosteum. Tends to the formation of new bone or to necrosis. Is often unaccompanied with suppuration. Does not involve neighboring articulations. Frequent in bones of the cranium. Tubercular Osteitis. Osteitis of tuberculosis occurs in persons who have other symptoms of this disease. Begins in the medulla. Tends to disintegration of the parts. Generally terminates in the formation of pus. Apt to do so. Almost never found in this situation. 164 AX AMERICAN TENT-BOOK OF SURGERY. Syphilitic Osteitis. Tubercular Osteitis. Histologically, consists of a relatively large Made up of a varying number of tubercle- mass of granulation-tissue. granulations and surrounded by isolated granules. In the majority of cases can be cured, or at We know of nothing short of operative in- least arrested, if taken in time, by judi- terference which materially affects the cious specific treatment. course of this disease. Syphilitic dactylitis occurs at various periods of the disease, and in two varieties. One of these appears usually in the late secondary stage, and involves chiefly the periosteum and the fibrous and integumentary tissues surrounding a joint. It is characterized by slow, almost painless, SAvelling and discoloration of the affected member. This is due to a gummatous infiltration, which, upon subsiding, leaves the finger or toe temporarily stiff, but not permanently disabled. The second form is a specific osteo-myelitis with accompanying inflammation of the periosteum, and appears from five to fifteen years after the infection with syphilis. It is chiefly limited to the bones and periosteum, the integu- ment being but seldom involved; erosion of the articular cartilages often takes place; the ligaments and the capsule become thickened, and the function of the joint is sometimes entirely lost. The absence of acute symptoms in the subcutaneous variety enables us to diagnosticate it from paronychia, whitlow, and gout. Rheumatoid arthritis begins in the joints, is associated Avith other symptoms, deformity of the fingers comes on early in the disease, and the sheaths of the tendons are involved. The second variety might be taken for enchondroma or exostosis, but these swellings involve only a limited portion of the bone, increase very slowly, and present dense, circumscribed tumors. Syphilis of the Nervous System.—The dura mater is frequently the seat of tertiary syphilis, chiefly owing to its intimate connection Avith the cranial bones, toward which it bears the relation of a periosteal lining. The internal surface of this membrane, in contact with the pia mater and Avith the surface of the brain, is frequently attacked at the same time—an accident Avhich manifests itself by various cerebral symptoms: intense cephalalgia, trembling, dulness, intellectual torpor, loss of memory, and coma. Besides these peri-encephalic lesions, the pia mater, and even the brain- substance and the spinal cord, may be the seat of sclerosis or of gummata. The pia mater presents two varieties of lesions: A chronic inflammation, followed by fibrous thickening and by adhesions to the surface of the brain; and gummata, lesions much more characteristic than the foregoing. Cerebral gummata may be found in two forms: 1st. As large gummatous masses developed on the surface of the brain within the convolutions and in the gray substance or encroaching upon the white substance, and usually attacking the base, the cerebral peduncles, the pons Varolii, and the optic tract. They are also found upon the cerebellum and upon the superior surface of the cerebrum. 2d. In the form of smaller nodules accompanying the cerebral arteries, and in particular the middle cerebral arteries. These two varieties of syphilitic lesions do not differ materially as regards their structure; their evolution is slightly different. The latter are generally accompanied by endarteritis, which results in a limited anemic softening of the brain. Symptoms of Cerebral Syphilis.—The symptoms depending upon the SYPHILIS. 165 different alterations of the meninges, of the brain, and of the vessels differ, it is needless to say, according to the region of the brain Avhich is affected by them. The lesions of the dura mater, of the pia mater, and often those of the cranial bones, coincide with gummata or with more or less extended softening in such a manner that multiple manifestations have to be analyzed and explained. Despite these difficulties, the progress of these encephalopathies, a certain num- ber of characteristics Avhich appertain to them, and, in doubtful cases, the ante- cedents of the patients and trial of the iodide treatment, Avill ordinarily indicate their nature. The most common initial phenomenon is headache, Avhich is frontal, occipi- tal, or parietal, very intense, often Averse during the night, and accompanied frequently by vertigo and mental dulness, and sometimes by convulsions. This pain is at times intolerable, or, on the contrary, there may be a stupor resem- bling coma. The headache may last for a long time before any other symptom sIioavs itself. If syphilis has been suspected from the antecedents of the patient, and iodide of potassium has been given Avith the result of lessening the pain or causing it to cease, the diagnosis is assured. During the headache the patients often experience a diminution of their intellectual faculties, forgetfulness of cer- tain words or of their actions of the day before, etc. Different forms of paral- ysis supervene. They are at first very limited. The nerves at the base of the cranium are those most frequently attacked. The paralysis of muscles sup- plied by the common oculo-motor nerve produces, for example, external strabis- mus, diplopia, etc. The diminution of the sense of taste, and even its complete abolition, the loss of the sense of smell, the diminution or the loss of hearing, have also been noted. The disturbances of vision are exceedingly variable, and depend upon the seat of the lesion—Avhether it is localized in the cuneus, in the optic tracts before their intercrossing, at the optic chiasm, or upon the optic nerves beyond the chiasm. Subjective symptoms are observed, such as muscee volitantcs, circles of fire, etc., the perception of only a portion of objects, hemianopsia, or a partial or total loss of vision. These conditions are fre- quently cured by iodide of potassium. The partial paralysis first shoAvs itself in a limb—in the lower extremity of one side, for example—and is folloAved by amelioration if iodide of potas- sium employed in time has produced its curative action; if the lesion contin- ues its progress, complete hemiplegia may supervene. This is generally pro- gressive, sIoav at the commencement, Avith incomplete aphasia, especially if the paralysis is on the right side. These cases of hemiplegia are not accompanied, like those of copious hemorrhages or of apoplectiform softening, by a total loss of consciousness. Patients preserve, on the contrary, to a great extent, their consciousness, as is the case in certain forms of cerebral softening, and the paralysis affects only the poAver of motion. Finally, along with several other phenomena connected Avith the intelligence or the poAver of motion, convulsive symptoms often predominate—veritable attacks of epilepsy. The diagnosis of cerebral syphilis is based less upon the symptoms taken singly or in groups than upon the progress of the affection and upon the therapeutic action of iodide of potassium. An intense headache of long dura- tion, Avhich is cured or benefited by the iodide, but relapses, and Avhich is accom- panied by loss of memory, hebetude, slight paralysis ; then a paralysis very sIoav in progress, ending in hemiplegia, aphasia, and epileptiform convulsion,— such are the symptoms upon Avhich the diagnosis is established. These symp- toms are slow in shoAving themselves, and they groAV more intense very gradually. At their commencement they are benefited or cured by the iodide of potassium. Each of them presents some characteristic peculiar to 166 AX AMERICAN TENT-BOOK OF SURGERY. syphilis in such a way that recognition of the cause is possible in the great majority of cases. The diagnosis from apoplexy and softening is generally easy. The sudden onset of an attack with absolute loss of consciousness and complete hemiplegia excludes the idea of syphilis. It is more easy to confuse it Avith chronic softening; but in syphilis there are the violence of the head- ache, the effects of the iodide, the epileptiform convulsions, and especially the presence of old syphilitic lesions. Cerebral tumors are easily confounded with syphilis, but the consideration of cerebral tubercle is unnecessary, as it is an affection of infancy. Sarcomata might be mistaken for gummata; however, they are exceedingly rare, and the symptoms which characterize them are progressive, without its being possible to benefit them by the iodide treat- ment. The prognosis of cerebral syphilis is very grave. Syphilis, when it affects the spinal cord, may involve the meninges by a specific pachymeningitis, or the cord itself may be invaded by gummata originating either in its substance or in the membranes. The symptoms are those connected with pressure upon or degeneration of the cord itself, and the diagnosis is to be made chiefly by the presence of concomitant lesions of syphilis or by the effects of treatment. The interesting question of the rela- tion of locomotor ataxia to syphilis is not yet settled, but there is enough evidence to justify the following recommendations : In every case of ataxia careful and minute search should be made for evidences of antecedent syphilis, either acquired or inherited. If this be found to have existed, the patient should be placed at once upon vigorous specific treatment, and should be directed to continue it through long periods. If only a fair presumption of previous syphilis exist, the same treatment should be employed, as it would, at the most, be useless, but not hurtful. If the disease be recognized in its earliest stages, and found to be associated with syphilis, and treated in this manner, a prognosis may safely be given of a more favor- able character than at present seems justifiable in any other variety or under any other mode of treatment. Unlike cerebral syphilis, in which the question of operative treatment is often discussed, syphilis of the intestinal tract in the adult has little interest for the surgeon. The involvement of the liver, and especially that of the spleen, in newborn children are of great diagnostic importance, but will be fully considered in the chapter on Hereditary Syphilis. Syphilis of the respiratory tract is of greater surgical interest and importance, on account of its relation to the larynx, where it may simulate carcinoma or tubercle. Some help in the diagnosis of tertiary ulcers of the larynx from those of pthisis and cancer may be found in the points which have been tabulated as follows: Syphilis. Development of ulcer acute, occupying only a few days. Considerable irregular in- flammatory or oedematous swelling. Epiglottis affected, if at all, on upper surface. Ulcer solitary; rarely more than two. Phthisis. Development slow; follows throat symptoms after sev- eral months. Uniform, pale swelling, look- ing like an infiltration. Lower surface. Numerous. Cancer. Intermediate in time; ap- pearance of ulcers in a few weeks. Nodular excrescences and acute inflammation of neighboring mucous mem- brane. No uniformity. Solitary. SYPHILIS. 167 Syphilis. Proceeds from center to periphery, or from above downward. Deep, round, or oval. Diameter of 1 to 1J centi- meters. No cachexia. Treatment usually highly beneficial. Syphilitic Orchitis. Syphilitic history. Usually occurs at about twen- ty-five or thirty years of age. Begins in the testicle. Is situated primarily in the connective tissue. Tends to fibrous overgrowth. Slow in its progress. Skin of the scrotum rarely involved. Ulceration or suppuration rare. Fistuhe uncommon. A feeling of great weight, with only such pain as results from dragging on the cord. Phthisis. The reverse is true. Generally round. 2 or 3 millimeters. Phthisical appearance. Treatment has but very moderate effect. Encephaloid Carcinoma of Testicle. No history of any special condition. Any age. Begins in the body of the organ. Begins by the deposit of small nodules in the semin- iferous tubules. Tends to formation of patches of softened, white, pulta- ceous material. Rapid in its course. Skin of the scrotum finally involved. Ulceration and fungus com- mon. Fistulae common. Pain severe and lancinating in advanced stages. Cancer. Irregular in their course. Irregular in shape. 2 or 3 millimeters. Cachexia. No effect. Tubercular Orchitis. Tubercular history. Not often seen after thirty. Begins in the epididymis. Exists primarily in the tubules. Tends to fatty, caseous, or purulent degeneration. Slow in its progress. Skin involved only just be- fore the formation of ab- scess. Suppuration common. Fistulae common. Little pain. Syphilis of the Testicles.—Syphilitic lesions of the testicles may consist in gummatous nodules of the epididymis, Avhich appear at the end of the sec- ondary period, or later in orchitis, which may be either interstitial or gum- matous. There is also a syphilitic interstitial orchitis of newborn children. Gummata of the Epididymis.—ToAvard the end of the secondary period there is occasionally observed upon the epididymis a limited induration, gen- erally at its head, varying in size from that of a bean to that of a Avalnut or larger, connected with the testicle, hard and indolent. More rarely it is situ- ated upon the body of the epididymis. It may be uni- or bilateral. There is no accompanying affection of the tunica vaginalis or of the skin. The tumor very soon disappears under treatment by mercury and iodide of potassium. Interstitial Orchitis.—Interstitial orchitis of the adult belongs to the period of the later tertiary lesions. It seldom occurs before the third year. It may affect one or both sides. The testicle is the seat of a chronic interstitial inflam- mation. The epididymis is seldom affected; if it be involved, it is its head that is changed. At the beginning of interstitial orchitis the gland is a little larger than normal, but its shape is retained. If the disease is not treated, the gland gradually atrophies, still remaining indurated. There is frequently a notable effusion into the tunica vaginalis, Avhich is inflamed. The folloAving table clearly presents the main points of difference between syphilis, encephaloid carcinoma, and tubercle of the testicle: 168 AX AM ERIC AX TEXT-BOOK OF SURGERY. Syphilitic Orchitis. Tumor very hard, uniform. Skin of scrotum purplish, but unaffected. Of moderate size : rarely ex- ceeds twice its normal diameter. Painless on pressure. Both testicles often affected. Fungus rare. No discharge or bleeding. Lasts many years. Curable. No imrolvement of inguinal glands as a rule. Encephaloid Carcinoma of Testicle. Soft and fluctuating. Network of large veins over surface of tumor. Attains great size. Painless on pressure. Generally only one testicle affected. Fungus ahvays present in advanced stages. Bleeds freely; offensive dis- charge. Rarely extends beyond tAven- ty months. Usually fatal. Inguinal, iliac, and lumbar glands and cord affected. Tubercular Orchitis. At first hard, knotty, irregu- lar. Skin congested, but other- wise unaffected. Of moderate size. Often painful on pressure. Often both testicles affected. Fungus common. Not so apt to bleed; dis- charge not so offensive. Lasts several years. Generally incurable. Usually no inflammation of glands. TREATMENT OF SYPHILIS. The prejudice which for many years existed against the employment of mercurials in syphilis has largely disappeared. A careful and impartial revieAv of the testimony as to the results of the mercurial and of the non-mercurial treatment of syphilis will prove convincingly the far superior efficacy of the former method. Without denying that certain cases of syphilis do well Avithout any treatment or with simple attention to hygiene, diet, etc., or even while admit- ting that in the majority of instances at the present day the disease tends to a spontaneous cure, it may still be considered as well established that, Avithout detriment to health, the probability of that cure can be increased and the duration of the active stage of the malady lessened by a careful administration of some form of mercury. Similar, though not quite so conclusive, evidence exists in favor of a continuous as opposed to an intermittent plan of treatment, although various circumstances may render the latter desirable. The reasons which have been advanced for the employment of mercury in syphilis are— 1. The clinical evidence of its usefulness in the control of early symptoms and the prevention of later developments. 2. Its " tonic " action, Avhich, by counteracting the anemic tendencies of syphilis, lessens the severity of the disease. 3. Its action as a physiological antidote to the syphilitic poison, Avhich it destroys probably through its antibacterial or germicidal poAver. 4. Its properties as a promoter of destructive metamorphosis and fatty degeneration, through which it renders possible the absorption and removal of the neAv cell- growth Avhich causes the secondary symptoms. With regard to the beneficial influence of the iodides in the later stages, a therapeutic fact established beyond all possibility of contradiction, a similar diversity of opinion as to their mode of action prevails. A tonic effect is again claimed as one of the causes of the good results obtained by the admin- istration of these preparations. The vieAvs held as to their modus operandi will depend upon the particular theory of the tertiary stage which is adopted. HoAvever this may be, the clinical evidence is quite sufficient to justify the employment of these drugs, and the proper methods of administering them may be epitomized as follows, beginning Avith the appearance of the initial lesion: 1. Do not employ mercurial treatment until either by confrontation or by the development of constitutional symptoms the diagnosis of syphilis is assured. SYPHILIS. 169 Mercury always retards the appearance of the secondary symptoms, and some- times prevents it altogether. As no venereal sore can with absolute certainty be pronounced syphilitic, it is umvise to add an element of uncertainty to the case by delaying indefinitely the outbreak of unmistakable symptoms. There is sufficient evidence to prove that the subsequent course of the case is not materially affected by this delay. 2. When the time has arrived for the admin- istration of mercury, it is well to explain to the patient the necessity for long- continued treatment and to point out the risks of neglect. Having done this, in the majority of cases the most satisfactory method of giving the drug will be by the mouth, a useful preparation being the protiodide of mercury in pill form, in the dose of I to ^ of a grain, three or four times daily: T^. Hydrarg. iodid. vir., gr. xx ; Confect. rosse, q. s. M. et ft. pill. no. lx. If these should disagree Avith the stomach and produce dyspeptic symptoms, or should give rise to colicky pains and diarrhea, from 2V to A^ gr. of opium may with advantage be added to each pill. At the same time a saturated solution of chlorate of potassium should be given as a mouth-Avash, to be used twice daily as a prophylactic against salivation. 3. To ascertain the proper dose of the drug in each individual case, continue gradually to increase the dose until slight tenderness of the gums or of the posterior molars is noticed. Then dimin- ish it to two-thirds, or even to one-half, of that dose, when its further adminis- tration for an indefinite period will be possible with no unpleasant results. 4. If the preparation selected agrees Avith the patient and controls the symptoms, and if there are no intercurrent complications, pursue this treatment contin- uously for two years. If, however, the protiodide gives rise to persistent bowel trouble, as it does in a small number of cases, substitute for it the bichloride in solution or in combination Avith a tonic: T^s. Hydrarg. chlorid. corros., gr. iss ; Tinct. cinchonas co., f^iv. M. et sig. One teaspoonful in water after meals. Hydrargyrum cum creta in one-grain doses four to six times daily is a very useful preparation in cases of gastro-intestinal irritability. A half-grain to a grain of Dover's powder added to each dose will often control any tendency to diarrhea. In some cases of irritable stomach, or Avhen it becomes desirable to intensify the mercurial influence, inunction may be used. Half a dram of the 10 per cent, oleate of mercury, or, better, a dram of mercurial ointment, rubbed into different portions of the cutaneous surface once daily, may be employed for a short time. The uncleanliness of the procedure and the almost certain eczematous irritation of the skin Avhich it produces render it unsuitable for long-continued use. Vapor baths of mercury may be taken in various ways, the simplest being the volatilization by means of an alcohol lamp of a dram of calomel, the apparatus being placed beneath a chair upon Avhich the patient sits, a blanket extending from his shoulders to the ground serving to retain the fumes in contact Avith his body. 5. By Avhatever method the mercurial influence is kept up, the dose should be temporarily raised whenever new symptoms make their appearance, and, after they haATe vanished, should be dropped to the standard dose for the particular patient. 6. The local treat- ment of symptoms is of secondary importance, and altogether subservient to 170 AX AMERICAX TEXT-BOOK OF SURGERY. the constitutional treatment. It may, hoAvever, be useful as an adjuvant. Mucous patches should be treated Avith sulphate of copper or nitrate of silver if on mucous membranes; Avhen on cutaneous surfaces they should be dusted with powder of starch and calomel or of calomel and lycopodium. The scaly and tubercular syphilides will be benefited by the application of a salve con- sisting of equal parts of citrine ointment and cosmoline, or by ammoniated mercury and cosmoline, two drams to the ounce, or by any other stimulating and absorbent ointment. Ulcers may be dressed with iodoform, or, when sluggish, touched Avith nitrate of silver or acid nitrate of mercury. Enlarged glands may be painted Avith iodine or let alone; they rarely run on to sup- puration. 7. At the end of two years small doses of iodide of potassium should be added to the mercurial, and this "mixed treatment" should be persevered in for six months longer. If during this period any symptom of syphilis makes its appearance, the six months of mixed treatment should be dated from that time. In other words, some such formula as this: B/ Hydrarg. biniodid., gr. ij ; Potass, iodid., gij ; Syr. sarsaparillae co. Aquas, ad. f^iij- M. et sig. A dessertspoonful in water after each meal, should be administered for the last six months of the treatment, and should be recommenced and continued for six months if any symptoms appear later. Great care should be taken to give the mixture largely diluted, and so to vary it as to do aAvay as far as possible Avith any irritation of the intestinal tract. In obstinate tertiary conditions the dose of the iodide may with impunity be run up to tAventy, thirty, or sixty grains, or even more, four times daily. If this be done, the cases which refuse to come under its control will be very rare. 8. At the end of tAvo and a half years the patient should be kept under observation for another full year, and if during that time no symptoms are developed, he may consider himself as in all probability cured. If such symp- toms do appear, however, he should recommence treatment, and should con- tinue it for at least six months after their subsidence. CHAPTER XVIII. HEREDITARY SYPHILIS. The most important points bearing upon the general subject of hereditary syphilis may be enumerated as follows: I. Is syphilis transmissible in all its stages (a) to the Avife or husband, or (b) to the offspring ? In other words, is it ever proper to consent to the mar- riage of a person Avho has had syphilis ? If so, under what circumstances ? II. By what means or through what channels can the disease of the parents reach the child ? III. What are the pathology and symptoms of hereditary syphilis ? IV. What is the treatment—(a) prophylactic, applied to the parents, (b) curative ? We shall take these up seriatim. HEREDITARY SYPHILIS. 171 I. Is Syphilis Transmissible in All its Stages?—No more important questions can be submitted to the surgeon than those pertaining to the marriage of syphilitica. Involving as it does the Avelfare of many indTviduals, modify- ing or fixing the conditions of one or more lives, his opinion should be excep- tionally definite and Avell grounded. There are tAvo distinct methods of arriving at an answer to the'question under discussion : First, by considering the probabilities in regard to the essen- tial nature of syphilis; and second, by carefully weighing the clinical evidence in the matter. It seems evident that belief in any particular theory of syphilis, assigning it to this or that class of disease, must have an important influence in determining the opinion which is held as to its curability, or, at least, as to its indefinite transmissibility. In regard to the first, the main point is the recognition of the fact that modern syphilographers, as a rule, regard the tertiary or late symptoms as indicative of damage done during the active period—as relapses or sequelae, and not as fresh outbreaks of a highly contagious and transmissible disease. Their time of appearance, their entire want of symmetry, their non-contagious- ness, their non-inoculability, all favor this view, and much corroborative evi- dence may be obtained from clinical facts. It is necessary to admit that there seems to have been but little doubt in the minds of many syphilographers that in rare instances syphilitic children have been born to parents who had long passed the limits of the secondary period. At least, the majority of writers upon this subject speak confidently of the exceptional occurrence of such cases, and assert that syphilis may be transmitted during any of its stages. If, hoAvever, Ave look for positive evi- dence in this respect, Ave shall find very little that is entirely satisfactory. Cases are reported, to be sure, in Avhich eight, ten, twelve, or even fifteen or twenty years after the primary sore, syphilitic patients have become the parents of children who shoAved unmistakable indications of the disease. When Ave examine the history of these cases, Ave find usually that many important points have been omitted without Avhich it is impossible to be certain of their true character. Were both parents originally affected ? If not, has a recent case of syphilis occurred in the one Avho at first escaped ? If they were both dis- eased originally, has either been subsequently re-infected ?—a much more fre- quent accident than has been commonly supposed. On applying these tests to the cases in question it will be found that few if any are thoroughly convincing. Fournier, AA-hose immense experience and acuteness of observation entitle his opinion to the utmost consideration, says that in cases of paternal heredity the duration of the power of transmission never exceeds, at the maximum, three or four years. Of the many hundreds he has observed, in no case has he knoAvn a syphilitic father to infect a child—the mother being healthy—at a later period than the one mentioned. And he is equally positive that the gradual diminu- tion and final extinction of the syphilitic reaction of the parents upon the chil- dren constitute a veritable pathological laAv, "absolutely demonstrated." Mr. Hutchinson says : " It is almost an acknoAvledged laAv that parents in the late tertiary stages do not transmit taint." These quotations indicate what is noAV the prevailing vieAv—viz. that the period of transmissibility of syphilis is more or less strictly limited even Avhen the disease is alloAved to progress without treatment. As to the fact that it becomes milder with time, so that with each succeeding year after the termina- tion of the secondary period the chances of escape of the product of conception increase in a rapidly augmenting ratio, there is no difference of opinion Avhatever. 172 AX AMERICAX TEXT-BOOK OF SURGERY. Neither is it seriously disputed that the length of time during Avhich the disease remains active, as well as the degree of its activity, may be markedly influ- enced by treatment. Under proper medication patients Avho have married in the height of the secondary period have had children born healthy who never subsequently manifested any symptoms of the disease. We may therefore assume safely that syphilis after a certain period, not extending much over four years Avhere the disease is allowed to run its 0A\n course, and probably someAvhat reduced by treatment, ceases to be a contagious disease, and at about the same time or someAvhat later loses, in the majority of cases, its capability of being transmitted by parent to offspring. As there are probably exceptions to the rule that this poAver of transmission disappears spontaneously Avithin any specified time, it is never safe to trust alto- gether to nature, but a vigorous and sufficient specific treatment must be employed. Given, hoAvever, the lapse of a sufficient time—say from three to four years as a minimum—and the history of a proper and continuous plan of treatment, the risks of marriage are so reduced as to Avarrant a careful surgeon in permitting it. And, conversely, of course in any doubtful case Avhere such a history can be elicited, and where all these precautions have been observed, it is improba- ble that any taint of syphilis has been transmitted. Beyond this in positive- ness it is not safe to go. There may be exceptions to these as to most other hygienic or therapeutic rules, but they will be of excessive rarity. Before considering the methods by AA'hich syphilis can reach the child from one or the other of its parents, it may be Avell to mention the modes in which the parents can infect each other. The man can derive syphilis from the woman only in the usual way—i. e. by contagion through a breach of surface permitting of the direct absorption of the poison, the development of the disease being attended by the usual phe- nomena—chancre, lymphatic enlargement, skin eruptions, etc. The woman may—and in the majority of cases does—acquire the disease from the man in a similar manner. But the mother may also become infected through the medium of the child, Avhich receives its syphilis directly from the father, the mother up to the time of conception having escaped contagion. More than this, it appears to be highly probable that no woman ever bears a syphilitic child and remains herself absolutely free from the disease. No surgeon of large experience in this class of cases can fail to have seen some in Avhich the husband, having had syphilis and having married after an insufficient interval or an imperfect course of treatment, has infected his wife with the disease, although at the time no discoverable symptom is to be found upon his body. An equally careful inspection of the Avoman will also in such cases be attended by negative results as regards the primary sore, and yet she Avill be found with unmistakable evidences of constitutional syphilis. There is a clue to all such cases which Avill immediately resolve the difficulty. In every instance, provided that no mistake has been made and that both husband and Avife are really free, the one from any contagious lesion, the other from any evidence of a present or previous primary sore, it Avill be found that pregnancy has occurred ; that the Avoman has either been delivered of a syphilitic child or has had an abortion or miscarriage at some time before the outbreak of the symptoms of syphilis. Another argument lies in the application to the case in question of the Avell-knoAvn tv law of Colles," which, from the date of its first enunciation in 1837 down to the present day, has been found to be absolutely without exception. It may be given in his own words: " One fact well deserving our attention is this: that a child born of a mother who is HEREDITARY SYPHILIS. 173 without obvious venereal symptoms, and which, Avithout being exposed to any infection subsequent to its birth, shoAvs this disease when a feAv weeks old,— this child Avill infect the most healthy nurse, Avhether she suckle it or merely handle and dress it; and yet this child is never known to infect its oavh mother, even though she suckle it while it has venereal ulcers of the lips and tongue." As to the absolute and unvarying truth of this law there is not a shadow of doubt. There can be but one rational explanation of these facts—viz. that the mothers who have thus acquired immunity have done so by first acquiring the disease through pregnancy. We may conclude, then, that the husband may infect his Avife—(1) In the usual manner or by direct contagion ; (2) through the medium of the child, or at any rate by the production of conception. There is no proof whatever that the semen of a syphilitic man is contagious or can transmit the disease in any way but that above discussed. On the con- trary, it has been shown experimentally that it is entirely non-inoculable. All other theories as to methods of contagion are so entirely hypothetical and unsupported by trustAvorthy evidence that we can afford to disregard them. II. We may noAV consider the ways by which syphilis reaches the child. These may be broadly classified into— 1. Descent from the father; 2. Descent from the mother; 3 Direct in- fection. As a matter of course, the influence of the father upon the child, so far as regards heredity, ceases at the moment of conception, or, to be more exact, no subsequent condition of the male parent, no development or acquirement of disease, can exert any further effect. That the existence of active syphilis in the father may result in the transmission of the malady to the child cannot be doubted. The relative effect of paternal as compared with maternal influence may be considered after we have described the latter. 2. Descent from the mother may occur theoretically in consequence of— a. Infection of the mother previous to conception; b. Infection of the mother at the moment of conception; c. Infection of the mother during the period of utero-gestation. a. As to the first of these methods of transmitting the disease there is little if any difference of opinion. Even those Avho claim the most for paternal influence include among the conditions Avhich may give rise to syphilis in the child disease of the ovule, and it may be stated as incontrovertible that recent or active syphilis in the mother at the time of conception will almost certainly be followed by syphilis in the child. The cases in Avhich treatment of the father has resulted in healthy children, Avhereas Avithout treatment he pro- created syphilitic children, the mother being without either symptom or treat- ment, have been urged as evidence of the direct descent of syphilis from the father to the child Avithout the intervention or participation of the mother. But it does not follow because the mother has latent or hidden syphilis that she must infect her child. In those cases in Avhich she does not do so the treat- ment of the father will remove the only active source of syphilitic infection. b. The second method, or that in Avhich the mother becomes syphilitic at the moment of conception, is really, strictly speaking, an example of paternal heredity, as the resulting germ is syphilitic, not because the ovule of the mother Avas infected, but on account of the disease of the spermatozoid of the father. c. There remains for consideration the influence upon the child of a syphilis acquired by the mother during some period of utero-gestation. That under 174 AX AMERICAN TENT-BOOK OF SURGERY. these circumstances the child can become infected has been and is still abso- lutely denied by some very respectable authorities. All that is necessary for proof of its occurrence is, "however, (1) freedom of both parents from syphilis at the time of conception, or, in other words, syphilis must have been acquired by both—not alone by the mother—after the beginning of pregnancy; (2) that the syphilis of the child be unmistakably prenatal—that is, not acquired by some accident during or after birth. Several cases reported by acute observers seem to combine both these requisites, and, after reading them carefully, there seems to be no reasonable escape from the conclusion that in some manner the poison of syphilis may find its Avay from the mother to the child. The old idea that the latter was directly infected in utero from the semen of the father is, -of course, altogether Avithout foundation. 3. Direct infection of the child during birth does not properly come under the head of Hereditary Syphilis. There is no possible reason Avhy, when the mother has contagious lesions of the genitals, acquired too late to infect the child in utero, this should not occur, but as a matter of fact no such case has ever been recorded. One explanation of this circumstance may be found in the protective covering of vernix and mucus Avhich coats the infant's body and lessens greatly the risk of absorption. This hardly accounts satisfactorily, hoAvever, for the entire absence of such cases from medical literature, and it is fair to suppose that in all except those cases in Avhich the primary sore is ac- quired during the last month of gestation—AA'hich for obvious reasons are ex- cessively rare—the infant acquires some immunity Avhich protects it from its mother, and is similar to that which, under Colles's laAv, operates in her favor. In other words, even though apparently free from syphilis at birth—a not un- common event, as Ave shall see—it has a latent or modified syphilis which pro- tects it from contagion. (Profeta's law, see p. 134.) We may noAv briefly restate the conclusions at which we have arrived: 1. After a certain interval, not less than four years, and after thorough specific treatment, a person who has contracted a syphilis not especially severe or malignant in its type may be permitted to marry. The assent to marriage will then be based on a belief in the curability of syphilis or in a cessation of its contagiousness, its inoculability, and, in the vast majority of cases, its transmissive power, at the end of the secondary stage. 2. It may be inherited from either parent or from both, and the probability that this will occur increases in a direct ratio with the nearness of the time of conception to the date of their infection Avith the disease. The severity of the inherited disease in the child increases in the same proportion. 3. It is undoubted that, the father being healthy and the mother syphilitic, the child may, and in all probability will, have the disease. 4. It is probable, but less so than in the preceding case, that, the mother being healthy and the father syphilitic, the child will be infected. 5. It is highly probable that in all cases \\-here a child becomes syphilitic through paternal influence the mother is also the subject of syphilis, Avhich may, hoAvever, assume a latent form, the only evidence of its presence in a feAv cases being the protection Avhich it affords against contagion through the medium of the child. 6. Syphilis may be transmitted from mother to child even Avhen it is ac- quired by the former as late as the seventh month of utero-gestation. III. The Pathology and Symptoms of Hereditary Syphilis.— Syphilis of the placenta is of especial interest in its relation to the abortions and stillbirths so frequent in syphilis. Under the influence of that disease cell- proliferation begins in the villi, which are, normally, only sparingly supplied with HEREDITARY SYPHILIS. 175 cells, and extends to the connective-tissue stroma and the epithelium. This proceeds to such an extent that it leads to compression of the vessels, and finally obliterates them. The vascular spaces into which the villi dip become filled up and narrowed, and often disappear. In this way, and also by reason of the thickening of the epithelium, the interchange betAveen the maternal and the foetal blood is interfered Avith, and at last is prevented. If this process is spread over the Avhole placenta, the foetus perishes before it is complete. If it is limited to circumscribed areas, it may continue to live for a shorter or longer period. Syphilis in the parents Avill manifest itself in the children in one of several Avays, which are determined chiefly by tAvo factors—viz. first, the length of the interval between the infection of the parent and the date of conception; and, second, the thoroughness of the treatment of the parents during that interval. To these may be added as subsidiary, but still of definite importance, a third, the type of disease Avhich has affected the father or the mother, Avhether mild or severe, benign or malignant. From what has already been said in reference to the question of marriage, it will at once be understood that the danger to the offspring in untreated cases, and in those Avhere conception has occurred during the early secondary period of the disease, is of extreme gravity. In such cases the usual result of pregnancy is abortion at from the first to the fifth or sixth month, the foetus sometimes exhibiting the evidences of syphilis in the shape of large bullae upon the palms and soles, or in the presence of characteristic visceral lesions, but quite as often showing nothing distinctive. It has generally undergone more or less maceration, and the skin, which is readily detachable, is of a con- gested, purplish color. At least one-third of syphilitic children are dead-born. As time goes on and other pregnancies folloAv, either the abortion occurs at a later period of pregnancy or the children are brought alive into the world. Even then, hoAvever, and although at birth they may show no evidences of the disease, their chance of escape is but small. One-fourth of them die within the first six months. If they survive that period, the chances for life are slightly in their favor, but those for health or for freedom from deformity and disease are still overwhelmingly against them. The Primary Stage is never found in true hereditary syphilis. Of course in congenital or infantile syphilis, in which by direct contagion, either from the mother or from any one else, the disease Avas acquired by the child, the course would not differ materially from that observed in the adult, and the primary sore Avould be present. But as this stage of acquired syphilis corresponds to the period during Avhich the poison is finding its way into the system through the lymphatics, it is not found in the child Avho is infected from the moment of conception or who receives the poison from the mother directly into the circulation. The Secondary Stage.—For from one to three weeks the newborn infant often shoAvs no symptoms of the disease. In 158 cases collected by Diday, 86 manifested symptoms before the expiration of the first month, and 60 of the remainder before the end of the third month. When to these are added the statistics of Boger, we find that of a total of 172 cases 159 shoAved syphilitic symptoms before the end of the third month. When these symptoms are present at birth, they consist largely in a general withered, atrophied, Aveazened appearance of the child; a hoarse cry, due to SAvelling, with sub- acute inflammation, or even ulceration, of the laryngeal mucous membrane; a coryza, due to a similar condition of the Schneiderian membrane; and 176 AX AMERKAX TEXT-BOOK OF SURGERY. certain cutaneous eruptions, the most common of which at this early date is the large vesicular or bullous eruption knoAvn as syphilitic pemphigus. Pemphigus.—With regard to the specific or non-specific character of this eruption there has been much difference of opinion, and, as it is often the earliest distinctive expression of syphilis, a diagnosis of Avhich could hardly be founded on the general appearance of the child, or even on the hoarse cry and the coryza, it becomes important to have definite ideas upon the subject. Nearly a century ago it Avas denied that this eruption Avas a manifestation of venereal disease; and this vieAv has found supporters down to the present day. The progress of clinical and pathological knoAvledge enables us noAV to assert, hoAvever, that although, as an exception, bullae may sometimes be due to a profound cachexia not dependent on syphilis, yet in the large majority of cases they are specific in their character. If Ave find an infant at or immediately after birth presenting on the soles, the palms, the fingers and toes, or on the limbs an eruption consisting of blebs more or less perfectly distended Avith a liquid which may be clear, cloudy, or bloody, circular or oval in shape, sometimes irregular, seated on inflamed, red- dish skin, and surrounded by trifling areolae, we may strongly suspect the presence of syphilis in an active and most menacing form. And this suspicion becomes a certainty if, in combination Avith such an eruption, the general cutaneous surface is yellowish or muddy in hue, is hard and dry, without elasticity or softness—owing to the absence of subcutaneous fat—and, for the same reason, is furrowed and wrinkled about the face, imparting an appearance of senility; if the child has a hoarse cry, and a discharge from the nostrils; and, of course, if there are at the same time other syphilodermata. This eruption is specially important, however, because upon the recognition of its specific character in cases of stillbirth or in those in Avhich the child survives only a few days—not long enough for the development of further symptoms— Avill depend the opinion as to the cause of death, which, AA'hether expressed or not, "will determine the future treatment of both parents during the interval betAveen pregnancies and of the mother during the next pregnancy. Coryza is one of the most characteristic, and at the same time one of the most important, of the early symptoms of syphilis in its influence on the health of the child. It is due to the same condition of the mucous membrane lining the nasal fossae Avhich manifests itself simultaneously or soon afterward on the skin in the shape of erythema, roseola, or papules; in other words, it is a hyperemia with papillary infiltration. The excessive supply of blood to the parts induces a catarrhal condition Avhich shoAvs itself in a thin, Avatery dis- charge. As the child during suckling is compelled to breathe through the nose, this discharge is rapidly dried into crusts, causing the peculiar nasal, noisy respiration Avhich has given the affection the popular name of snuffles. Roseola is apt to present itself about the second or third Aveek after birth. As in the adult, it begins upon the abdomen in the form of little oval, circular, or irregular spots, dull red in color and disappearing upon pressure. Later the color becomes deeper, the eruption extends to the trunk and limbs, and, as exudation and cell-proliferation succeed to simple capillary stasis, it ceases to disappear when pressed upon. It is often moist, and sometimes excoriated, owing to the thinness of the epidermis. Occasionally it is confluent, and covers large areas Avith an almost unbroken sheet of deep-red color. The diagnosis in the early stage is often difficult on account of the resem- blance to the simple erythema of infancy. As the disease progresses, hoAvever, maculae form here and there; the cell-infiltration involves the papillae, several of which coalesce, forming flat papules ; the nutrition of the superficial layers HEREDITARY SYPHILIS. ■177 of the epidermis is interfered with, especially where it is thick, as on the palms and soles, and the eruption in these regions becomes scaly: and then the diagnosis is not difficult. Papules and Mucous Patches.—In the ordinary evolution of the dis- ease the next manifestation is usually the development of papules on the general cutaneous surface and of mucous patches on the tongue, lips, and cheeks; probably also on other mucous membranes not exposed to examina- tion. The papules for the reason already mentioned—the thinness and moisture of the skin—are apt to be of the broad, flat kind, especially, as in the adult, in those regions where the elements of warmth and friction are superadded to moisture, as in the folds of skin about the genitalia, the neck, the flexures of the joints, etc. They are then moist, covered with a grayish secretion or a thin crust, and are in reality mucous patches. Mucous patches in the infant are among the most important of the early syphilitic lesions, as they are almost constantly present, and thus constitute by far the most frequent vehicle for convey- ing the disease from the child to its nurse or to others with whom it may come in contact. No child that has even been suspected of having a taint of heredi- tary syphilis should be permitted to nurse at the breast of any one but the mother, or to share its cup or nursing-bottle with other children, or to receive the caresses of relatives or friends; and in this last restriction we should include the father. The mucous patches should be actively treated both locally and constitutionally, and during their demonstrable presence a most rigorous quar- antine should be observed. Syphilitic condylomata are due to hypertrophic changes in the papules, which under the influence of heat and moisture in certain regions coalesce and become more elevated. They vary in size from an eighth to a quarter, or even a half, of an inch in diameter. Their surface is flat and covered by a crust or by an offensive secretion. They are found most commonly about the anus or at the angles of the mouth. Pustular Syphilides.—A little later in the secondary period, usually at about the sixth week, but sometimes much earlier, the papules may become transformed into pustules, the change taking place slowly. Iritis.—Another symptom of the secondary period, but of later develop- ment and of rarer occurrence than the syphilodermata which have been described, is iritis. In spite of its rarity, this is extremely important, because it is frequently overlooked until it has reached such a stage that occlusion of the pupil results, and also because when it is recognized it constitutes an almost pathognomonic sign of syphilis. If the condition is observed, the diagnosis is not usually difficult. The pupil is irregular, especially under atropine; there are streaks of lymph, dulness, swelling, and change of color, and on very careful inspection a faint pink zone may be seen in the sclerotic. The conjunctiva and cornea are generally clear. The prognosis depends on the stage at which the patient comes under treat- ment. The lymph, if recent, no matter in Avhat quantity, will probably be absorbed under mercurial treatment, Avhich will often be of great benefit even in those cases in which a certain amount of organization has occurred. The foregoing symptoms are characteristic of the secondary period of hereditary syphilis, or that extending from birth, or more commonly from the age of three or four weeks, to about the end of the first year. They may be again enumerated as follows: coryza Avith snuffles; an erythematous, papular, or pustular eruption on the skin; mucous patches on the lips, tongue, cheeks, etc. ; a marked tendency to general wasting; a hoarse cry or cough ; 12 178 AX AMERICAX TEXT-BOOK OF SURGERY. senility of aspect; iritis. The majority of syphilitic children born alive die during this stage. Before its termination, sometimes even at birth, other lesions have been noticed (especially those affecting the liver), which, however, may be better described in connection Avith the special organ or organs involved. Succeeding this stage—i. e. beginning in about a year or eighteen months— comes an intermediate period, Avhich extends to second dentition, to puberty, or even much later, and which is characterized rather negatively—that is, by the absence of symptoms—than othenvise. The evidence of the general diath- esis will of course be present in the shape possibly of malnutrition, stunted growth, or retarded development, perhaps shown in the weazened or withered face, the sunken nose, the pallor of the skin, the premature loss of the first upper incisor teeth, or the malformation of the others if they have erupted. There is but little tendency to recurrence or relapse of any of the secondary symptoms; and in certain cases this stage extends through life, or, in other words, as is frequently the case Avith the adult who has followed a proper course of treatment, the disease appears to terminate Avith the secondary stage. In other cases, hoAvever, it recurs, and the symptoms which it then presents may be taken up in connection with the different organs or tissues involved. Syphilis of the ear is for obvious reasons not often discoverable until the patient has reached an age at Avhich interference Avith the function of hearing becomes a noticeable phenomenon. The only symptom likely to be noticed during the stage of inherited syphilis which we are now considering is a catarrh of the middle ear. This may lead to perforation of the membrana tympani, purulent infiltration of the mastoid cells, etc., and when accompanied by an otorrhea which attracts attention to the ear will be easily discovered by the surgeon. The affections of the middle ear and Eustachian tube are said to be contem- poraneous Avith the keratitis which appears in the neighborhood of puberty, while those of the auditory nerve are somewhat later in point of time, and are almost always conjoined Avith retinitis, choroiditis, and optic neuritis. Syphilitic disease of the liver in neAvborn children is distinguished espe- cially by increase in size and weight of the organ. This increase depends upon a proliferation of cells from the connective tissue betAveen the acini, or from the adventitia of the interlobular vessels, this growth becoming trans- formed into connective tissue. The change is quite analogous to that Avhich is taking place at the same time in the skin, the mucous membranes, and other tis- sues. It does not, however, go on to organization, but may be just as suscepti- ble of absorption and resolution as are the papules or maculae of the skin. A portion of the enlargement may be due to a passive congestion caused by the presence of this cell-accumulation. As to the diagnosis of hepatic syphilis in infants, the symptoms are indef- inite, or they are identical with those often observed in children who have poor or insufficient nourishment. The only physical sign Avhich properly belongs to hepatic syphilis. Avhen it exists at all, is increase in the size of the liver. Bone syphilis in children is essentially of the nature of the syphilitic bone troubles with which Ave are familiar in the acquired form of the disease, consisting primarily and throughout of an unnatural accumulation of cell-ele- ments, Avhich in the later stages by their pressure produce various degenerations of surrounding structures, and Avhich, as they occur during the process of bone- formation, are accompanied by irregular and abnormal deposits of lime-salts. They especially affect the junctions of the epiphyses and diaphvses, because at that time those points are the seats of great physiological activity. HEREDITAR Y SYPHILIS. 179 The symptoms which obtain in this condition of syphilitic osteochondritis are as folloAVS. There is a SAvelling at the diaphyso-epiphyseal junction of one of the long bones, which in the emaciated subjects of hereditary syphilis is often visible and can always be discovered by palpation. This consists of a ring or collar which more or less completely surrounds the bone, is apt to be smooth rather than irregular, and, Avhen tAvo bones situated near to each other are simulta- neously affected, may conjoin them. A moderate amount of synovitis is often present. This affects chiefly the elboAV and the knee, but may appear in any joint. It is readily influenced by specific treatment and avell-regulated pres- sure. When the last stage is reached, or that of the formation of granu- lation-tissue, with degenerative changes of the cartilages and of the bones themselves, deformity often becomes more marked. There are unnatural curves or angles in the bones, Avith more or less complete separation at the point of junction. The most important differential diagnosis to be made in these cases is betAveen the rhachitis of young children and the form of syphilis in question. The points of resemblance are manifest, just as they are between a syphilitic and a variolous pustule, but they end in both cases Avhen we come to study the evolution of the phenomena either from an anatomical or from a clinical stand- point. They may be expressed as follows in tabular form: Osseous Lesions due to Inherited Syphilis. The swellings, particularly those of the long bones, show themselves at or soon after birth. A history of syphilis or evidence of existing syphilis in one or both parents. Preceded or accompanied by snuffles, coryza, and cutaneous and mucous lesions. No such prodromata in most cases. Cachexia absent or moderate. Physiognomical peculiarities of syphilis pres- ent. Circumscribed tumors on frontal and parietal bones, rarely on occiput. Ribs not markedly affected. Disease of ribs, when existent, not ordinarily coincident with that of other bones. Fontanels close at usual period. Other syphilitic symptoms present-—enlarge- ment of phalanges, metatarsal bones, etc. Often accompanied by sinuses, synovitis, ab- scesses, cutaneous ulcers, etc. Generally disappears by resolution, without leaving any permanent change. Mortality among children in whom many bones are involved is very great. Specific treatment useful. In the first stage there is an exuberant cal- cification of the ossifying cartilage, caus- ing necrosis of the new-formed tissue and a consecutive inflammation, which termi- nates in the separation of the epiphyses.1 Rickets. Rarely appear before six months, generally still later. No such history necessarily. No such prodromata. Pallor, restlessness, sweating, nausea, diar- rhea, etc. constitute a combination of symptoms which often precede the bone disease. Cachexia marked. Not present as a group. Cranial bones thickened in spots, usually upon the occiput. All or nearly all involved. Nearly always so. Closure delayed. Syphilitic symptoms absent. Little external or surrounding involvement. Usually leaves some bending of shaft and distortion of the neighboring joint. Much less. Of no benefit. This is less marked. There is formed, in- stead, a soft and non-calcified osteoid tissue. 1 This table is founded on one published in the translation of Cornil On Syphilis, bv Drs. Simes and White, and is compiled chiefly from the excellent work of Dr. Taylor on this subject. 180 AX AMERICAX TEXT-BOOK OF SURGERY. The bone lesions of hereditary exostosis can readily be recognized by the facts that they are stationary, appear later, and are of larger size, by the ab- sence of syphilitic history or symptoms and by their resistance to specific treat- ment. The diagnosis from accidental separation of the epiphysis or from fractures may be made from the history of the case. In cases of separation of the epiphysis, complicated with suppuration, sinuses, etc., the trouble may be mistaken for a similar condition due to non- specific inflammation. In all the recorded instances, however, the latter has occurred much later in life, is attended Avith much more acute inflammatory symptoms, lymphangitis, etc., and is of course Avithout concomitant symptoms of syphilis. In both cases there is a decided osteo-periostitis, and, as so much depends on the early and vigorous use of specific treatment, it may be worth Avhile to contrast the two forms of the disease. Syphilitic Osteo-periostitis. Occurs in infants under three months of age. History of syphilis in child and its parents. Implication of other bones. Coincident with the development of the shaft of the bone. Other lesions of syphilis—nodes, skin erup- tions, etc. All the local symptoms comparatively mild. Disease sharply localized. Lymphatics of limb unaffected. Beneficial effect of specific treatment if em- ployed early. Non-specific Osteo-periostitis. Seldom if ever occurs in children under one year of age. No history of syphilis ; sometimes a history of traumatism. Usually confined to one bone. Coexists with the ossification of the epiph- yses. No such symptoms. Pain, redness, and swelling very marked. Involves neighboring parts. Lymphangitis sometimes present. No such effect. Fir; Syphilitic Dactylitis (Fig. 14) in the inherited variety of the disease, as in the acquired, consists of tAvo varieties. The one of these Avhich generally appears earlier affects chiefly the periosteum and the fibrous and integumentary structures surrounding a joint, usually a meta- carpo- or metatarso-phalangeal articulation, involv- ing a phalanx, and is characterized by slow, almost painless, SAvelling and discoloration of the affected member. This is due to a gummatous infiltration, Avhich, after absorption under proper treatment, leaves the toe or finger temporarily stiff, but not permanently disabled. The second form is a specific osteo-myelitis, Avith periostitis, coming on later, and often destroy- ing the bone or the articulation involved. The absence of acute inflammatory symptoms in the first variet}7 distinguishes it from paronychia, Avhitlow, and gout. Rheumatoid arthritis begins in the joints and is associated with other symp- toms ; deformity of the fingers comes early in the disease, and there is a teno-synovitis with contrac- tion. The second variety might be taken for enchon- droma or exostosis, but these growths increase much more sloAvly, involve only a limited portion of the bone, are of greater density, and are much more strictly circumscribed. Ulcerated Syphilitic Dactylitis. HEREDITARY SYPHILIS. 181 As a rule, especially in cases which are recognized early and treated actively, the prognosis is good. Syphilis of the Teeth.—Syphilis of the teeth has its chief interest from its very important bearing on diagnosis. Manifesting itself at an age when the child is not apt to present the active and unmistakable cutaneous and mucous lesions of the disease, the recognition of Avhich is therefore often extremely difficult, this diagnostic importance is greatly increased. The teeth of the first dentition, although exhibiting the usual signs of interference Avith nutrition in their irregular development, opaque and chalky enamel deficient in quantity and unevenly distributed, soft and friable dentine, incongruity of size individually and relatively, and proneness to decay, do not often display any distinctive evidence of syphilis. The same conditions may, and often do, depend on other causes, and are commonly associated with various cachexiae. In the permanent teeth, likeAvise, the same condition may be due to the same causes. Stomatitis, hoAvever produced—by mercury, by gastro-intestinal derangements, by local irritation of any kind—is apt to result in imperfectly organized dental structures. Mercurial teeth, for example, are usually irregu- larly aligned, horizontally seamed, honeycombed, scraggy, malformed, of an unhealthy dirty-yellow color, separated too widely, and deficient in enamel. The diseases of childhood by temporarily arresting or greatly interfering Avith nutrition during the developmental period of the teeth often cause horizontal furroAvs across their crowns. None of these conditions, hoAvever, are in the least degree characteristic of syphilis, the special expression of which in the mouth is to be found only in the permanent upper median incisors. It may be considered as well established that when these teeth are stunted, abnor- Fig. 15. mally narroAV at the cutting edge, crescentically rounded ^^^^iiS^%^^ with the convexity upward, and the surface inclined upward ^Vr^Hp^/* and forward, instead of backward as in normal teeth, widely upper Median incisors separated, but converging at their loAver edges, they are "* Hereditary syph- pathognomonic of hereditary syphilis (Fig. 15). They are generally knoAvn as " Huteh in son's teeth." They are often Fig. 16. described as pegged, having been likened to a roAv of pegs stuck in the gums. This appearance is due to the facts that they are shortened, often projecting not more than half the normal distance from the gum, and are also widely erratlTeetn. °rma separated; which abnormalities often affect the adjoining teeth, and sometimes the entire denture. A mistake which is frequently made is the confusing of the serrations of the cutting edges of recently-erupted normal incisors (Fig. 16) Avith. the peculiar crescentic edges of syphilitic teeth. Interstitial Keratitis.—The frequency of this form of diffuse inflamma- tion of the cornea, and the diagnostic significance Avhich has been so positively attributed to it—and as positively denied—render it of special interest. It begins, commonly, as a slight, diffused haziness situated in the substance of the cornea itself, usually not far from the centre, and at first affecting only one eye. This condition may persist for one or two months, after Avhich the other cornea is nearly always attacked, and is similarly affected, although the disease is apt to pass through its different stages rather more rapidly than in the first eye. When the height of the disease is reached the corneae are nearly opaque, a bare perception of light remaining. Then the cornea Avhich was first in- volved begins to clear; this is soon followed by improvement in the other one, which in the course of a year or two results in a return to fairly good sight, 182 AX AMERICAX TEXT-BOOK OF SURGERY. although in most cases there remain a slight haziness and an abnormal ex- pansion of the cornea. The diagnosis of this condition may generally be made with ease. The ground-glass appearance in the earlier stages and the dull pink or salmon color in the more vascular stage are very characteristic. The vascularity differs from that attending other chronic forms of keratitis, granular lids, etc., in Avhich the vessels are large and superficial: in syphilitic keratitis they are much deeper and very closely interwoven, so that the effect is almost that of an ecchymosis. In non-syphilitic cases both eyes are not so apt to be affected nor is the tendency to spontaneous cure so marked. The absence of ulceration and the very slight degree of accompanying sclerotic or ciliary congestion are also valuable features. The chief point of interest, however, in the diagnosis of interstitial keratitis is its association Avith other symptoms of syphilis, upon Avhich, for the general practitioner at least, the diagnosis Avill usually depend. There is such unequivocal clinical evidence in this direction that it is safe to say, as of the question of syphilitic teeth, that the burden of disproof rests with the doubters, and Ave may venture the assertion that interstitial, diffuse, or parenchymatous keratitis is a symptom of inherited syphilis, and that the unmistakable presence of the former disease is sufficient proof of the existence of the latter. Syphilis of the Nerve-centres and Nerves.—Until a compara- tively recent period our only guide to the course of the nerve diseases of inherited syphilis was to be found in analogy. We knew, for instance, that in acquired syphilis three forms of cerebral disease could be recognized in a general way : one characterized by a sudden attack of paralysis, in Avhich the lesion was usually thrombosis from specific endarteritis : one in which the symptoms of brain-tumor Avere present, and in which gummata were the cause of the difficulty; and one in Avhich pain, headache, and various functional or convulsive disturbances—chorea, epilepsy, paralysis of single nerves, etc.— Avere the customary phenomena, and in Avhich periosteal, meningeal, or neu- roglial thickenings constituted the pathological basis. The last two are often intermingled both symptomatically and histologically. In spite of certain striking differences—more apparent than real, however— between inherited and acquired syphilis as regards cause, duration of stages, etc., the essential pathological changes are the same. When syphilis in its later periods attacks the brain or spinal cord or nerve-trunks or vessels of a foetus, it proceeds just as in the adult, the same characteristic accumulation of cells taking place and setting up an arteritis or a meningitis, thickening the sheaths of nerves, or constituting a pericranial node or a gumma, according to their number and their situation. We find, thus, that in these patients men- ingitis, growths, and arterial disease constitute the three clinical divisions of the disease which have thus far been distinctly differentiated, and the reported cases, with or without autopsy, fall naturally into these classes. Syphilis of the Sp'leen.—Disease of this organ in inherited syphilis is especially important from two points of vieAv. It is a valuable aid to diagnosis, and by the size of the organ and the degree of persistence of the swelling gives an approximate indication of the severity of the case. Enlargement of the liver, although it ought to be noted because it is often present in hereditary syphilis, has but little value as a confirmatory symptom: first, because the liver is dis- proportionately large in infancy, and it is difficult to state the limit of what is actually normal; and, secondly, because other causes besides congenital syphilis lead to its enlargement. With regard to enlargement of the spleen the case is different. Gee's observation, that in the early stage of infantile syphilis some HER ED IT A RY SI DHILIS. 183 enlargement of the spleen occurs in a large number of cases, has been abun- dantly confirmed. The importance of this sign is greatest when noted early, as, for example, when the child is from two to three months old, for at that period the enlargement of the spleen due to rickets can hardly come into ques- tion. The condition of the spleen during this period of enlargement seems to be simply that of hyperemia, or at the most of hyperplasia. The cause seems to be in all probability the Avell-known effect of syphilis on the glandular system in general and on the lymphatic system in particular, to which the spleen is noAV usually assigned. The analogy betAveen this slow, persistent, painless enlargement preceding the cutaneous symptoms, unaccom- panied by inflammatory symptoms, unattended by any breaking down of tissue, subsiding slowly but evenly under specific treatment, and the behavior of the buboes of acquired syphilis, is certainly very striking. In most cases of hereditary syphilis there are evidences of disturbance of the gastro-intestinal tract. Vomiting, diarrhea, colic, anorexia, and ema- ciation are well-knoAvn, but of course not at all characteristic, symptoms. It has been supposed that the mucous membrane of the entire tract is probably, during the early period at least, and coincidently with the cutaneous eruption, in a condition of hyperemia and irritation comparable to that of the skin. Whether this is so, or whether it is due to associated involvement of the glandular apparatus, has not yet been determined. Syphilis of the Larynx.—The hoarse cry of the neAvborn infant, so cha- racteristic of hereditary syphilis, depends upon the presence of hyperemia, of mucous patches, or even of extensive ulceration, in the larynx. The first is probably the most common, as, if it Avere otherwise, cases of death from oedema glottidis or other forms of laryngeal obstruction would be oftener met with. When ulceration does exist it is generally, but not invariably, secondary to pharyngeal ulcers. Bronchial catarrh, giving rise to cough, and sometimes to considerable embarrassment of respiration, is a not infrequent complication of laryngeal syphilis. Later troubles of the larynx in connection with inherited syphilis have not yet been studied carefully enough to warrant us in drawing any dis- tinction betAveen them and the usual symptoms seen in the acquired disease. Syphilis of the testicles is found to consist of a true interstitial orchitis, very closely resembling that seen in the syphilitic testicles of adults. The dis- ease usually occurs at from two months to three years of age; both testicles are generally involved, and are enlarged, hard, inelastic, and frequently nodu- lated. Mercurial treatment generally causes a marked improvement unless the inflammation has already resulted in the development of a neAv fibroid forma- tion, in which case it will be likely to remain unaffected by treatment. Inunc- tions Avith diluted mercurial ointment, iodoform, etc. are useful adjuvants. The Diagnosis and Prognosis of Inherited Syphilis.—In reviewing the general course of a case of inherited syphilis it seems evident that the differ- ences betAveen it and the acquired disease which have been so much dwelt upon are apparent rather than real. The primary stage is of course missing, and on any theory of the essential nature of syphilis this is readily comprehensible. Whether the chancre is the first symptom of a constitutional disease, or is the simple accumulation at the point of original inoculation of the cells affected by the syphilitic virus, it would naturally be in the first case undiscoverable, in the second non-existent. The secondary stage, characterized in the acquired form chiefly by lymphatic engorgement and symmetrical, widely-spread, polymorphic cutaneous and mucous eruptions, and pathologically by a marked tendency to the proliferation of cer- LSI AX AMERICAX TEXT-BOOK OF SURGERY. tain new small round nucleated cells, upon the presence of Avhich depend all the manifestations of the disease, is in inherited syphilis strictly analogous. The lymphatic engorgement either exists in the infant as in the adult, or has its analogue in the enlargement of the spleen and of the liver, especially the former. The tertiary stage, except in the fact that its phenomena may appear unusu- ally early and may be commingled Avith those of the secondary period, does not widely differ in the hereditary form from that of the acquired disease. In considering the question of diagnosis, therefore, Ave have an excellent guide in the facts that the disease conforms in most respects to the general laws of acquired syphilis, and that our knowledge of the latter affection will be a valuable aid to recognition of the former. The chief elements of diagnosis and prognosis of inherited syphilis in its various stages may, then, be summarized as follows: A history of syphilis in either parent is important just in proportion to the shortness of the interval between the time of infection and the date of conception. If both parents were syphilitic at or before the time of conception, the probability that the disease will be transmitted, and in a severe form, is much increased. There is no sufficient evidence that inheritance from one parent results in a graver variety of the disease than Avhen it is derived from the other. A history of abortion or miscarriage on the part of the mother should have weight in the determination of any given case, and if such accidents have been very frequent their diagnostic importance is greatly increased. Upon examining the product of abortion or stillbirth the most easily observ- able symptoms will be those of the skin. Maceration of the epidermis and its elevation into bullre are in themselves hardly characteristic, though both of them—and especially the latter—may be regarded as suspicious. If the cuta- neous lesions are, however, distinctly papular or pustular or ulcerative, or if the bullae have all the characteristics of syphilitic pemphigus, the diagnosis is assured. The most distinctive symptom—one which may really be considered pathognomonic—is, hoAvever, the inflammation of the diaphyso-epiphyseal articulations, Avith or Avithout their disjunction. Distinct enlargement of the spleen or of the liver and arachnitis Avith hydrocephalus are valuable diagnostic points, and the presence of gummata, Avhich are not very infrequent, would of course be conclusive. At birth the syphilitic child may be small, stunted, emaciated, Aveazened, senile in appearance : this Avould properly give rise to suspicion, but might be associated with any disorder of nutrition on the part of either child or mother. It may also disclose cutaneous or mucous eruptions evidently specific in charac- ter. In any event, marked symptoms at birth render the prognosis highly unfavorable. It is quite common, hoAvever, for the subject of hereditary syphilis to give no evidence of the disease at birth, but even to appear healthy and Avell nourished. In such cases the first symptoms of the disease appear, on an average, in from six Aveeks to tAvo or three months, and consist principally of coryza, snuffles, hoarseness of voice, and syphilodermata. Mucous patches on the tongue, cheeks, tonsils, and pharynx are common, often extending to the larynx, increasing the hoarseness, and to the nasal cavities, aggravating the snuffles. Both of these occurrences, by interfering Avith the respiration of the child and rendering its nursing interrupted and insufficient, greatly add to the gravity of the case. Enlargement of the spleen HEREDITARY SYPHILIS. 185 (common), enlargement of the liver (less so), and iritis (rare) may be mentioned among the phenomena of this stage often associated with the skin eruptions. About the time of the subsidence of the rash there may be developed the specific inflammation at the junction of epiphyses and diaphyses which pro- duces a swelling of the long bones near their ends. The child will be noticed to cry a little when, for example, the wrist or elbow on one side is Avashed, and not to use these joints as much as the corresponding ones on the other side. The parts are slightly tender, and as yet there is but little swelling. Later, the droop and disuse of the affected limb become more noticeable and simulate infantile paralysis. There is, however, no Avasting, no alteration of reaction by faradism, no real loss of power, so that the term pseudo-paralysis is an ap- propriate one. In a week or two similar symptoms will occur in the bone on the opposite side, and finally the ends of all the long bones will be affected; ordinarily the elboAVS, Avrists, knees, and shoulders are the joints involved. Suppuration is rare, disjunction of the epiphysis from the diaphysis common. Recovery is apt to take place spontaneously within a month. The associated changes are chiefly endosteal at the junction of the shaft Avith the epiphysis, but there is also a little periostitis or perichondritis, which is the principal cause of the external SAvelling. Moderate deformity may ensue. Similar changes occurring in the cranial bones give rise to Avhat has been called the natiform skull. During the first year it is very common for syphilitic children to develop a number of lenticular swellings on the cranium, which appear symmetrically around the anterior fontanel, but at a little distance from it—i. e. one on each frontal and one on each parietal bone. They are said to be " bossed." They are originally circumscribed, and in a child nine or ten months old often measure from three-quarters of an inch to an inch in diameter. They are at first circular, afterward more irregular, and finally tend to organize, becoming diffused and massive and causing a permanent thicken- ing of the skull. The symptoms which have been described are the prominent ones occur- ring during the first six, eight, or twelve months of life. If they do not manifest themselves before the eighth month, it is highly probable, even in a case with a syphilitic parental history, either that the child will escape alto- gether or that the secondary stage has been very slight and altogether intra- uterine and unattended with noticeable phenomena. If during this first year the child's cachexia is marked, if there are any intercurrent diseases, if the symptoms show themselves early, if the nasal or laryngeal affection is severe, if the eruptions are markedly bullar or pustular or ulcerative, if the enlarge- ment of the spleen is great or the osseous lesions are precocious or grave, and if, especially, there is any intermingling of tertiary symptoms, gummata, nodes, etc., the prognosis will be unfavorable. From adolescence through adult life the diagnosis of inherited syphilis will depend on the folloAving points: First, of course, the history of parental or of infantile syphilis, or of both. Then a group of physical and physiognomical peculiarities, which are not definitely characteristic, and are of little value when taken separately, but of considerable importance when all or a majority are present in any given case. These are low stature or puny development pro- portionate to the severity of the intra-uterine and infantile symptoms: a pasty, leaden, or earthy complexion, a relic of previous syphilodermata, probably also a result of malnutrition; a prominent forehead, bulging in the middle line at and Avithin the frontal eminence, and due either to thickening of the skull or to a previous arachnitis and hydrocephalus before the ossification of the fon- tanels ; a flat, sunken bridge of the nose, due to the coryza of infancy ex- 186 AX AMERICAN TENT-BOOK OF SURGERY. tending to the periosteum of the delicate nasal bones, and either interfering with their nutrition or partially destroying them; dryness and thinness of the hair, with brittleness and splitting of the nails; synechise and dulness of the iris (rare); ulcerations of the hard palate ; and periosteal thickenings or en- largements of the shafts of the long bones near the ends, or slight angular deformity, the result of the osteochondritis of infancy. A much more valuable group of symptoms, hoAvever, are the following, which are mentioned in the order of their importance, any one of the first three being almost or quite conclusive: Dwarfed permanent median upper incisors, broader at the top than at the cutting edge, which is crescentically notched, separated by an undue interval, and converging toward each other. Evidence of past or present keratitis—a dusky and thin sclerotic in the ciliary region and slight clouds here and there in the corneal substance, there being no scars on its surface ; or of disseminated choroiditis; patches of absorp- tion, especially around the periphery. A radiating series of narrow cicatricial scars extending across the mucous membrane of the lips, or a network of linear cicatrices on the upper lip and around the nostrils, as Avell as at the corners of the mouth and on the loAver lip. Periosteal nodes on one or many of the long bones; sudden, symmetrical, and complete deafness, without otorrhea and unattended by pain or other sub- jective symptoms. Late or tardy hereditary syphilis is rarely dangerous to life. The prognosis is almost unvaryingly favorable unless some grave visceral complication, such as interstitial pneumonia, gummata of the brain, liver, or kidney, or meningeal and periosteal inflammation within the cranium, should occur. Treatment.—The prophylactic treatment, or that directed to the health and sexual relations of the parents previous to conception, has already been sufficiently considered. That of the mother during pregnancy, after having conceived from a syphilitic husband, or having had antecedent syphilis, or hav- ing contracted it by direct contagion subsequent to impregnation, is simply that of acquired syphilis in either adult or child. Mercury in its full physiological dose is the drug indicated. It may not be amiss to combine with it iodide of potassium in moderate doses, but the practice of employing the latter to the exclusion of the former is both theoretically and clinically unsound. Care should especially be taken to give it in such a manner, either by inunction or vaporization or so guarded Avith opium, that it shall not produce any irritating effect on the intestinal canal, the sympathy between Avhich and the uterus may, in the event of a strong purgative action being set up, lead to an abortion. As Ave have seen that the pathology, the stages, and the general course of hereditary syphilis are all closely related to or identical Avith the same phe- nomena in the acquired disease, and so knoAv that they both depend upon the same ultimate cause, it follows that the same principle should govern us in the treatment of the one as in that of the other. We knoAv from clinical experience that mercury exercises an almost con- trolling influence over the secondary manifestations of acquired syphilis. We knoAv also that iodide of potassium, probably by virtue of its powerful stimu- lating influence on the lymphatic system, has an equal power over the tertiary growths. In hereditary syphilis, however, there are two elements which should modify the treatment someAvhat, and must be taken into consideration. These are—1st. The existence of a more or less profound cachexia influencing all the nutritive and formative processes, and in itself, entirely apart from any definite specific involvement of vital organs, threatening life. 2d. The not infrequent HEREDITA R Y S YPHILIS. 1ST occurrence during the secondary period of symptoms—notably gummata— belonging to the tertiary stage. The first indication is met by making the treatment from first to last not only antisyphilitic, but also supporting or even stimulating; and with this object in view especial attention should be paid to nutrition. It may be stated, axiomatically, that for every reason, Avhenever it is Avithin the bounds of pos- sibility, the nurse of a syphilitic child should be its mother. To her it is harmless; to every other woman, not already syphilized, it is in the highest degree dangerous. If neither mother nor wet-nurse can be had to suckle the child, it must be fed by coav's, goat's, or ass's milk or by artificial alimenta- tion ; but its prospect of life will be immeasurably reduced. In addition to careful feeding, a little tonic treatment should be employed from the first, in conjunction Avith the specific remedies, iodide of iron, cocl-liver oil, and prepa- rations of the phosphates being the most useful drugs. The existence of the second condition Avhich exercises a modifying influ- ence upon treatment—the early appearance of tertiary symptoms—is probably due, in many cases at least, to an overwhelming of the lymphatic system by the neAv cell-growth. This leads us to combine Avith the mercury from the beginning, at least in all cases Avhere bony or periosteal involvement, suppura- tion, or the existence of gummata point to this condition, small doses of iodide of potassium or of some other soluble and easily-decomposed iodine salt. The principle of treatment being recognized, the routine procedure may be thus described: Give mercury as soon as the diagnosis of syphilis is assured— preferably by inunction. Sir Benjamin Brodie's opinion, expressed many years ago, still represents that of the profession: "I have tried different Avays of treating such cases. I have given the child gray powder internally and given mercury to the Avet-nurse. But mercury exhibited to the child by the mouth generally gripes and purges, seldom doing any good, and given to the Avet-nurse it does not ansAver very Avell, and certainly is a very cruel practice. The mode in which I have treated cases for some years past is this: I have spread mercurial ointment, made in the proportion of a dram to an ounce, over a flannel roller and bound it around the child once a day. The child kicks about, and, the cuticle being thin, the mercury is absorbed. It does not either gripe or purge, nor does it make the gums sore, but it cures the disease. I have adopted this practice in a great many cases with signal success. Very few children recover to whom mercury is given internally, but I have not seen a case Avhere this method of treatment has failed." When, for any reason, as irritation of the skin, this cannot be employed, probably the best form of giving mercury by the mouth is in the following formula: B/. Hydrarg. cum creta, gr. j-vj ; Sacch. alb., gr. xij. M. et div. in chart. Xo. xij. Sig. One powder three times a day, to be taken soon after nursing. Iodide of potassium may be given separately in a syrupy solution in doses of a half-grain to a grain, or, if there are any marked tertiary symptoms, even in much larger doses, three or four times daily. The treatment of course should be continued long after the disappearance of syphilitic symptoms, and it Avould probably be well to continue the mixed treatment intermittently until after puberty. The cases of visceral syphilis in very young children are generally fatal. Those that recover do so in response to the active use of the above remedies. 188 AX AMERICAX TEXT-BOOK OF SURGERY. Later, the prognosis is more favorable, the treatment the same. Of course, moist eruptions should be dusted with some astringent or absorbent powder; mucous patches should be cauterized or stimulated; and great attention should be paid to avoidance of sources of cutaneous irritation, by frequent changing of diapers, etc., but the general methods are the same as in the adult. CHAPTER XIX. TUMORS. A tumor is a new growth or neoplasm Avhich produces a localized enlarge- ment of a part or an organ, has no tendency to spontaneous cure, has no useful function, in most cases tends to groAV during the whole of the individual's life, its development and groAvth, except in rare instances, being uninfluenced by drugs or by the greater or less general vigor of the individual. The exceptions to which the above definition does not apply are—first, such new growths as tubercle, lupus, etc.; second, certain epitheliomata and the Avithering scirrhus of the breast, Avhich do not produce enlargement; and third, CAsts not the result of new growth. Lymphadenoma or lympho-sarcoma, a malignant disease of the lymphatic glands, in a few instances temporarily, or more rarely perma- nently, seems to have undergone cure from the use of arsenite of sodium given internally in increasing doses. All tumors originate from the pj'e-existing tissues (except when of meta- static origin), and are composed of tissue-elements resembling those of these tissues either in their fully-developed or in their embryonic state. When limited to the tissue in Avhich it starts, the tumor merely displaces the tissues, and is, almost Avithout exception, constituted of fully-developed cells similar to the tissue from Avhich it started, as fat, fibrous, or muscular tissue: to this class of tumors, Avhich are generally benign, the term homologous has been applied. When the neAv-groAvth no longer remains confined to the tissue in which it starts, but infiltrates the surrounding tissues, its component elements tending to be more embryonic in their type, it is usually malignant; such groAvths have been termed heterologous. Nearly all secondary tumors—i. e. those forming in parts distant from the primary growth, as in the lymphatics or the viscera—are therefore heterologous. Both innocent and malignant growths may be multiple. Multiple malignant growths are usually the result of lymphatic or vascular embolism, but cases are not uncommon Avhere more than one primary focus has been observed; thus tAvo or three portions of the lip or of the tongue may be simultaneously attacked. Tumors Originate from Many Causes.—Some, as nawi, are con- genital, or the tendency to their development in later life is inherited. Of the causes initiating those occurring in later life, the folloAving are regarded as most effective and unquestioned. While inflammatory new formations cannot be regarded as tumors, there is little doubt that inflammation—especially that following a contusion—stands in frequent causative relation to many neAv growths, notably the sarcomata. Anything AA'hich acts chemically or mechan- ically so as to maintain a constant but slight degree of undue vascularity of a part, such as the irritation of soot (scrotal cancer), the hot, rough stem of a clay pipe (labial epithelioma), a jagged tooth (carcinoma lingua?), favors the TUMORS. 189 development of a malignant growth. Abnormal conditions of parts where the epithelial elements are in excess, as certain benign growths, such as warts (cutaneous papillomata), pigmented moles, and leucoma of the tongue (a chronic inflammatory affection involving the surface of that organ), predis- pose to the formation of malignant growths. Age and sex predispose to tumor-formation. Thus carcinoma is a rarity under thirty years of age; the mammary gland of the female is infinitely more liable to carcinoma than that of the male, owing to their differing functional activity; while, on the other hand, the oesophagus, lip, and tongue in the male seem to be more liable to be attacked by malignant disease than the same organs in the female. The depressing emotions long continued, such as sorrow or anxiety, generally considered as predisposing causes, can act only, as does age, by Ioav- ering the vitality of the tissues, inducing as it were premature senescence : their action is therefore doubtful. Growth.—This is dependent upon its structure primarily, and to a less degree upon the part in Avhich the tumor starts. Cceteris paribus, the more embryonal the structure, the more rapid the increase and the more malignant the tumor, but tumors of similar structure pursue widely differing courses accord- ing to the organ in which they originate. This is partly due to their lymphatic and vascular connections, partly to the importance to life of the part involved or of neighboring parts which may become diseased by contiguity, or mechan- ically rendered partially or wholly useless ; thus a small carcinoma of the pylorus will terminate life by starvation; a tumor of the larynx Avill early endanger life by suffocation. Clinically, tumors are divided into the benign and the malignant. A benign tumor is usually composed of tissues resembling those in Avhich it originates, and is circumscribed, because usually encapsulated, Avhence its mobility among the circumjacent tissues. Its vascular supply is small; hence generally it groAvs slowly. It is painless; it never infiltrates surrounding tis- sues, but displaces them; it does not recur when thoroughly removed, does not give rise to enlargement of the lymphatic glands intervening between it and the venous circulation, and consequently does not affect distant parts. A malig- nant tumor usually consists of tissues Avidely different from those in which it originates; its groAvth is rapid, and therefore often painful; it infiltrates all the surrounding tissues, hoAvever resistant, even bone, because it is almost never encapsulated; it thus early becomes immovable; the superjacent skin is apt to become adherent, especially when the breast is involved; sooner or later it usually infects the group of lymphatic glands intervening between it and the venous circulation, and from these new centres or directly through the veins gives rise to secondary deposits in the internal' organs. Diagnosis.—In general terms this must depend upon the history, age, sex, situation, rate of growth, fixity to the surrounding parts and overlying skin, or the reverse, lymphatic or visceral involvement, and the physical cha- racters of the growth. The liability of tumors to degenerations resulting from disease or injury— since morbid growths are no more exempt from such influences than normal tissues—should be clearly recognized and constantly kept in mind. Thus the vascular supply determines the occurrence of ulcerative inflammation in both benign and malignant growths. For instance, an ordinary sessile fatty tumor (lipoma) is no more liable to be attacked by ulceration than any other portion of the normal fatty tissue of the body, but when such tumors become pendulous, with narroAv pedicles, the blood-supply is often interfered with—especially the venous return—and ulceration is prone to occur from trivial causes. Again, 190 AX AMERIU1 .V TEXT-BOOK OF SIRGER Y. epithelial carcinomata are chiefly formed of masses of cells the majority of which are distant from any direct blood-supply ; thus they readily undergo fatty degeneration and break down early; the 'overlying skin inflames, gives way, and ulceration is initiated. This process is often so active that the major part of the groAvth ulcerates or sloughs away, Avhile at the periphery the disease extends into the adjacent tissues. Very rarely, from injury, gangrene of the Avhole groAvth ensues, resulting in its total destruction and the cure of the disease. One most important class of malignant neoplasms—viz. the sarcomata —are liable to such developmental transformations into structures resembling normal tissues, as to give rise to errors both in diagnosis and in prognosis. It must, then, never be forgotten that any of the structures normally developed from connective tissue may form either the bulk of some of the most malig- nant growths or isolated portions of them: thus cartilage, bone, or fibrous tissue may form the mass of a malignant groAvth; but these changes into tissues of a permanent type in no Avay modify the malignancy of the remain- ing tissues of the embryonal type. Such benign groAvths as fibromata may undergo calcification, Avhile cartilaginous tumors may soften (undergo mucoid change). Treatment.—The only effectual treatment is removal or destruction of the groAvth. Benign growths should be removed if much inconvenience or deformity is present, or if disturbance of health or danger to life—present or prospective —is undoubted. It is needless to say that all malignant growths should be promptly removed, including, when possible, the Avhole of the organ attacked and the neighboring lymphatics and glands, as the entire breast with the axil- lary contents in cancer of that organ ; the whole tibia by amputation in sarcoma of that bone. Special therapeutic indications will be considered when treating of each particular class of growths. Classification of Tumors. Tumors are best classed according to their supposed origin and their histological structure ; thus— I. dlesoblastic or Connective-Tissue Tumors. A. Those conforming to the types of fully-formed connective tissues: 1. Fibrous Tumors (Fibroma, plural Fibromata); 2. Fatty Tumors (Lipomata); 3. Cartilaginous Tumors (Chondromata) ; 4. Osseous Tumors (Osteomata): 5. Mucous Tumors (Myxomata). B. Those conforming to the types of the higher connective tissues: 1. Muscular Tumors (Myomata); 2. Warty or Villous Tumors (Papillomata); 3. Vascular or Erectile Tumors (Angeiomata) ; 4. Lymphatic (vessel) Tumors (Lymphangeiomata); 5. Xerve Tumors (Xeuromata) ; 6. Lymphatic (gland) Tumors (Lymphomata) ; 7. Glandular Tumors (Adenomata). C. Those conforming to the type of embryonic connective tissue: 1. Round-celled Sarcomata ; 2. Spindle-celled Sarcomata : 3. Myeloid Sarcomata. D. Tumors intermediate betAveen the sarcomata and the carcinomata: The Endotheliomata. TUMORS. 191 II. Epiblastic and Hypoblastic Tumors—i. e. those conforming to the type of Epithelial Tissues: A. The acinous or spheroidal-celled carcinomata: 1. Hard Spheroidal-celled (Scirrhous, or Chronic Carcinomata); 2. Soft Spheroidal-celled (Encephaloid or Acute Carcinomata); 3. Colloid Carcinomata. B. Epithelial carcinomata: 1. Squamous-celled Epitheliomata; 2. Cylindrical- or Columnar-celled Epitheliomata. III. Tumors composed of Epiblastic, Hypoblastic, and Mesoblastic Ele- ments : Teratomata, tumors containing bone, hair, teeth, etc., situated in the ovaries or testicles. I. Mesoblastic or Connective-Tissue Tumors. A. Tumors conforming to the types of fully-formed connective tissues: 1. Fibrous Tumors, or Fibromata (Fig. 17).—Consisting of fibrous tissue, they may be as dense and firm as a tendon or as soft as the subcutaneous areolar tissue. They commonly possess a distinct capsule; when completely removed they neither recur locally nor become generalized, and consequently are absolutely innocent tumors. They rarely consist solely of pure white fi- brous tissue, but the firmer varieties are composed of a dense mass of interlacing bundles of this tissue, intermingled Avith a few yellow elastic fibers and connect- ive-tissue corpuscles. The bundles may form concentric circles around the blood-vessels in some fibromata, but usually they present no definite arrange- ment. On section they are smooth, glistening, firm, and of a grayish-Avhite color. Usually the blood-supply is scanty, the vessels being small and thin- Avalled, but some naso-pharyngeal polypi are excessively vascular, being trav- ersed by large cavernous blood-spaces. The softer varieties consist of a more or less loose, succulent, fibrous tissue permeated with numerous large blood- Fibrocystic Tumor of Parotid Region. vessels, and according to the propor- tions of the different forms of fibrous tissue Avhich enter into their composition they Avill appear more or less yellowish, glistening, semi-transparent, or gelatin- ous ; a serous fluid can be expressed from their cut surfaces. When superficial they often become pedunculated. Fibrous tumors are prone to undergo certain secondary degenerative changes —viz. calcification, mucoid change, and ulceration. Seats of Predilection.—Fibromata may occur Avherever fibrous tissue is found in any of its forms, but the commonest seats are the periosteum, espe- cially that of the jaAvs, for the harder forms, Avhen the tumor is called a fibrous epulis; in the uterus ; in the neurilemma of nerves—then miscalled neuroma 192 A X AM ERIC. 1X TEXT-B O OK OF SIR GER 1". (false neuroma) ; in the subcutaneous tissue on terminal nerve-filaments, termed painful subcutaneous tubercles; in the rectum and naso-pharynx, forming fibrous polypi. Hard fibromata are also found in the testis or may spring from the sheaths of tendons. The softer forms originate chiefly from the intermus- cular septa or the subcutaneous and submucous tissues, and are oftenest found in the scrotum, labia majora, or scalp. The soft fibroma was formerly called fibro-cellular: the ordinary nasal polypus is a typical example of this variety. Fibromata attack adults chiefly, but have been observed at all ages; they are usually single, but may be multiple Avhen springing from the nerves (false neu- romata), the skin (molluscum fibrosum), and the uterus. Pure fibromata and fibro-lipomata sometimes form large renal tumors. Diagnosis.—In general terms, fibromata are ovoidal, hard, nodular, or bosselated, of uniform consistence, of sIoav groAvth, painless—except when involving nerves—movable, those in the breast and subcutaneous tissues being unattached to the skin or circumjacent tissues. In these situations, or Avhen arising from the jaAvs or other bones, in their earlier stages it is difficult to dis- tinguish them from the harder sarcomata, the latter being often encapsulated. The sIoav growth, the regular contour, and the non-involvement of the overlying tissues in the case of fibrous groAvths are the chief points of distinction. Car- tilaginous and bony tumors present the same characteristics, but are much harder and more nodular. The softer fibromata are smooth, globular, elastic, soft, and painless. Treatment.—When possible, they should be completely removed, either by enucleation Avith their capsules, as in most of those occurring in the breast, the interior of the jaAv, etc., or sometimes by a dissection, which may be tedious. Recurrence never takes place except where a sarcoma—portions of Avhose mass in certain instances consist largely of fibrous tissue—has been mistaken for the benign groAvth. 2. Fatty Tumors, or Lipomata, consist of adipose tissue identical with normal fat. They are innocent, groAV sIoavIv, may reach a large size, are usu- ally single, but occasionally multiple, are almost never painful, occur chiefly during adult life, and do not recur after removal. Composed of masses of fat- vesicles bound together by delicate connective tissue in which the blood-vessels ramify, they are usually surrounded by a thin capsule Avhich is attached by fibrous septa to the skin. Fatt}T tumors may undergo such secondary changes as calcification, mucoid softening, inflammation from pressure, and, as a result of this in some rare instances, ulceration. Seats of Predilection.—On the shoulders, back, nates—possibly from the pressure of the suspenders, from sitting, etc. Diagnosis.—A fatty tumor forms a circumscribed, usually painless, lobu- lated, soft, pseudo-fluctuant, inelastic, flattened growth—if subcutaneous, caus- ing dimpling of the skin when this is pinched up, due to the passage of the fibrous septa from the skin to the capsule. It is best distinguished from chronic abscess—Avith Avhich it may be confounded—by its dimpling and by the slipping away of the edge of the tumor from beneath the finger Avhen pressed upon : possibly the grooved needle may be requisite. Certain variations should be noted. Thus there is a diffuse form, producing symmetrical swellings at the back of the neck, or beneath the chin, forming so-called " double neck " and ''double chin." Again, the presence of more fibrous tissue than usual may render lipomata unusually firm. They may be deep-seated, springing from the intermuscular septa or even from the surface of a bone. Moreover, they occasionally become pedunculated. Lastly, some of the most typical cases of PLATE VTt. A ~ *■■*. ENOKMOIS CHONDROMA OF ILIUM. TUMORS. 193 "painful subcutaneous tubercle" are composed of fat. The average case can be readily diagnosticated from a cyst, a chronic abscess, or a bursal enlargement by the symptoms given above, Avhile the deeper-seated can hardly be mistaken for any other than soft fibrous or myxomatous growths—an error of no practical moment, since both should be removed. Treatment.—For the circumscribed variety a free incision, opening the capsule, should be employed, when the tumor will usually shell out; if more adherent, some dissection with the knife may be necessary: all portions of the growth must be removed, since occasionally, although rarely, the portions left have formed the starting-point of a neAv tumor. Multiple growths, unless pain- ful ones, seldom require removal. The diffused form should not usually be attacked Avith the knife. The prolonged internal use of liquor potassse in 10-minim doses, t. d., has in certain instances caused their disappearance. 3. Cartilaginous Tumors, Chondromata or Enchondromata (PI. VIL), are composed of some variety of cartilage, forming hard, elastic, sloAvly enlarg- ing growths, often nodular or lobulated. They may consist of a single mass or of a number of small masses each enclosed in its capsule, all bound together by connective tissue and blood-vessels. They are homogeneous or coarsely granular on section, presenting a translucent, bluish-gray or pinkish- Avhite surface, sometimes marked out into irregular lobules. Histologically, they are usually composed of hyaline- or fibro-cartilage. Where unattached to bone their fibrous capsule serves as a perichondrium, and Avhen exposed to friction a bursal sac often forms between them and the superjacent parts, Fatty or mucoid secondary changes may render some of the nodules centrally diffluent, producing cyst-like cavities containing synovia-like fluid, thus so completely metamorphosing the tumors that they sometimes are hardly recog- nizable as chondromata; Avhile, on the contrary, some become calcified or ossified. This latter change is especially apt to affect chondromata springing from the juxta-epiphyseal region of the long bones, the change progressing so far that only a thin layer of cartilage caps them, forming what are termed cancel- lous exostoses. Chondromata are apt to be single, but they are often multiple and symmetrical, as those attacking the phalanges. While pure cartilaginous growths are benign, sarcomata are often partly, or even chiefly, composed of cartilage, especially those found in the testicle and the parotid. Multiple chon- dromata of the hand, if of rapid groAvth, should be vieAved Avith suspicion as possibly cartilaginous sarcomata. Occurring at any age, they are more com- mon in the young, especially those springing from the long bones near the epiphyses. Sometimes the tendency to their formation seems to be inherited, the tumors being similarly located in both parents and children. While they often attain a large size, they groAV sloAvly, so that unusual bulk with rapid growth Avould justify a strong suspicion of the intermixture of sarcomatous elements. Mixed tumors containing cartilage have been already referred to. Seats of Predilection.—The bones, especially on or in the phalanges of the fingers or toes; the loAA-er juxta-epiphyseal region of the femur; the upper ends of the tibia, fibula, and humerus, the scapula and ilium, on or in the jaAvs, especially the upper; the salivary glands, notably the parotid ; the testicle ; in or around joints attacked by rheumatoid arthritis ; and the subcutaneous tissues. Diagnosis.—This must depend on the hardness yet elasticity of the tumor, its nodular circumscribed outlines, and its sIoav continuous growth; later, on the development of softened spots indicative of cystic degeneration, and on the location of the tumor, as upon a young bone near an epiphysis. A carti- laginous sarcoma—the growth Avith Avhich chondromata are most likely to be 13 194 AX AMERICAN TEXT-BOOK OF SURGERY. confounded—presents less definite outlines—i. e. infiltrates somewhat, is apt to be of unequal consistence from the outset, and grows with much greater rapidity. Treatment.—Complete removal of a pure chondroma will secure future immunity, and should ahvays be adopted Avhen possible. Mixed chondromata containing sarcomatous elements commonly recur. In the parotid gland and sub- cutaneous tissues they can usually be enucleated with their capsules, and some- times this can be done when the phalanges are involved, but more often in the latter event and when the testicle is attacked the Avhole part or organ must be sacrificed : usually those springing from the surfaces of the larger bones can be removed Avithout sacrificing the bone, Avith but small chance of their recurrence. 4. Osseous Tumors, or Osteomata, are formed of true bone, and are gene- rally composed almost solely of either cancellous or compact bone. The can- cellous have been just described as resulting from the ossification of chondro- matous groAvths springing from the juxta-epiphyseal portions of such long bones as the tibia, femur, humerus, fibula, etc., Avhere they form exostoses. The ungual surface of the distal phalanx of the great toe is often the site of such a tumor, producing a subungual groAvth. The compact osseous tumors rarely grow from any other bones than those of the cranium. Certain exostoses, called from their hardness "ivory exostoses," are said to differ from other bony groAvths by the-absence of Haversian canals, and are composed of "layers of bone lamellae laid concentrically over a central point or pedicle." They rarely attain a greater size than that of a small Avalnut, are so dense that they can hardly be cut by any instrument, and it is difficult by the exercise of great force to fracture their pedicles, even when comparatively slender. The ivory exostosis springs from the exterior of one of the cranial bones, Avhile the more ordinary forms of compact osteomata originate in the cranial or nasal sinuses, grow sloAvly, and thrust aside or cause absorption of adjacent structures, thus pro- ducing marked deformities. Although usually single, osseous tumors in some patients may be multiple, being found by the score, in such cases commonly commencing at a very early age, being then hereditary and often symmetrical. Seats of Predilection.—These have been mentioned above in describ- ing these groAvths. Diagnosis.—This is usually easy, depending on the evident connection of the tumor with bone or cartilage, for tumors growing apart from these struc- tures in the connective tissue are probably tumors of some other class Avhich have undergone osseous change, or are structures, such as tendons, muscles, etc., which have undergone calcification or ossification. The pedunculated form when the osteoma occurs as an exostosis, the dense, hard, irregularly nodulated surface Avhen the tumor is non-pedunculated, and its slow groAvth, serve as dis- tinguishing points. The more rapid growth and unequal consistence of the calcifying or ossifying sarcomata serve to distinguish this variety of malignant groAvth from the benign osseous tumors. Treatment.—Although operation alone can remove these growths, not every one should be meddled Avith, but only those should be attacked which are steadily groAving and are painful or produce great deformity or loss of function, and the proposed operation on which will not unduly risk the life of the patient. Thus, most of the exostoses of the flat and long bones and certain osteomata of the upper and lower jaws should be removed, for valid reasons, such as those just given. Those of the facial and cranial bones, Avhich are ill defined and often extend so deeply as to involve the base of the skull, should not be touched. It was formerly taught that it was inadvisable to at- TUMORS. 195 tempt the removal of non-pedunculated, sessile exostoses of the long bones, Avhich arc usually covered by thick masses of muscle, because of the risk of profuse and deep-seated suppuration; but Avith modern methods of operating such complications ought to be avoided, so that if good reasons exist for their removal such tumors should be subjected to operation. With the exception of the cancellous exostosis of the ungual phalanx of the great toe, a pure osteoma when removed does not return, even when some of the surface from Avhich it has sprung is allowed to remain. An ossi- fying sarcoma, for Avhich osteoma has sometimes been mistaken, will of course return. In the exceptional case mentioned the distal portion of the phalanx should be removed Avith the tumor to obviate any risk of recurrence. 5. Mucous Tumors, or Myxomata, resemble both to the naked eye and to the microscope the Whartonian jelly of the umbilical cord and the vitreous humor of the eye. They groAv sloAvly, and may attain a large size, but are in- nocent tumors, not returning Avhen pure and if completely removed. Sarcomata may undergo an analogous change—i. e. mucous softening—and of course such tumors are apt to recur. Mucoid softening also attacks fibromata, chondro- mata, and other connective-tissue tumors, so that many tumors called myxo- mata are chondromata, fibromata, or sarcomata undergoing mucoid (myxo- matous) change. Structurally, a true myxoma is soft, gelatinous, semi-translucent, encapsu- lated, and intersected by septa of fibrous tissue. Their cut surfaces are pinkish- or yelloAvish-gray, and exude large quantities of glairy fluid containing much mucin. Microscopically, they are seen to be composed of numerous anasto- mosing stellate cells, with branching processes Avhich form a delicate stroma in Avhich the gelatinous basis-substance is contained: some round and spin- dle cells are also found. Inflammation, fatty degeneration, ulceration, and the formation of blood-cysts from rupture of capillary vessels are the secondary changes to which these tumors are liable. Seats of Predilection.—The nasal cavities, in which they form gelatin- ous polypi; the mammary gland ; the intermuscular spaces ; the submucous and subserous tissues; more rarely the periosteum, the bone medulla, and sheaths of nerves. Diagnosis.—Before removal their close physical resemblance to fatty and fibro-cellular tumors renders certainty impossible, since they present the same soft, elastic feel, and may even seem to fluctuate, thus simulating a chronic abscess: in such cases the hypodermatic needle would settle the diagnosis. Treatment.—This should be removal Avhen practicable. This is usually readily effected, the growth shelling out of its capsule; but careful dissection is required Avhen they spring from large nerves, since these not uncommonly pass through the center of the tumor, so that sections of the nerve have been accidentally removed Avhen excising such growths. B. Tumors conforming to the types of the higher connective tissues: 1. Muscular Tumors, or Myomata.—Only those of congenital origin seem to be composed of striated muscle-elements (rhabdo-myoma), but even in such tumors the bulk of the neoplasm is not usually composed of muscle-cells. XeAv groAvths made up in part of smooth, non-striated muscle-cells {leio- myoma) frequently occur in the uterus, forming such considerable portions of most fibromata of that organ as to induce many writers to term them myomata of the uterus. In like manner most enlarged prostates are composed in great 196 AX AMERICAN TEXT-BOOK OF SURGERY. part of unstriped muscle. Prostatic enlargements are more apt to be due to fibro-myomatous growths involving the whole organ or an entire lobe, although distinct pedunculated growths are not uncommonly found; Avhile those of the uterus, often very large, consist usually of an aggregation of separate tumors. Uterine fibromata also often assume the polypoid form, from the extrusive efforts of the organ excited by the presence of the growth. Situated elsewhere, myomata rarely attain a great bulk. Wherever situated, they grow sloAvly and are quite innocent, although from their size or position they often cause the utmost inconvenience or even danger to life. They are firm, some- times smooth, but more often nodular, their cut surfaces closely resembling those of a fibrous tumor, OAving to the presence of varying quantities of true fibrous tissue; glandular structures form part of prostatic tumors. Diagnosis.—As they are at the outset so situated as to be inaccessible to sight or touch, the reader is referred to the sections on Diseases of the Prostate and the Uterus. When the oesophagus, stomach, or intestines have been the parts affected, the nature of the tumors has rarely been diagnosticated. Treatment.—When accessible, they should be removed. Xot seldom this may require total hysterectomy. 2. Warty or Villous Tumors, or Papillomata, closely resemble in their structure hypertrophied papillae of the skin or mucous membrane, some of the varieties receiving other special names, as condylomata, mucous tubercles, and " benign villous tumors." They are often due to some form of irritation, as in the case of those Avhich develop on the glans penis from the action of acrid discharges, or those on the hands from dust and dirt. Rarely attaining a large size, and attacking only the skin or the mucous membranes, they are innocent groAvths, although during the cancerous period of life they are apt to degenerate into epithelioma, and the villous tumor of the bladder may destroy life by the hemorrhage to which such a growth often gives rise. Structurally, they are composed of a varying amount of connective tissue surrounding one or more central blood-vessels, and are covered in by one or several layers of epithelial cells resembling those of the skin or mucous membrane from which they are developed; but the cells never transgress their connective-tissue limit—i. e. they do not infiltrate, as epithelioma does. Warts or warty growths either occur as circumscribed growths, or more rarely form caulifloAver masses, large relatively to the size of the part, such as those occurring in the larynx. The enlarged papillae are covered by a layer or layers of horny epithelium, and their vascular supply, as a rule, is small. Mucous tubercles and condylomata consist of flattened elevations composed of enlarged papillae ; their connective tissue, of rapid groAvth, is infiltrated with numerous small round cells, and their epithelial covering is moist and sodden. They are most commonly due to syphilis. Villous tumors, when springing apparently from the vesical mucous mem- brane, Avhere papillae do not normally exist, originate from the subepithelial con- nective tissue and owe their papillary form to the concentric arrangement of the connective tissue and epithelium around the blood-vessels. These can, however, best be described here. Such growths assume the branching, dendritic form of the villi of the chorion, and are very vascular, the vessels being often dilated and thus liable to give way, producing the frequent and serious hemorrhages common to this affection of the bladder. Their epithelial layer is thin, and often removed mechanically, being passed in the urine, where it can be detected by the microscope. Seats of Predilection.— Warts and warty growths occur most fre- TUMORS. 197 quently on the skin, especially of the hands and genitalia, and on the mucous membrane of the larynx. Mucous tubercles and condylomata are most com- monly found about the anus and genitals or in the mouth and throat. The villous growths attack the bladder, rectum, and larynx. Such secondary and degenerative changes as pigmentation, ulceration, and atrophy are common, while Avith advancing years the epithelial elements may infiltrate the connective tissue, resulting in epithelioma. Diagnosis.—The signs and diagnosis of tumors attacking such diverse organs cannot be profitably discussed here, and can be best studied in the arti- cles on the Skin, Bladder, Rectum, Larynx, and Syphilis. Treatment.—As this varies Avith the parts involved, it can only be said, in a general way, that these groAvths should be removed by such means as sul- phuric or nitric acid, etc., Avhich will destroy the base from Avhich they spring; or this base, after their excision by the knife or scissors, must be destroyed by a caustic or by the actual cautery in some form. 3. Vascular or Erectile Tumors, or Angeiomata.—Under this head are classed all neoplasms the chief constituents of Avhich are blood-vessels, either arteries, veins, or capillaries, or in which the blood is contained in cav- ernous spaces not true vessels. Many sarcomata, and some fibromata and car- cinomata, are permeated with enormous quantities of blood-vessels or channels of large caliber, but the essential element composing each tumor is not the vascular tissue, but the sarcomatous, fibrous, or carcinomatous element. 4. Both Angeiomata and Lymphangeiomata will be more thoroughly dis- cussed in the chapters on Diseases of the Blood-vessels and Lymphatics, Avhere their treatment by excision, cauterization, ligature, or electrolysis is described. 5. Nerve Tumors, or Neuromata.—Such growths are of rare occurrence, whether composed of medullated or of non-medullated nerve-fibres. To avoid repe- tition, the student is referred to the section on Injuries and Diseases of the Nerves. 6. Glandular Tumors, or Adenomata, are innocent groAvths, and originate only from pre-existing glandular tissue, Avhich they closely imitate. As of normal gland-tissue, so of these tumors there are tAvo types, the acinous and the tubular. The acinous are composed of acini lined with spheroidal epithe- lium, intercommunicating by duct-like channels: mammary adenomata are of this type. The acini are bound together by a varying amount of connective tissue in which the blood-vessels ramify. Pure adenomata are rare, the inter- acinous tissue usually being replaced by a considerable amount of fibrous tissue (adeno-fibroma), mucous tissue (adeno-myxoma), or sarcomatous cells (adeno- sarcoma); again, the admixture of fibrous tissue Avith the sarcomatous elements, or of mucous tissue similarly disposed, results in other groAvths (adeno-fibro-sar- coma, adeno-myxo-sarcoma); still further, from obstructive pressure the acini or ducts may become dilated, forming cysts into which proliferating groAvths (intracystic growths) may project: such groAvths receive their names from the character of the interacinous and intertubular tissue, being termed adeno-cys- toma, cysto-sarcoma, etc. The Tubular Adenomata consist of tubules lined Avith cylindrical epithe- lium, and therefore spring from mucous membranes the glands of which are similarly constructed, as from that of the intestines. Closely resembling carci- nomata in many respects, unlike them the epithelial elements do not infiltrate the connective tissue. Seats of Predilection.—The acinous occurs chiefly in the mammae— 198 .IV A ME RICA X TEXT-BOOK OF SURGERY. generally in the form of adeno-fibroma—in the lip, ovary, testis, prostate, thyroid, parotid, lachrymal gland, the cutaneous and sebaceous glands: the tubular variety occurs in the intestine, especially the rectum. Secondary degenerations, such as mucoid softening of the stroma and fatty degeneration of the epithelium, frequently produce cystic changes by obstructive pressure on the acini or duct-like portions of these growths. C. Tumors conforming to the type of embryonic connective tissue. These neoplasms, called Sarcomata (PI. VIII and Fig. 18), closely imi- tate in their structure normal embryonic or immature connective tissue, and to this class belong the fibro-nucleated, fibro-plastic, myeloid, recur- rent fibroid, and many of the encephaloid cancers of the older authors. While normal embryonic connective tissue goes on to the formation of fibrous tissue, cartilage, bone, and so on, the sarcomata always retain the embryonic character at their circumference—i. e. their growing, advancing border, and therefore their youngest and least mature part—even in cases in AAhich the older portions may have developed almost normally into fibrous tissue, cartilage, or bone. Therefore any rapidly-growing tumor of the connec- tive-tissue type must have its periphery especially subjected to careful micro- scopic examination to determine Avhether sarcomatous elements exist there. While the sarcomata vary much in their structure and clinical course, they all present the following characteristics. The component cells contain one or more nuclei, the masses of protoplasm of which they are formed not being surrounded by any dis- tinct cell-wall, and the cell-body is large as compared Avith the nucleus. The cells are "in constant relation with the stroma"—i. e. the intercellular cement, that which corresponds to stroma, surrounds each cell, varies in amount, and has no definite arrangement, no alveoli being formed as in carcinoma. The blood-vessels ramify among the cells, not, as in the carcinomata, running in the stroma, because of the absence of any such structure, and are very thin-Availed. Indeed, they often appear to be nothing more than mere spaces bounded by the cells of the growth themselves. A considera- tion of these peculiarities of struc- ture and of the distribution of the blood-supply readily explains the frequent occurrence of hemorrhage into the substance of sarcomata. The fact that dissemination takes place almost invariably by the blood-vessels, and not by the lym- phatics, as is the case Avith carci- nomata, is also explainable by the peculiar relation of the vessels and cells. Again, for the same rea- sons, the lungs, being the organs first reached by the blood after fragments of the groAvth have been swept aAvay by the current, are the organs most often the seat of secondary deposits. The meta- static deposits are usually similar Since sarcomata grow by infiltrating Fig. 18. Sarcoma of the Scalp. in structure to the primary growth. PLATE VTTT. t '•}%'*■■ L ' i, f." 1 '- £ 1 » : a^**- \1 i '••• X KNORMOl S SARCOMA OF Bl'TTOCK. TUMORS. 199 the surrounding tissues, they are exceedingly apt to recur locally, doubtless because some infiltrated tissue has been left. Secondary lymphatic glandular involvement, except Avhen the tonsil or testis is implicated, is the rare excep- tion—as is alleged, because of the absence of lymphatic vessels in most sar- comata: if the organs just mentioned are attacked, glandular involvement is the rule. Their growth is not sIoav and steady as in the carcinomata, but spasmodic, noAV fast, noAV sIoav. While carcinoma attacks old or senescent tissues, sarcoma most frequently occurs in organs or tissues which are develop- ing, are in active function, or are at least in their prime; hence it is a disease of youth or early middle life. Another point in which it differs from carci- noma is that scraping a freshly-cut section does not yield a milky juice like that obtainable from the latter form of malignant growth. Not infrequently sarcomata result from an injury, such as a bloAv or a fracture. So closely does one of the varieties of sarcoma—the round-celled—resemble ordinary granulation-tissue that they cannot be distinguished from each other microscopically. They both consist of small round cells similar to the white cells of the blood, separated from one another by a very small amount of homogeneous intercellular material permeated by delicate capillary vessels arranged in the form of loops. The sarcomata exhibit nearly every step in the development of the connective tissues, from this round-celled, immature tissue to bone. Thus, the cells become elongated and spindle-shaped, while the intercellular substance may shoAV an attempt at fibrillation ; or further develop- mental changes may ensue, converting the major part of the groAvth in some instances almost wholly into fibrous tissue, cartilage, or even bone, although, as has been already said, sarcomatous elements are ahvays discoverable at the growing margins, while its malignancy, as shoAvn by invasion of the surround- ing tissues and dissemination throughout the internal organs, is in no Avay less- ened. Calcification is often mistaken for true ossification, which is seldom met Avith except in bone sarcomata, and while it is true that bone may form part of any variety of sarcoma, yet it is most common in the spindle-celled and the mixed forms. Where the new bony spiculae, in any tumor connected Avith a long bone, grow at right angles to the shaft of that bone, they will usually be found to be surrounded by some soft tissues, which upon microscopic examination will prove to be of a sarcomatous nature: this arrangement of the bony spiculae is the exact reverse of that commonly prevailing in the structure of true osteo- mata, where they pursue a course parallel to the long axis of the bone and are surrounded by cartilage or periosteum. Sarcomata may be grouped in three main classes—viz. the round-celled, the spindle-celled, and the myeloid or giant-celled. 1. The Round-celled Sarcomata usually form soft, vascular, and very rapidly growing tumors, often becoming very large, and early giving rise to metastatic deposits in distant parts and in the viscera. Microscopically, they consist of round cells of varying size closely resembling leucocytes, imbedded in a small amount of granular or homogeneous intercellular basis-substance. On section they so much resemble brain-matter in consistence and vascularity that the old terms encephaloid and medullary seem not inappropriate. Many of those tumors formerly called encephaloid cancer or fungus haematodes were really round-celled sarcomata. Mucoid softening, fatty degeneration, and ulceration are common secondary changes, together Avith the extravasation of blood into their substance, resulting in the formation of cysts (sarcomatous blood-cysts). Seats of Predilection.—They attack most frequently the periosteum, bone, lymphatic glands, subcutaneous tissue, testicle, eye, ovary, uterus, lungs, 200 AX AMERICAX TEXT-BOOK OF SURGERY. kidneys, and more rarely the skin, although they may originate Avherever fibrous tissue exists. Sub-varieties.—(a.) The glioma. This form grows from the connective tissue (neuroglia) of nerve-centers, and its basis-substance resembles that structure; the cells are apt to be small. It occurs in the retina and brain. (b) The lymphosarcoma, groAving in lymphatic glands, is composed of cells usually of large size, lying in a reticulum resembling lymphoid tissue, (c) The psammoma or nest-celled sarcoma is of rare occurrence, attacking only the pineal gland, (d) The alveolar sarcoma is so called because the basis-sub- stance encloses each cell in a separate space or alveolus, (e) In the melanotic sarcoma both the cells and the intercellular basis-substance are pigmented. Both the alveolar and the melanotic form may be of the spindle-celled variety. The melanotic form is found as a primary groAvth only in parts normally contain- ing pigment, as the skin and the choroid coat of the eye, becomes rapidly dis- seminated—the secondary groAvths being usually also pigmented—is probably the most malignant of the sarcomata, and by the older Avriters Avas called melanotic cancer or melanosis. Warts are sometimes pigmented, and thus look like this form of sarcoma, but Avarts are firm, often pedunculated or lobulated, and of sIoav groAvth: in very rare instances pigmented warts undergo epi- theliomatous change, when their rapid growrth excites the suspicion that they are pigmented sarcomata, but in the epithelial growths the glands early become implicated. 2. The Spindle-celled Sarcomata are formed of cells varying much in size, some tumors being composed of very small oat-shaped cells, others of greatly elongated bodies Avith long, fine, tapering extremities. Often the cells are arranged in the form of trabecular, Avhich so closely imitate fibrous bands that the tumor may be diagnosticated as a fibrous or even a muscular growth. The sub-varieties are the melanotic, just mentioned, and the small-celled and large-celled. When portions of these tumors have undergone developmental changes they are sometimes called chondrosarcoma, osteo-sarcoma, etc. Seats of Predilection.—The skin and subcutaneous tissue, the fasciae and intermuscular septa, the periosteum and the interior of bones, the eye, the antrum, the breast, and the testicle. Sarcomata consisting of an admixture in varying proportions of round and spindle cells, or of cells of many different forms and sizes, are sometimes called mixed-celled sarcomata. To the naked eye they present the same cha- racteristics as the round- and spindle-celled forms, and they may undergo the same developmental and degenerative changes. Seats of Predilection.—Chiefly the bones. 3. The Myeloid or Giant-celled Sarcomata consist chiefly of large elements formed of masses of protoplasm, containing two or more nuclei—up to tAventy, or even fifty—Avith a varying number of round, spindle, or mixed cells. They usually spring from the interior, cancellous tissue of bones, and vary in consistence from that of jelly to almost that of muscle. A section appears smooth, shining, succulent, but presents no appearance of fibrillation, and is of a greenish or of a livid red or maroon color, varied by pink or darker red spots, due to extravasations of blood. They have been compared in color to the muscular tissue of the heart. Seats of Predilection.—The loAver jaw, the loAver end of the femur, and the head of the tibia; although they may occur elsewhere. The courses pursued by the several forms of sarcomata are partly depend- TUMORS. 201 ent upon their structure, partly upon the organ or tissue Avhich they attack. For example, the commonest form attacking the mamma, the spindle-celled, occurs most frequently betAveen thirty and forty years of age, is at first encapsulated—therefore freely movable—hard and nodular, groAvs Avith great rapidity, and sooner or later, from softening or the development of cysts, is apt to present points of unequal consistence, some of the consequent bosses actually feeling fluctuant. The tumor remains for a considerable time isolable from the mammary gland proper, thrusting this to one side. The skin does not usually become adherent, even Avhen intracystic growths fungate, after having caused ulceration; although, if the tumor is left to pursue its natural course, in time not only the skin but also the subjacent parts Avill be infiltrated, and death Avill ensue from sloughing or involvement of the lungs, liver, or other viscera; the axillary glands remain uninvolved. Examine the other extreme as exemplified by the course pursued by a giant-celled sarcoma, usually occurring in an adult over forty years of age, and attacking the body of the loAver jaAv, sloAAdy expanding the bone into a smooth tumor, involving both its inner and its outer surface, the bony Avails of which are often so thin as to crackle under pressure, yet growing so sloAAdy that years may elapse before it attains the bulk of a Avalnut; the groAvth does not become adherent to the surrounding tissues, and consequently rarely ulcerates; involvement of the lymphatic glands seldom occurs. From the preceding remarks it will be seen how difficult the diagnosis of sarcoma often is, varying as the symptoms do Avith the organ attacked. Occur- ring at all ages, sarcoma is more apt to attack the young—i. e. the tissues during the developmental period. Although it is the rule for sarcomata to groAV rapidly, especially the secondary groAvths, yet some of the primary ones develop slowly, the rate of growth and bulk attained depending largely upon the tissue attacked. Those of the eye or brain are apt to be small, while those of bone often reach a huge size. While those Avhich attack the subcutaneous tissue, the fasciae, and the intermuscular planes are usually surrounded Avith a capsule, there is none for those springing from the surfaces of bones, nor for those arising in the interior of such organs as the lymphatic glands, the tonsil, etc., which are soon entirely infiltrated by the groAvth. Infiltration of the surrounding tissues, even those external to its capsule (Avhen such exists), is a peculiarity of sarcoma: this is especially true of the small spindle-celled variety (recurrent fibroid of Paget), Avhich occurs chiefly in the subcutaneous tissue and sometimes in the breast, recurring in the course of many years a dozen or more times, Avhile distant parts and the lymphatic glands never become infected. Attention has already been called to the early implication of the glands in sarcomata of certain organs, as the testicle, etc. The subperiosteal sarcomata are very apt to give rise to secondary tumors in other bones, the skin, the subcutaneous tissue, and the viscera, lymphatic involvement being the rare exception. Finally, certain of the softer sarcomata by hemorrhage into their substance become completely broken down and converted into cyst-like tumors filled Avith blood, partly fluid, partly coagulated. These if punctured bleed profusely, the hemorrhage being often difficult to control; Avithout a microscopical examination it may be impossible to distinguish such a growth from a true hematoma (blood-cyst). Diagnosis.—This is often difficult, and must depend on a careful con- sideration of the foregoing facts, together Avith those noAV to be given. The consistence of the tumor varies much in different parts; cysts are of frequent occurrence, especially Avhen affecting the bones, breast, or testicle; moreover, these develop, as does the groAvth, with a rapidity unknown in benign cystic 202 AX AMERICAX TEXT-BOOK OF SURGERY. growths; sarcomata are more apt to ulcerate than benign tumors—this is peculiarly true of recurrent growths; the ulceration, Avhether the giving Avay of the skin be due to infiltration, as is the rule, or merely to advancing pressure, is apt to be preceded by a reddened, tender, hot skin, thus presenting such symptoms of inflammation as will embarrass the diagnosis in doubtful cases. In any given case the questions to be considered are—Is it an inflammatory trouble, or is it a malignant growth ? If a malignant groAvth, is it sarcoma or carcinoma? The first question can probably be ansAvered by the history, by the absence of the systemic indications of an acute suppurative inflammation, and, above all, by the marked differences of consistence exhibited by different portions of the tumor. The second query, as to the class of malignant disease to which any given growth belongs, can, with the exception of primary groAvths attacking the tonsil, the testicle, or the lymphatic glands themselves, be settled by the early involvement of the lymphatic glands in carcinoma and their immu- nity in sarcoma, and by the frequent presence of cysts, the greater mobility, the freedom of the overlying skin, the enlargement of the superficial veins, and the greater rapidity of growth in the latter disease. Retraction of the nipple in a case of tumor of the breast points to carcinoma rather than to sarcoma. The peculiar features assumed by sarcoma as it affects each organ often afford valuable information, and for this the student is referred to the appropriate sections of this work. The prognosis varies with the site of the disease; thus, a myeloid (giant- celled) sarcoma of the loAver jaw is not uncommonly curable by operation, Avhile a sarcoma of the tonsil or lymphatic glands destroys life with great rapidity. As has just been pointed out, recurring small-celled sarcoma of the subcutaneous tissue may be repeatedly removed, the system remaining free; or amputation, if a limb be involved, Avill probably cure the disease. It also varies with the variety of the disease: the more embryonic the form the greater the malignancy. Thus the round-celled variety is by far the most malignant form, the spindle- celled less so, and the myeloid the least. Treatment.—This depends partly on the variety, partly on the organ attacked. While it is true that a myeloid tumor of the lower jaw may after thorough enucleation never recur, it is far safer to remove at the same time as much of the surrounding tissue as can be done Avith safety. When the long bones are the seat of sarcoma, amputate high up—if possible, through the joint above: this is likeAvise good practice Avhen sarcomata of the soft parts of the extremities recur, especially if they are of the round-celled type. If the upper jaw is attacked, the whole maxilla of that side must be removed, but the prog- nosis w ill be bad. Sarcomata of the lymph-glands or of the tonsil are so little influenced for good by operation that, except as a mere palliative, removal, as a rule, should not be attempted. Tumors of the subcutaneous tissue or inter- muscular fascia should be removed as often as they recur, or amputation may be resorted to Avhen a limb is concerned. D. The Endotheliomata. These, as yet, little-knoAvn tumors, occupying apparently the border-land between sarcomata and carcinomata, must be briefly considered, since it ap- pears probable that some sarcomata of the testicle are of this nature, and, developing at least in part from the endothelium of the lymphatics, give rise to that early infection of the glands so characteristic of testicular sarcoma, and yet so contrary to the natural history of the disease as it occurs in nearly every other situation. When arising in the pia mater, structurally and from their mode of origin TUMORS. 203 many of these endotheliomata are alveolar sarcomata, while those originating in the pleura or peritoneum are carcinomatous, consisting of nests and clusters of epithelial cells presenting at their periphery a columnar appearance, these cell-masses being surrounded by a dense fibrous stroma: the cells follow very exactly "the course of the lymphatic vessels." They present themselves in the form of " multiple flattened nodular groAvths, Avhite in color, and either isolated or connected by neoplastic bands, the intervening serous membrane being more or less thickened;" metastasis is common, giving rise, Avhen the pleura, for instance, is the seat of the primary tumor, usually to secondary groAvths in the peribronchial fibrous tissue, the bronchial glands, and the thoracic muscles. Attacking as they do chiefly the pleura and peritoneum, nothing definite can be said concerning their diagnosis or treatment, and they have been mentioned here because of their apparent etiological relations to other malignant growths, and because, although rare, recorded cases are becom- ing more frequent. II. Epiblastic and Hypoblastic Tumors, or those conforming to the Types of Epithelial Tissues—the Carcinomata. These tumors are composed of cells of the epithelial type "in constant relation Avith one another"—i. e. no visible intercellular matrix is discoverable —forming nests surrounded by more or less fibrous stroma. This alveolar arrangement of the cells is due to the fact that the cells, having broken through their "connective-tissue limit," now occupy the interstices of this tissue—i. e. the radicles of the lymph system—forming intercommunicating columns of cells, which in cross-section, surrounded with their fibrous stroma, present the appearance of true alveoli. Lmlike adenomata, the cell-groups are not limited by any basement membrane, Avhile the vessels differ from those of sarcomata by having Avails of normal thickness and construction; moreover, they ramify in the stroma, not among the cells themselves. Tavo points should be noted—viz. that although the individual cells differ somewhat from one another, they retain the type of the parent epithelium, being more or less spheroidal Avhen originating from a gland, squamous if derived from the skin, squamous or more often columnar Avhen springing from a mucous membrane. Still further, the cells of the secondary groAvths usually closely resemble those of the primary tumor. The normal connective tissue of the part, Avhich at first forms the stroma, is infiltrated Avith numerous cells, Avhich later, by develop- ment into fibrous tissue, produce the denser stroma characteristic of some forms of carcinomata. The development of this fibrous tissue, studied in connection with the dispo- sition of the blood-vessels, explains the differing behavior of the rapidly- growing tumors and those of sloAver groAvth. In the former the vascular supply is rich and tolerably evenly distributed throughout the growth, Avhile there is relatively little stroma, what is present probably being not much more than the normal connective tissue of the part incapable of active contraction and consequent obliteration of the blood-vessels. In the tumors of slower groAvth the blood-supply is more scanty originally, and is found chiefly at the periphery of the growth, having been obliterated in the more central older portions by the contraction of the large amount of neAvly-formed fibrous tissue. Hence the fatty degeneration of those portions, resulting in their breaking doAvn, Avith loss of substance, Avhen occupying a free surface or after giving Avay of the skin in more deeply situated groAvths: this is the so-called ulceration of new growths. Owing to the abundance of blood-vessels and the 204 AX AMERICAX TEXT-BOOK OF SURGERY. lack of support afforded by the scanty stroma of the rapidly-growing carcino- mata, hemorrhage into their substance is not uncommon, Avith free bleeding from the surface when ulceration has taken place. Carcinomata possess no capsule at any stage of their development, growing by endogenous cell-division and by infiltration of the surrounding tissues, as a rule sooner or later break- ing down and ulcerating. As the cells proliferate in the lymphatic spaces of the connective tissue, or, as is alleged for the breast, originate in what are said to be spaces in direct continuity Avith the lymphatic vessels, the nearest lymphatic glands early become involved, then those next in order, and finally the viscera. In external carcinoma the general health does not usually suffer until after ulceration, Avith its consequent purulent and bloody discharges, or secondary implication of one or more of the important viscera, has occurred, Avhen Avhat is knoAvn as "the cancerous cachexia" sets in, characterized by a peculiar salloAV, earthy hue of the skin, anxious, careworn facies, and more or less marked emaciation. Death finally results from the combined effect of the purulent and hemorrhagic discharges, from the impairment of nutrition through involvement of important viscera, and from pain, anxiety, and loss of sleep. In internal carcinoma, especially of the digestive organs, this cachexia soon sets in, inasmuch as the general nutrition of the body is disturbed very early in the disease. Possibly also the absorption and diffusion of secondary products of the carcinoma may have some influence in causing this cachexia. Carcinomata are divisible into two main classes, Avith certain sub-classes: (A) The acinous or spheroidal-celled : 1. The hard spheroidal-celled (scirrhus); 2. The soft spheroidal-celled.(encephaloid); 3. The colloid, probably a degenerative form of one of the preceding varieties. (B) The epithelial: 1. The squamous-celled; 2. The cylindrical- or columnar-celled. (A) Acinous or Spheroidal-celled Carcinoma originates only from the epithelium of the acinous glands or from that lining the tubular glands possessing glandular epithelium. The essential difference betAveen the two chief divisions of this class is in the relative amounts of stroma and cells, the hard form containing large amounts of fibrous tissue, Avhile in the soft carcinomata the cells preponderate. The term Scirrhus has been applied indiscriminately to the harder forms of spheroidal-celled carcinomata and to the Avhole class. 1. Hard Spheroidal-celled Carcinoma, or Scirrhus, appears as a hard, irregular, tuberous groAvth of moderate size ; if originating in a glandular struct- ure, it is continuous Avith it; at the outset freely moving with the gland, but later by infiltration losing this mobility because adherent to the skin, fascia, muscles, etc. Implication first of the nearest group of lymphatic glands, and next of the viscera, and finally ulceration of the superjacent tissues, complete the natural history of the groAvth. The carcinomatous ulcer is irregular in outline and depth, has hard, nodular, everted margins, Avhile the base is indu- rated and irregular, sometimes more or less covered Avith sloughs, and but rarely presents any evidences of granulations, although in very exceptional cases these exist Avith slight attempts at cicatrization. The duration of life in this affection is about tAvo years, but occasionally patients live for many years, even tAventy, during much of Avhich time ulceration may exist. Of course these remarks apply only to external tumors. OAving to the large amount of newly-formed TUMORS. 205 connective tissue in the hardest forms of scirrhus, in some instances the tumor, instead of groAving larger as time goes on, becomes smaller, the surrounding tissues being irregularly puckered and draAvn in toward the small central shrivelled lump Avhich forms the tumor; this is the so-called withering or atrophic scirrhus, best seen in the breast, Avhere after it has existed for years nothing but an irregular mass resembling a cicatrix is to be found, blending into one inseparable groAvth Avhat formerly Avas skin, mammary gland, and chest- Avall. Unfortunately, the malignant tendencies of the groAvth are not abolished by its shrinkage, for secondary tumors develop in the viscera, destroying the patient. On section, hard carcinomata are firm, of a white color, often traversed by fibrous septa, and creaking under the knife; the cut surface is cupped. The section is succulent, yielding on pressure or scraping a milky fluid, the so-called cancer-juice. HoAvsoever circumscribed the tumor may appear, it is one of the rarest of pathological curiosities to find it encapsulated. Islets of normal tis- sue or fat can often be detected at the periphery of the neAv growth surrounded by carcinomatous tissue; indeed, no definite tumor is discoverable in certain cases, the neoplasm being disposed throughout the affected organ in the form of nodules and cord-like bands. Seats of Predilection.—The mammary gland, the alimentary tract, especially the pyloric end of the stomach, and, in a feAv instances, the glands of the skin. 2. Soft Spheroidal-celled (Medullary or Encephaloid) Carcinoma. —Differing, as already said, from the preceding variety merely by the amount of fibrous tissue, in its typical form soft carcinoma on section closely resembles brain-tissue both in appearance and in consistence. Clinically, the chief points wherein it differs from the hard form are the greater softness of the growth—so soft as at times to simulate and be mistaken for abscess—the greater bulk attained, the short time required to reach this size, and the rapidity Avith which it runs its course. In form the soft carcinomata differ according to the organ attacked. Thus those of the testicle form large, bossellated masses, while mam- mary groAvths tend to form a large globular mass or one composed of an aggre- gation of rounded masses. When ulceration has taken place a fungating, readily-bleeding mass often forms ; hence the old name of "fungus hosmatodes." The secondary and degenerative change Avhich these carcinomata undergo is softening at their central older portions, due chiefly to fatty degeneration, but partly to giving Avay of the blood-vessels, which often results in the formation of such large fluctuating areas that, as has been said, they have not infrequently been mistaken for abscesses. Such tumors on section show that their central portions are converted into a soft, diffluent mass, wThile the periphery of the growth presents the ordinary grayish-white or cream-colored, brain-like surface, blotched here and there Avith blood. This softening also results in cyst-like cavities of considerable size, giving to the tumor the appearance of a true cystic groAvth. In some carcinomata of the testicle, the mamma, and other glands true retention-cysts form. Locally, carcinomata extend by infiltration of the circumjacent tissues; this accounts for the clinical phenomena of adhesion of the tumor to neighbor- ing parts, its decreasing mobility as it grows, and its final absolute fixation. With occasional exceptions, as in some carcinomata attacking the eye, the antrum, or the pylorus, early secondary lymphatic involvement is the rule, the secondary groAvths usually resembling the parent one. Occasionally they are of the soft form, even though the primary tumor is of the hard variety, thus demon- 206 AX AMERICAX TEXT-BOOK OF SURGERY. strating the essential unity of both forms. The organs and viscera most apt to be affected by metastatic deposits are the skin, the bones, especially the vertebrae, the liver, the lungs, the kidneys, and the brain. Even Avhen, after operation, no local recurrence takes place, the possibility of this visceral implication must never be lost sight of, especially if pains in the loAver limbs are complained of, if so-called " spontaneous " fracture of a long bone occurs, preceded or not by pain or tumor, if obscure symptoms of vertebral disease or if peculiar cerebral symp- toms appear. Among surgical rarities is the secondary carcinomatous involve- ment of the medulla of many bones Avithout the formation of distinct tumors in any, but so reducing their strength that numerous fractures occur, either from the application of trifling force or, as it is said, "spontaneously." Seats of Predilection.—The testicle, liver, bladder, kidney, ovary, fundus oculi, and more rarely the breast. 3. Colloid Carcinoma.—This is really one of the preceding varieties the cells of Avhich have undergone mucoid or colloid degeneration and so dis- tend the alveoli that these can be seen by the naked eye. The colloid material is a semi-translucent, glistening, jelly-like substance, in some parts of the groAvth being even diffluent: generally here and there a feAv spheroidal cells are found; it pursues a course similar to, but someAvhat slower than, that of other carcinomata. Seats of Predilection.—The stomach, intestine, omentum, ovary, and occasionally the mammary gland. Diagnosis of the Carcinomata.—They are exceedingly rare before thirty years of age, and are common after forty years ; early lymphatic involve- ment is the rule—contrary to Avhat is true of the sarcomata. Innocent growths occur, as a rule, in younger patients, do not grow so rapidly, do not infiltrate the organ or neighboring parts—/. e. do not become adherent—and almost never ulcerate ; and Avhen ulceration does occur, the characteristics of the result- ing ulcer differ Avidely from those of the ulcer attendant upon carcinoma. It is said that carcinoma never attacks the testicle in the child, but that at any age a malignant tumor of the testicle which on section contains either cartilage or bone cannot be carcinomatous, but is sarcomatous. While it is usually easy to make the diagnosis of carcinoma, yet at times this is difficult or impossible, competent surgeons having removed breasts, believing them to be carcinomatous, Avhen the disease Avas simply cystic or merely a chronic abscess. There is no means of distinguishing that very rare condition, encap- sulated carcinoma, from a benign tumor—e. g. a fibroma. BetAveen chronic mastitis or abscess and carcinoma the association of pregnancy or lactation in most instances Avhen the mamma is the organ involved will assist in the diagnosis, while the greater density of carcinoma and its unequal consistence in its different parts Avhen undergoing softening will often remove all doubt. Unfortunately, the skin over a chronic abscess and that over a softening car- cinoma are not so dissimilar in appearance as to preclude all chance of error, especially as the glands may be enlarged in both affections. The decided elasticity of a cyst, even if fluctuation cannot be detected, its circumscription, and its free mobility, serve to distinguish this class of tumors from carcinoma. It is far better, in any case of doubt Avhether the tumor is really an abscess. a cyst, or a softening carcinoma, either to explore Avith a hypodermatic needle or at the time of operation to make first an exploratory incision directly into the tumor. V, $ & TUMORS. 207 (B) The Epithelial Carcinomata.—1. The Squamous-celled Epithe- liomata ahvays spring either from free epithelium-clad surfaces, as the skin or mucous membranes, or from the glands of the same, since the hair and sebaceous glands in certain instances have been observed to take the initiative in the carci- nomatous process. These groAvths appear Avith great frequency at the points of junction of mucous and cutaneous surfaces (PI. IX, Fig. 1), probably because'there subjected to more frequent and varied forms of mechanical and chemical irrita- tion. Structurally, they are composed of pegs or columns of squamous cells, which infiltrate first the subjacent connective tissue, then every underlying structure, including bone, in their track. The epithelial ingrowths contain globular masses of flattened cells, the so-called " cell-nests" or epidermic pearls. The surrounding fibrous stroma is usually infiltrated with small cells. Epithelioma commences either as a wart-like groAvth, a flattened tubercle, or a fissure, ulceration in all these forms setting in early. In many instances this proceeds with such rapidity that the tumor-formation barely keeps pace Avith it, the resulting disease resem- bling—and being often mistaken for—an ulcer, the indurated base and margins either escaping detection or being looked upon as inflammatory. The other ex- treme is often met with Avhere tumor-formation is in excess, only superficial ulcer- ation obtaining until the groAvth is of considerable size. Epitheliomata are not encapsulated, although upon section their margins appear sharply defined from the surrounding tissues, Avhile the cut surface is Avhite, dense, homogeneous, poor in juice, but if compressed laterally giving vent to milk-white, twisted, thread- like masses Avhich have been likened to the " comedones " that can be pressed out from the sebaceous glands of the skin. The consistence varies much, but is distinctly greater than that of the surrounding tissues, and the part feels dense and inelastic. Although an epitheliomatous ulcer may resemble that resulting from any other form of carcinoma, yet sometimes it is a mere fissure with indu- rated margins, a relatively indolent ulcer with the same peculiarities, or has superadded numerous papillary projections, producing a Avarty or caulifloAver- like groAvth. When originating from an old Avart—a not unusual occurrence— ulceration is apt to be the first symptom, with subsequent induration of the base of the growth. The same remarks are applicable to many cases of epithelioma of the tongue, AAThere an indolent ulcer may last for weeks before the charac- teristic induration of its base and margins can be detected. The rate of groAvth varies with the vascularity and looseness of texture of the tissues. Thus, Avhen attacking the lower lip the progress is slow, lasting sometimes for a year or more before the tumor attains a size greater than that of a hickory-nut, Avhile relatively bulky tumors will form in a feAv months in carcinoma linguae. " Spontaneous fracture " or gradual bending of the tibia is not uncommon from the infiltration of that bone by cancerous tissue, either when an old ulcer undergoes a malignant change (Marjolin's ulcer), or when a scar, after long-indo- lent ulceration, commonly starting at its center, becomes similarly diseased. In like manner complete solution of continuity of the lower jaw may result from epithelioma of the lip extending to the gums and thence to the bone. Local recurrence is common after operation when the removal has been imperfect, and death usually results from the exhaustion incident to ulceration and hemorrhage. Secondary lymphatic involvement occurs Avith most squamous-celled epithelio- mata, but usually late in the disease, Avhen the antrum, the interior of the larynx, or the skin of the eyelids, nose, and other parts of the face is attacked. In these latter situations, indeed, the disease being apt to be superficial and of that form called "rodent ulcer," the glands are rarely affected. The exception in the case of the intrinsic parts of the larynx is the more striking because epithe- lioma of the extrinsic parts affects the glands certainly and early. Visceral 208 AX AMERICAN TEXT-BOOK OF SURGERY. involvement is rare, the liver, lungs, kidneys, bone, and skin suffering most frequently. Seats of Predilection.—Any cutaneous or mucous surface covered with squamous epithelium. When the disease attacks the skin, the parts most com- monly involved are the nose, the lower lip, the penis and scrotum, the vulva, the anus, and more rarely the hands and feet. The mucous surfaces most commonly affected are those of the tongue, palate, gums, tonsils, larynx, pharynx, and oesophagus doAvn to the cardiac orifice of the stomach, the bladder, and os uteri. Diagnosis.—The disease is very uncommon under thirty years of age; it is quite common after forty : it is limited in some of its forms, as epithelioma of the loAver-lip, almost exclusively to men, and, Avherever occurring, attacks men much more frequently than Avomen. If, then, a man of from forty to seventy years of age develops a small tumor in the lower lip which ulcerates early, giving rise to an indolent, slowly-extending sore, with indurated base and margins, no evidence of surrounding inflammation being detectable, the ulcer per- haps presenting the peculiar warty, cauliflower surface mentioned, and especially if the submaxillary glands are enlarged, the disease may be safely considered car- cinomatous. Or, again, an obstinate fissured ulcer, often scabbed over, forms in the same situation, discharging a Avatery matter, with induration extending in all directions for full one-fourth to one-half of an inch, involving not only the mucous and cutaneous tissues, but all the structures of the lip; perhaps in addition the patient states that the disease first appeared as a wart which had been picked off or cauterized—i. e. had been irritated, not destroyed. Epithelioma of the tongue may appear at an earlier age, and in from three to six months will often reach a considerable size in the rarer form, AAhere the disease appears as a hardened, non- inflamed mass on the free border of the tongue—not uncommonly near a broken tooth—its surface eventually becoming fissured, ulcerated, and painful. Or, again, there may be merely an indolent, sloAvly-extending, unhealthy ulcer with indurated base and margins situated as just mentioned. Although the diagnosis between carcinoma and tubercle or syphilis of the tongue is often difficult, coex- isting syphilitic lesions or old scars of the tongue, with antisyphilitic treatment, will usually settle the question, while signs of tubercle elseAvhere ought to arouse grave doubt of the carcinomatous nature of the ulcer. Further diag- nostic points are given in the section on Syphilis. Warts on the hands or scrotum, or elseAvhere, in elderly chimney-sweeps or in coal-tar- or paraffin-workers should be viewed with suspicion, especially if they are growing and if their bases are becoming indurated, because in such cases, sooner or later, an unhealthy ulcer, discharging foul matter, usually forms, presenting all the clinical evidences of epithelioma. It hardly needs to be said that epithelioma is evidently induced by persistent irritation, since the localities Avhere it occurs are subjected to frequent slight traumatisms, and the occupations which give rise to it supply constant sources of mechanical and chemical irritation. Local recurrence is common after operation as a consequence of imperfect removal of the disease, and death in these cases, as Avell as in those not operated upon, results from the exhaustion incident to ulceration and hemorrhage rather than to dissemination, Avhich, as has been already pointed out, is of rare occur- rence. 2. Cylindrical- or Columnar-celled Epithelioma.—This is a less common form of carcinoma than the spheroidal-celled or the squamous-celled varieties, and originates from either the cylindrical surface epithelium of a mucous membrane or that of its glands, closely imitating these structures in microscopical appearance; no "cell-nests" are found. These groAvths form TUMORS. 209 indurated, infiltrating masses in the walls of the organs attacked, and vary much in the rapidity of their course, producing considerable stenosis of the lumen of such holloav viscera as the rectum and small intestines, which may ter- minate life by producing more or less intestinal obstruction ; ulceration occurs early. Dissemination throughout the liver, lungs, and other organs occurs, as a rule, only after infection of the intervening lymph-glands. (See Diseases of the Intestines and Rectum.) Seats of Predilection.—The rectum, uterus, and intestinal tract. Diagnosis.—This is to be made by attention to certain secondary results, which will be found detailed in the sections on Diseases of the Intestines and Rectum. Treatment of the Carcinomata.—The first question to be answered is, Can this case be treated radically, or does it admit only of palliation ? If it can be treated radically, the whole organ should be excised, including as much as can safely be removed of the surrounding apparently healthy tissues, before lymphatic involvement has occurred, if possible: after this involvement has taken place the primary growth must be removed Avith an unsparing hand, while the lymphatic glands and peri-adenoid tissues must be thoroughly cleared out. Indeed, if this last all-essential requisite cannot be secured, removal of the pri- mary groAvth is indicated only for the relief of pain, or, if ulceration has set in, to get rid of a disgusting sore. For instance, in a case of mammary carcinoma, if axillary glandular involvement is present, and there is any question as to the pos- sibility of clearing the axilla, as a preliminary to further operative interference an incision should be made into the armpit to determine Avhether all diseased tissue can be removed. If this cannot be done—unless the breast tumor is ulcerated, Avhen removal may be indicated as a palliative measure—the wound should be closed and the breast allowed to remain, since its removal Avould add a risk Avith no compensating advantage. (See Diseases of the Breast.) Amputation of the limb high up, Avith extirpation of any diseased glands, is ahvays in- dicated where epithelial carcinoma has invaded the bone from an overlying tumor, as, for instance, the tibia. Malignant disease of such parts as the penis and the tongue is properly treated by amputation of these organs, even Avhen secondary glandular disease is beyond removal, merely as a palliative measure to secure urination in the former case and painless SAAallowing in the latter. Epitheliomata of the lips, nose, and eyelids can often be successfully removed by the knife even Avhen extensive, and the defects can be repaired by plastic operation or by Thiersch's method of skin-grafting. The more super- ficial forms can often be effectively handled by freezing Avith rhigolene spray, thoroughly curetting, the application of pyrogallic acid, and an after-dressing Avith an ointment of the same (grs. x@3j), until healthy granulations are formed, when ordinary measures Avill secure healing or Thiersch's skin-grafting may be used. Potassa fusa or the actual cautery may be employed as the destruc- tive agent, and, after separation of the slough, the defect may be left to Nature's efforts or skin-grafting may be resorted to. The chances of cure vary with the part involved, but even with extensive glandular complications, where complete extirpation is possible, some carcinomata of the lip, tongue, and breast do not recur either locally or in the viscera. Carcinomata of the testicle, oesophagus, or tonsil are rarely benefited by operation, except for the palliation effected. When operation is contraindicated, opium to relieve pain, local applications of lead-water and laudanum, extract of aconite and belladonna rendered of a proper consistence by glycerin, or other similar remedies, with attention to the general health, constitute the treatment in non-ulcerated carcinomata. For 14 210 AX AMERICAX TEXT-BOOK OF SURGERY. ulcerated carcinomata measures to control pain, to lessen discharge or hemor- rhage, and to arrest fetor are the main indications. Iodoform Avith morphine in proper amount dusted over the surface, cocaine in solution applied either by spray or by painting, solutions of carbolic acid, Labarraque's solution, or a solu- tion of chloral may be used, as far as possible employing dry dressings or those which favor rapid drying of the discharges—i. e. lessen putrefactive changes. Esmarch's arsenical powder also serves an admirable purpose. No internal remedies of the many recommended having as yet proved of any real value, none need now be mentioned. Finally, the profession should clearly under- stand, and endeavor to educate the public in the belief, that early and radical operations will cure a considerable proportion of cases, and render life endura- ble in many more where a cure is impossible. III. Tumors composed of Epiblastic, IIypoblastic, and Mesoblastic Elements, and containing bone, hair, teeth, etc. (Teratomata), situated in the ovaries and testicles. These are considered Avith these organs, especially with the ovaries. Cysts. A cyst may be defined as a cavity bounded by a distinct envelope composed of fibrous tissue lined with endothelium, and called the cyst-wall; or it may be covered by epithelium and contain secreting structures: the cyst-contents may be either fluid or semi-fluid ; intracystic groAvths may nearly or completely fill the cavity. A cyst may result from the increase of the normal secretion of an already-formed space or cavity by extravasation into it, or the cavity may be of neAv formation. I. Cysts formed by the Distention of Preformed Cavities or Spaces: (a) Exudation cysts; (b) Retention cysts; (c) Extravasation cysts. II. Cysts of New Formation: a) Simple cysts; b) Blood cysts. III. Cysts of Congenital Origin. IV. Cysts due to Parasites. I. Cysts formed by the Distention of Preformed Cavities or Spaces. Exudation Cysts result when excessive secretion takes place into closed cavities, such as bursae, cysts, bronchoceles, etc. Retention Cysts.—These possess a distinct fibrous wall lined with epithelium, and are caused by obstruction of the duct of a gland or portion of a gland, the continuous secretion producing dilatation of the duct or gland- acinus. In most instances, as a result either of inspissation of the contents or of the mingling with them of exudation-products from the cyst-walls, the normal character of the secretion is totally altered. According to their origin, three sub-classes are usually described—viz. (1) Sebaceous (atheromatous) cysts, formed by the dilatation of sebaceous glands; (2) Mucous cysts, due to the dilatation of mucous glands; and (3) Cysts formed by the distention of large ducts—i. e. the salivary, lacteal, hepatic, renal, etc. (1) Sebaceous (atheromatous) Cysts present themselves as smooth, flattened ovoidal, sometimes semi-fluctuant tumors, usually movable on the deeper parts, TUMORS. 211 but often adherent to the skin. At times the orifice of the obstructed duct can be seen, indicated by a small black spot. Seats of Predilection.—The scalp and face chiefly, but they may be found on any part of the body, and are often multiple. When situated in the scalp they are sometimes apparently hereditary. Unlike dermoid cysts, the pultaceous, cheesy contents—often of an offensive odor—contain no hairs, while the cyst-wall possesses neither papillae nor hair-follicles. Certain second- ary changes may greatly alter their appearance and obscure the diagnosis. Thus by inflammation a sebaceous cyst may be converted into an abscess: after spontaneous opening the thinned coverings may ulcerate, abundant fungous granulations may form, and the margins and base of the sore may become indu- rated and elevated, closely resembling epithelioma. These fungous sores may also undergo actual epitheliomatous change: a portion of the coverings ulcerating, the secretion may be gradually forced out, drying as it protrudes, thus in time forming a cutaneous horn, sometimes inches in length ; finally, calcification of the cyst-wall may take place. Diagnosis.—They are most apt to be mistaken for fatty tumors or chronic abscess. From the former they can be distinguished by the fact that the edge of a cyst does not slip away from the finger Avhen pressed upon, by the absence of dimpling of the overlying skin, and when present by the black punctum indicating the duct-mouth ; from the latter, by the absence of symptoms of inflammation and by the use of the grooved needle. When suppuration has occurred, one of the degenerative changes already mentioned, the symptoms of suppurative inflammation, the increase in size, and the exploring needle if requisite, will demonstrate the condition. In those rare instances where a fungating ulcer folloAVS suppuration of a cyst, proper therapeutic measures will cause it to heal in a reasonable time, thus demonstrating that it is not epithe- liomatous. If healing cannot be secured, the ulcer has probably undergone epitheliomatous change in Avhole or in part. When such change has attacked the ulcer before the surgeon sees the case, the diagnosis must depend upon the presence of the characteristics described as indicative of this disease, together with the history. Treatment.—When situated upon the face, if the orifice of the obstructed duct can be discerned, it may be dilated with a small probe and the contents of the sac pressed out, this procedure being repeated from time to time, thus avoiding any scar; but final success is rarely attained, and the method is of very little value. Complete removal of every portion of the cyst-wall is usually the best treatment, and this can be most readily done by transfixion of the cyst and overlying integument with a curved bistoury, pressing out the contents, and then grasping the edges of the cyst-Avail with two pairs of forceps, tAvisting and pulling out each half. If too adherent for this, careful dissection will be required. 2. Mucous Cysts arise from dilatation of mucous glands, their Avails being comparatively thin and their contents a viscid mucoid fluid in which cholesterin is sometimes present. They form in the mouth one variety of ranula: so-called dropsy of the antrum is sometimes due to cystic dilatation of one of the mucous glands of its lining membrane. Seats of Predilection.—The lips, mouth, antrum, labia, and indeed wherever mucous glands exist. Treatment.—Excision of a considerable portion of the cyst-wall, and applications to the interior Avhich will destroy the secreting surface. (See Diseases of the Mouth and Antrum.) Descriptions of cysts formed by the 212 AX AMERICAN TEXT-BOOK OF SURGERY. dilatation of such ducts as those of Wharton (forming ranula), of the breast (galactocele), etc. will be found in the sections on the diseases of those organs. 3. Extravasation Cysts result from hemorrhage into closed cavities, as that of the tunica vaginalis testis (hematocele). Some authors describe extravasations into softened portions of solid tumors, or into the cellular tissue which condenses around the effusion, as extravasation cysts. II. Cysts of Neav Formation. (a) Simple or Serous Cysts (Fig. 19) possess a thin Avail lined with endothelial cells, and contain a serous or thick mucoid fluid. They originate from effusion, which takes place Fig. 19. into the lymph-spaces of the connective tissue from the local irritation of pressure, and push aside the (bundles covered with endothelial plates) until they are condensed into a cyst-wrall cov- ered more or less completely Avith endothelial cells : this is the method of formation of an adven- titious bursa. Simple cysts of the breast are similarly pro- duced, and possibly some of the neck, although most of these are of congenital origin, while those occupying the median line of the neck arise from effusion into some of the normal bursal spaces of that region—i. e. antethyroid or infrahyoid bursae. (b) Hematomata, or Blood Cysts.—There are tAvo varieties, the first being usually found in the cervical region, and consist- ing of thin-Availed cavities con- taining pure blood: their mode of origin is doubtful, but they appear to have some direct communication with the veins, because if tapped or incised they often bleed profusely. The second variety arises from the mechanical and inflammatory condensation of the tissues around an extravasation of blood, Avhich may eventually be absorbed or undergo so-called organization; or the blood may remain liquid, disintegrate, and be absorbed; or suppura- tion may ensue. This form results from injury, and is situated most commonly beneath the scalp, especially in neAvborn infants. (See Cephalhematoma.) So-called compound proliferous cysts, such as those found in the breast and ovary, are merely instances of primary cystic change in these organs, Avhere, as a result of secondary developmental changes, ingrowths occur arising from the cyst-walls. III. Cysts of Congenital Origin. These result either from inclusion of a portion of the epiblastic layer within the mesoblast, or from the distention of the cavity of some persistent foetal Serous Cyst of the Neck. TUMORS. 213 structure which should normally have become obliterated ; for instance, broad- ligament cysts developing from the parovarium, and, dermoid cysts, as alleged, by the inclusion of a blighted ovum in either the testicle or the ovary. Since all except dermoid cysts of the external parts will receive special mention elsewhere, only this variety of cyst will be here described. The cyst-wall contains hair-follicles and sebaceous glands, while the contents are formed of the secretion of these structures, of disintegrated epithelial cells, and of hairs which have been shed. They often have absolutely no connection with the skin, and, occurring about the face and head where in the embryo fissures exist, are probably the result of inclusion of a portion of epiblast. Similar tumors of the ovary and testicle Avhich contain bone, cartilage, and, in the case of the ovary, teeth, as before said, have been ascribed to inclusion of a blighted ovum, but this is at least non-proven. Seats of Predilection.—The outer angle of the orbit, over the root of the nose, the ovaries, and the testicle. Diagnosis.—This must depend upon the detection of a globular, tense, smooth tumor, usually situated at the outer angle of the orbit, unattached to the skin, generally freely movable upon the deeper parts, if overlying the bone often causing its partial or complete absorption, and of congenital origin. Processes of these cysts sometimes extend deeply into the orbit, or even into the cranial cavity. (For Ovarian and Testicular Dermoid Cysts, see the appropriate sections.) Treatment.—Removal by careful dissection, making the necessary incis- ions in such a manner, if possible, that they shall coincide Avith the natural wrinkles of the parts, or that some other structure, as the eyebroAV, shall conceal the scar. IV. Cysts due to the Presence of Parasites. Only those are of surgical importance which result from the growth of the echinococci. The irritation of the tissues induced by their presence and growth results in the formation of a more or less dense adventitious cyst-wall. Since these tumors may be found in any structure or organ, their symptoms and treatment varying accordingly, other sections of this work must be consulted for these data. BOOK II. SPECIAL SURGERY. CHAPTER I. SUKGEEY OF THE VASCULAR SYSTEM. SECTION 1.—DISEASES OF THE HEART AND PERICARDIUM. The diseases of the heart which may demand surgical interference are those which are accompanied by over-distention of the ventricles or by effusion ■ into the pericardial sac. In order to understand how to relieve these conditions by surgical means it is necessary to study the anatomy of the heart and of its covering. In the healthy chest the heart is contained in a space extending obliquely in front from the third to the sixth costal cartilage, and horizontally generally from half an inch to the right of the right border of the sternum to a point half an inch to the right of the left nipple. Posteriorly it occupies the space corresponding to that between the fourth and eighth dorsal spines. The auricles are on a level with the third costal cartilage. The pulmonary artery covers anteriorly the left auricle. The right ventricle is partly behind the sternum and partly to the left of it. The left ventricle, except at its apex, is behind the right ventricle. The pericardium is a fibro-serous sac in which the heart is contained. The base of the sac is at the diaphragm, and the apex is above and by its fibrous layer is connected Avith the deep cervical fascia. Over-distention of the heart occurs in cases of pulmonary congestion of an acute character. The operation of tapping the cavity of the heart has been suggested with the view of relieving the dangerous condition under which the heart labors. The right auricle is the place selected for puncture, because the position of that cavity is less subject to alteration in its relation to the sur- rounding parts, and because the antero-posterior internal diameter is greater than that of the ventricle, the Avails of Avhich are also much thicker than those of the auricles. The best place to perform paracentesis auriculi is the third intercostal space at the right edge of the sternum. The needle should be thrust directly back- ward. The operation should be performed as quickly as possible, and in order to abstract a sufficient quantity of blood with celerity it is necessary to introduce an aspirating needle about three times the size of a hypodermatic needle. The needle should be rendered perfectly aseptic before it is thrust into the auricle, and the end of the needle should be attached to the tube of an aspirator, because the blood-pressure is not sufficient to force the blood out through a canula. The needle must pierce the skin and fascia, the edge of the right lung and the pleural sac covering it, as Avell as both layers of the pericardial sac, before it penetrates the auricle. Tapping the cavity of the heart is fraught Avith extreme danger, and cannot be commended except in special and unusual cases, and even then should be resorted to only after consultation. 214 SURGERY OF THE VASCULAR SYSTEM. 215 Effusion into the pericardium occurs as a result of acute and chronic pericarditis, both of Avhich conditions may arise from various causes, including traumatism. Usually the effusion is moderate and undergoes absorption. Occa- sionally, hoAvever, the quantity becomes excessive and gives rise to alarming symptoms; under these circumstances tapping of the pericardial sac is indi- cated. The symptoms denoting great effusion in the sac are precordial oppres- sion, syncope, dyspnea, aphonia, feeble and irregular pulse, difficulty of deglu- tition, and dilatation of the veins of the neck, in addition to the signs of pericar- ditis during the different stages. An inspection of the chest shoAvs that the pericardial sac is dilated and that the respiratory movement of the left side is impaired. The physical examination, if made before the pericardial surfaces are sep- arated by the fluid, demonstrates the presence of a pericardial friction-sound, which must not be mistaken for an endocardial murmur. The distinguishing feature of the pericardial friction-sound is that it does not possess the same regularity of rhythm as an endocardial murmur, and is not propagated beyond the limits of the precordia. Percussion reveals the presence of flatness over an enlarged precordial space both laterally and vertically. The flatness maps out a quadrilateral or a pyriform area Avith the base below and extending to both sides of the heart-apex. Auscultation demonstrates the absence of vocal reso- nance and of fremitus, and sIioavs muffling of the heart-sounds. The apex-beat is pushed upward and to the left on account of the effusion, and in some cases it is lost. Paracentesis pericardii should be employed when the symptoms threaten life. For purposes of positive diagnosis and with a view to ascertaining the character of the fluid an aseptically clean hypodermatic needle can be introduced before tapping, after Avhich an aspirating needle can be used, or even a trocar, according to the consistency of the fluid. The best point for introducing the needle is at the fifth intercostal space, two inches to the left of the left border of the sternum. This Avill puncture the pericardium external to the internal mammary artery. The direction of the needle should be backward. The fluid should be AvithdraAvn very slowly, and the effects of the removal of the effusion carefully Avatched. The operation should of course be done under the strictest antiseptic precautions. Incision and drainage of the pericardium has been employed in cases of empyema of the pericardial sac. The incision, irrigation, and drainage of the sac should be resorted to only in the purulent form of the exudation. The operation should be performed at the same point as paracentesis pericardii. If necessary, part of a rib may be resected. Although this operation has as yet been done but seldom, the great mortality of empyema of the pericardium war- rants its performance. SECTION II.—INJURIES OF THE HEART AND PERICARDIUM. Rupture of the heart has folloAved complete obstruction of one of the branches of the coronary arteries, the obstruction having been caused by a thrombus or by an embolus in the artery. Mechanical distention of the heart has caused rupture, as when its cavities have suddenly been filled with blood escaping from a bursting aneurysm, or Avhen an abscess of the cardiac Avails has burst into the ventricles. Rupture of the heart has also been a cause of death in tetanus. Wounds of the heart are not infrequent. These may result from severe 216 AX AMERICAX TEXT-BOOK OF SURGERY. injury of the chest-Avail, or from penetration by a fragment of a fractured rib, or by a stab or a gunshot Avound. A Avound of the heart is not necessarily fatal, as is shown in the case Avhere a needle was removed by Callender from the substance of the heart. Other cases of like nature have been reported by Hahn, AgneAv, Stelzner, and others. The symptoms of Avound of the heart are not characteristic. Hemor- rhage is usually present, but a stab wound may occur with little or no hemor- rhage. The absence of hemorrhage is due to the anatomical arrangement of the muscular fibers of the heart. Pain is present as a constant symptom, and attacks of syncope occur at frequent intervals. If hemorrhage has taken place into the pericardium, the percussion note is flat and its area is increased, OAving to the presence of the fluid, and the heart-sounds are less distinct than normal. The cause of sudden death in wTounds of the heart may be syncope from pressure on the heart due to over-distention of the pericardium with blood; or the inability of the heart to contract, OAving to the wound of the cardiac wall, may produce fatal cerebral anemia. Shock and pulmonary anemia also have caused death in cardiac Avounds. Death is not ahvays sudden, but may be deferred for hours (Agnew). Traumatic Carditis and Pericarditis.—The results of inflammation of the Avails of the heart have been observed in cases of injury of the organ Avhere the patients have died after a fortnight. In these cases the substance of the heart was studded Avith inflammatory exudates. Inflammation of the pericardial sac is a more frequent result of traumatism than inflammation of the heart itself. The physical signs of a pericarditis of traumatic origin are substantially identical Avith those of an ordinary pericarditis. The treatment of Avounds of the heart and of traumatic carditis and pericarditis includes constitutional as Avell as local measures. The patient should lie Avith the head low, in order to prevent syncope from cerebral anemia. Absolute quietude should be insisted upon, and opium should be administered with a view to control subsequent inflammation, to tranquillize the circulation, and to relieve pain. Artificial Avarmth should be applied if indicated by the presence of collapse. It must not be overlooked that a certain amount of collapse is a favorable condition through its influence in checking hemorrhage and inflammation, and that over-stimulation must be carefully guarded against. In some cases violent reaction follows and neces- sitates the administration of cardiac sedatives. If a patient survives beyond the period of reaction, the stage of inflamma- tion ensues. This condition must be treated in the same manner as a peri- carditis depending upon idiopathic causes. section iil—diseases of the blood-vessels. part I.—diseases op the veins. Before discussing diseases of the veins it is necessary to review some points in the anatomy of the vessels. A vein, like an artery, has three coats. The internal coat of the veins is the same as the internal coat of the arteries, and its continuation forms the only coat Avhich the capillaries possess. The middle coat is composed of longitudinal and circular elastic fibers, interlacing with Avhich are involuntary muscular fibers that are not so abundant in the veins as in the arteries. The external coat is composed chiefly of white fibrous tissue. The coats of the veins differ from those of the arteries in the thinness of the mus- SURGERY OF THE VASCULAR SYSTEM. 217 cnlar coat and in the presence of valves in the internal coat of the superficial and a feAv of the deep veins; they correspond with those of the arteries in the presence of a common external fibro-cellular tunic and the internal endothelial coat. The thinness of the muscular coat of the veins prevents them from having that rotundity, elasticity, and contractility which are so characteristic of the arteries; it also permits the temporary distention or bulging of the vessels when there is some mechanical impediment to the free return of venous blood to the heart. To serve this purpose the veins possess an inherent capacity of limited distention Avhich is never required in the case of the arteries. It is important to remember this fact when the subject of wounds of veins is considered. Notwithstanding the thinness of the Avails of the veins, they are relatively as strong as those of the arteries. The presence of valves is a peculiarity of veins. These valves support the column of blood mechanically. They are found in the superficial venous system, and especially in the lower extremities. In the portal and hemor- rhoidal systems there are no valves; and this fact has an important influence upon the development of certain diseases in connection with these veins. I. Inflammation of Veins, or Phlebitis.—Inflammation of a portion of a vein produces changes in its coats in the same manner as inflammation of the coats of an artery alters the arterial coats. The disease is much more common than arteritis. Phlebitis may be acute or subacute. Acute Phlebitis is diffuse, and is the result of some irritation of a vein, as puncture or any other injury accompanied by infection; sometimes it follows the ligation of a vein in its continuity or after an amputation. It especially folloAvs any septic traumatism, and is then very dangerous, leading generally to pyemia. Subacute Phlebitis is circumscribed, and is not ordinarily so dangerous as the acute diffuse form. The subacute variety generally supervenes upon some chronic disease of the coats of the vein Avhich has led to their thickening by deposit of fibrinous matter, thus occluding the vein. An abscess may develop, and must be opened as an ordinary abscess. There is no hemorrhage from the vein, as it has been blocked up by external pressure or by an intra- venous inflammatory product; hence its lumen does not communicate with the abscess. Should the fibrinous deposit break doAvn, micro-organisms and their ptomaines get into the vein, and acute diffuse phlebitis is engrafted upon the chronic variety and pyemia results. The symptoms of phlebitis are pain and tenderness along the course of the vein, Avith discoloration of the skin and acute oedema beloAv the obstruc- tion. There are present also symptoms of a constitutional nature, such as rapid and irritable pulse, rigors, elevation of temperature, dry and broAvn tongue, and pain in the joints if pyemia has developed. Treatment of Phlebitis.—The patient should be kept perfectly quiet, the affected limb elevated, so as to favor the return circulation, and leeches applied in certain cases along the inflamed veins. Goulard's extract or a lead- and-opium wash should be used, or hot antiseptic fomentations, if a circum- scribed abscess is forming. Opium is indicated to relieve pain. Abscesses should be opened, for if they are not incised the micro-organisms and the ptomaines may break doAvn the plug in the vein and the softened thrombus obtain access to the general circulation. The patient's general condition must be kept up Avith nourishing food and stimulants, as there is a great tendency to exhaustion folloAving certain forms of phlebitis. II. Varix, or Varicose Veins.—By this is meant an enlarged, elongated, 218 AX AMERICAX TEXT-BOOK OF SURGERY. tortuous, knotty condition of the veins. The term " varicose veins " is restricted in general use to the veins of the extremities, and especially to those belonging to the lower extremity. The internal saphenous vein is the one most frequently affected (Fig. 20). The disease begins by a sIoav dilatation of the vein, which gradually becomes Fig. 20. thickened and tortu- ous. The inner lining membrane, or endo- thelial coat, of the vein is altered, and the valves are shortened, and thus rendered in- sufficient to support the column of blood. Besides these altera- tions in the inner coat of the vein, the outer coat becomes thick- ened on account of the connective-tissue infiltration and of the inflammatory neAv for- mation (periphlebitis). The varicose con- dition affects, as a rule, chiefly the super- ficial veins. When these are largely di- lated the circulation becomes sluggish and is carried on by the deep veins. Occasion- ally it happens that the deep veins are pri- marily affected. In- stead of the outer coat of the vein being thickened, this coat sometimes becomes ex- cessively attenuated, and separates at places, so that the internal coat protrudes through the slit and forms a protru- sion Avhich may even become pedunculated. This pathological con- V dition is, hoAvever, rare. When the vari- cose veins begin Avhere the venous radicles arise from the capil- capillary injection with an A'aricose ATeins of the Legs and Left Thigh. lary system, the varicosity appears as a fine 617854 SURGERY OF THE VASCULAR SYSTEM. 219 Fig. 21. Varicose Veins of the Abdomen. arborescent appearance. This condition is more frequently found in women. When the large trunks are affected, the veins are dilated, tortuous, and knotty. They rise above the level of the skin, and if pressure is made over them the presence of blood in the vessels becomes at once manifest. When the disease has existed for a long vvhile, they may burst from excessive thinness of the coats, and a serious or even fatal hemorrhage may result. Again, instead of the veins standing out boldly above the skin-level, there may be a passive exudation into the surrounding cellular tissue of the limb, Avhich causes it to become oede- matous. This is not the ordinary oedema from obstructed venous return, but a solid non-resist- ing oedema, which has a marble-like appearance and does not pit upon light pressure. Upon this peculiar oedematous condition there is often engrafted a most obstinate eczema. If the ecze- ma is allowed to progress Avithout any treatment, it will degenerate into a superficial ulceration which will become chronic and may extend doAvn into the tissues and give rise to " varicose ulcer." These ulcers may involve a vein and give rise to fatal hemorrhage. There is another condition arising from the presence of varicose veins Avhich does not ap- pear until late in the progress of the disease. Thrombi may be formed Avithin the vein, AArhich may become disintegrated and break doAvn, forming an abscess, if infection takes place (suppurative thrombo-phlebitis) or under certain conditions they may organize and completely occlude the vein (plastic thrombo-phlebitis), and thus bring about a radical cure. The thrombi may also become shrunken and contracted, and frequently laminae of fibrin are deposited upon them. Small hard concretions which have been called vein-stones or phleboliths have been observed. These are formed of laminated fibrin, phosphate of calcium, and the sulphates of calcium and potassium. Varix of the internal saphenous vein (Fig. 20) may give rise to symptoms similar to those of femoral hernia. In varix there is a tumor at the saphenous opening at the place Avhere a femoral hernia presents. The varix disappears Avhen the patient assumes the recumbent position, as in femoral hernia. Both SAvellings reappear upon the patient's coughing or assuming the upright position. The differential diagnostic point is that in varix of the saphenous vein, if pressure is made at the saphenous opening AAhile the patient is in a recumbent position, the SAvelling Avill reappear wdien he assumes the upright position, even though pressure is maintained. In femoral hernia, on the other hand, the tumor AA'ill not reappear under the same conditions. The causes of varicose veins are—I. Predisposing, and II. Exciting. I. Among the predisposing causes may be mentioned— (a) Sex. Varicose veins are most frequent in the female, and are apt to folloAv uterine enlargement from any cause. (b) Age. The tendency to the production of varicose veins increases as age advances. (c) Obstruction to the free return of blood in the veins, as tight garters Avorn below the knee or other constrictions obstructing venous circulation. 220 AX AMERICAN TEXT-BOOK OF SURGERY. ((?) Occupations which require habitual standing. II. Among the exciting causes may be mentioned— [a) Tumors in the abdomen or pelvis. It is evident that any obstruction to the return venous circulation has a tendency to develop varicose veins ; thus, tumors of any variety which press upon the iliac veins will give rise to varicose veins of the leg. It has been stated that the left leg is more frequently the seat of this disease than the right, on account of the sigmoid flexure, which Avhen distended presses upon the left iliac vein. The caecum, hoAvever, when distended, would press nearly as much upon the right iliac vein, and as a clinical fact the right leg is affected Avith equal frequency. (b) Diseases of the Heart and Lungs.—In these conditions there is found an important exciting cause. If the heart is feeble in action, the power to drive the blood back is lessened, and as a consequence the column of blood moves very slowly and becomes stagnant in places. The development of the ascites (hydroperitoneum) often incidental to heart affections also forms by pressure upon the veins a barrier to the free return of the venous blood. (c) Pregnancy by pressure of the gravid uterus upon the iliac veins. In a first pregnancy the veins of the extremities are not much altered patho- logically, and if attention is paid to this incipient stage of the disease, which is amenable to treatment, subsequent pregnancies will not be so likely to produce an incurable condition of varicose veins. Treatment.—I. Palliative, and II. Radical. Palliative treatment is to be directed to the removal of the causes of the obstruction and also of their effects, as far as possible, Avithout an operation. This object is best fulfilled by attention to the condition of the boAvels, to the state of the liver, to the affections of the heart and lungs; by enforcing quiet and rest in a recumbent position, which favors venous return circulation, and by attention to the general health, and often by out-door exercise in a suitable climate. The local palliative treatment consists in the application of an elastic bandage or a perfectly-fitting silk elastic stocking which shall afford support to the vessels, thereby equalizing the circulation. This elastic support has a tendency to turn the Aoav of venous blood from the superficial veins into the deep- veins, Avhich do not, as a rule, become varicose. The silk stocking should be made to order from accurate measurement of the limb, and should extend from below at the toes, Avhere the trouble begins, to or above the knee, Avhere it should be loose. The radical treatment has for its object the complete obliteration of the vein by one of the following surgical procedures: Exposing the vein and Fig. 22. fig. 23. Obliteration of A7aricose Veins by Ligation. Twisted Suture, occluding the Vein. ligating it; subcutaneous section Avith compression; injection of pure carbolic acid into the tissues about the vein; application of multiple subcutaneous SURGERY OF THE VASCULAR SYSTEM 221 catgut ligatures; excision of more or less of the diseased vein, or the use of acupressure pins and twisted sutures (Figs. 22 and 23). Of these methods, the multiple ligatures, as advocated by Dr. Charles Phelps, Avho ties the vein in thirty or forty places, and excision of the vein, are the best. All such operations on veins must be done Avith the most stringent antisepsis, or an acute septic phlebitis and pyemia may readily follow. III. ~Sjeyus.—This is an affection of the capillaries and the veins. When the naevus affects the capillaries there is a slightly elevated area of skin of a scarlet or purple color. Naevi are situated sometimes upon the trunk, but generally upon the face. They vary in size from that of a pin's head to that of a silver dol- lar, or even may involve an area nearly as large as the hand. They produce an unsightly appearance, but seldom give rise to any physical discomfort unless they undergo ulcera- tion, in Avhich event a troublesome and in some cases even alarming hemorrhage ensues. The vessels consist of capillaries held together by are- olar tissue. The term telangiectasis is often ap- plied to this form of naevus, and it is popularly called mother's mark (Fig. 24). The naevi formed of veins are found beneath the skin as Avell as in the skin. They are also seen in the orbit, the liver, and other viscera. They pulsate, and are much larger than the capillary naevi. They can be made partially to disappear by pressure, but reappear Avhen the pressure is discontinued. The anatomical structure is similar to that of carcinoma, but instead of the spaces being filled with epithelial cells they contain blood. They are painless. If punctured they give rise to alarming hemorrhage. This form of naevus is termed cavernous angioma. Treatment.—The operations for the removal of naevi are many. The best recognized surgical treatment includes ligation, excision, setons, vesicants, electro-puncture, coagulating injections, vaccination, application of caustics, and enucleation. Ligation is done by passing a pin under the mass and throwing a ligature around the base of the naevus below the pin. If large, a double ligature can be passed under and at right angles to the pin, and then the naevus is tied in tAAo halves. This and excision are the best of the above-mentioned methods. Setons lead to Avhat may be a dangerous suppuration, and coagulating injections may produce extensive thrombosis or distant embolism, and thus cause death. Naevi about the face and scalp should never be injected, on account of the danger of thrombi and emboli. In large cavernous angiomata electrolysis and excision have been employed Avith good results. part ii.—diseases of the arteries. ARTERITIS. I. The word arteritis signifies inflammation of an artery. Each coat of an artery may be primarily separately inflamed. Thus Ave distinguish inflammation of the internal coat, of the middle coat, and of the external coat. These inflam- mations are called, respectively, Endarteritis, Mesarteritis, and Periarteritis. All these different varieties may be either acute or chronic. 1. Acute Arteritis.—This is a rare surgical disease, and is due to an 222 AX AMERICAN TEXT-BOOK OF SURGERY. inflammation excited by an infectious or poisonous embolus lodged in the artery. The internal coats become SAvollen and infiltrated Avith pus-cells. The suppurative inflammation is transmitted to the other coats of the artery and to the surrounding parts, and may result in abscess. Acute Periarteritis is also usually secondary in origin, and is due to an extension of inflammation from the surrounding parts. The exudation is apt to be purulent. In these destructive inflammations of the arterial coats the lumen of the artery generally becomes occluded by a thrombus before perfora- tive ulceration occurs. Should this thrombosis not occur, severe and some- times fatal hemorrhage may arise if the artery be of sufficient size. It is still an open question Avhether acute arteritis occurs as a primary affection. A few doubtful cases have been recorded in which severe pain and tenderness existed along the course of an artery, in some instances accompanied by a certain amount of redness and swelling. The diagnosis of acute arteritis has been made, but, as the termination has been favorable, the pathological proof of its existence is Avanting. 2. Chronic Arteritis.—This is the atheroma of most authors, and its relation to the production of aneurysm is a subject of great surgical interest. By atheroma is meant a chronic inflammation of the internal coat characterized by a fatty degeneration, Avith a tendency to cheesy collections and calcareous deposits. The middle coat is not usually involved until late. The external coat becomes affected secondarily, and is hypertrophied and inelastic. As a result of the fatty degeneration the inner coat of the artery swells, the circula- tion is disturbed in that part, and an ulcer is formed by the rupture of a caseous mass into the lumen of the artery. Traumatism affecting the artery, alcoholic excesses, syphilis, Bright's dis- ease of the kidney, gout, and rheumatism are among the diseases Avhich are recognized as the causes of atheroma. This condition ordinarily involves the larger arteries, and in this respect differs from syphilitic arteritis, Avhich, as has been pointed out, affects chiefly the vessels of smaller size. Occasionally the lime-salts are deposited in the ulcer and a calcareous plate is formed. Atheroma is usually seen in persons of advanced age. Calcification of the artery consists in a Ioav grade of inflammation in the middle coat, and is characterized by the deposit of earthy matter, chiefly car- bonate of calcium and the phosphates. This deposit may be in plates, and it is then termed laminar calcification, or it may be arranged in a concentric manner around the muscular fibers, Avhen it is termed annular calcification, and Avhen the latter form is spread over a considerable area it is termed tubular calcification. This disease affects arteries in the extremities, and as a result the parts beyond are inadequately supplied Avith blood, OAving to the narroAved lumen of the vessel and to its loss of elasticity. When the disease is extensive enough completely to occlude the artery, gangrene of the limb may result. When it affects the vessels in the extremities, the calcification can be readily recognized by the finger placed upon the vessel. This is often observed in the radial artery, the vessel becoming roughened and rigid and hard like a pipe-stem. The treatment of arteritis depends upon the variety. If due to syphilis, the iodides and mercury are useful; if to rheumatism or gout, the remedies that are indicated in these affections should be employed. Little can be done to cure the disease, and the treatment should be directed toAvard the prevention of any extension of the inflammation. Great importance must be attached to the avoidance of all kinds of violent exercise, Avhich might lead to rupture of the vessel with its attendant consequences. SURGERY OF THE VASCULAR SYSTEM. 223 Fig. 25. ANEURYSM. The word aneurysm is derived from the two Greek wrords dvd, "through," and ebpupto, "I widen." An aneurysm is a tumor containing blood and communicating with the interior of an artery. There are some forms of blood-tumor which do not strictly come within the limits of this definition. These will be discussed before taking up aneurysm proper. The first variety is arterial varix. This consists in an elongation and dilatation of a single artery of medium or small size. The vessel is pouched, sacculated, and tortuous. This condition is similar to that of a varicose vein. The superficial temporal, occipital, and posterior auricular arteries are often the seat of this disease. The skin over the dilated vessel is exceedingly thin, or even ulcerated, and this condition may give rise to alarming hemorrhages. Cirsoid aneurysm is the next variety, and consists in a dilatation and elongation of a number of arteries of medium and small size. If a single artery is involved, and it is pouched and tortuous and dilated after the same manner as a varicose vein, the term artericd varix is applied. If a n umber of arteries held together by connective tissue are affected by these pathological changes, the tumor is called a cirsoid aneurysm (Fig. 25). Such an aneurysm usually involves also the capillaries in its immediate vicinity. The cause of this disease is supposed to be an injury in which the vaso-motor nerves have been paralyzed. The tumor thus formed is irregular in shape, compressible, bluish in appearance, and pulsating in character. The temperature Avithin the circumscribed area of the outgrowth may be elevated on account of the increased vascular supply. Cirsoid aneurysm is distinguished from a true aneurysm by the situation of the growth, the number of vessels involved, the superficial bruit and pulsation, the peculiar spongy, doughy feel, and the difference in the pressure-effects. The treatment of cirsoid aneurysm is usually unsatisfactory, and often attended Avith great danger from hemorrhage. Ex- tirpation, the lines of incision being carried wide of the tumor, multiple ligation of the afferent arteries, the application of the galvano-cautery, the injection of coagulating fluids, the introduction of the electro-puncture needle, acupressure of the main feeding artery, and ligation of the main trunk, are among the rec- ognized methods of treatment; often two or more of these may be combined with advantage. All aneurysms may be divided into two groups—the idiopathic and the traumatic. In the idiopathic variety there is a sac formed of one or more of the arterial coats, and the blood within the sac is in direct communication with the lumen of the artery. In the traumatic variety there is also a sac, but its walls are composed of inflammatory lymph and a proliferation of the con- nective-tissue cells. Idiopathic aneurysms are divided into— 1. Tubulated. Cirsoid Aneurysm of the Temporal Artery. 2. Sacculated, 8. Dissecting. a, true, b, false, 1, circumscribed. 2, diffused. 224 AX AMERICAN TEXT-BOOK OF SURGERY. The tubulated aneurysm (Fig. 2(3) is the fusiform aneurysm o£ some authors. In this variety the three coats of the artery are simultaneously dilated, in the Fig. 26. Tubulated or Fusiform Aneurysm circumference as Avell as in the length of the vessel. The middle coat is not preserved as a continuous layer, but its elements are separated. This aneurysm Fig. 27. Sacculated Aneurysm. is found in the cranial, thoracic, and abdominal cavities. The tubulated aneu- rysm rarely groAvs to be of any size, and scarcely ever ruptures unless a saccu- lated aneurysm is engrafted upon it. The sac in this form of aneurysm seldom SURGERY OF THE VASCULAR SYSTEM. 225 contains any laminated fibrin. It, hoAvever, gives rise to great discomfort, and often causes severe pain by pressure upon important organs. The sacculated aneurysm (Fig. 27) is one Avhich projects from a tubulated aneurysm or which springs from the side of an artery, the interior of which is in communication Avith the sac by an opening which is called the mouth. The sacculated aneurysm is subdivided into true and false. The true sacculated aneurysm is oue in which all three of the coats of the artery are equally expanded to form the sac. It seldom groAvs larger than an orange. In the false sacculated aneurysm the inner layer is the thickened and altered intima enlarged by successive additions so as to cover the vastly increased surface ; traces of the middle coat are to be found only near the neck of the sac; the wall is mainly formed by the condensed and multiplied con- nective tissue of the surrounding parts. In short, the wall of the aneurysm contains little or nothing of the original wall of the artery, except that its internal layer is continuous with and similar in character to the intima. This variety of aneurysm may grow to an enormous size. False sacculated aneurysms are subdivided into the circumscribed, in which the blood is confined Avithin a sac composed of some part of the arterial coats, and the diffuse, in which the sac is ruptured and the blood has extravasated into the neighboring tissue; or else the sac is ruptured, and the blood is con- fined within a cavity the walls of wdiich consist of lymph and condensed areolar tissue. The dissecting aneurysm is one in which the internal coat of the artery has given Avay, owing to some erosion caused by an atheromatous patch, and the blood dissects or makes its Avay through the middle coat (Fig. 28). The blood may burroAv for some distance through the middle coat untilit comes in contact with an eroded patch situated upon the outer coat, through which it bursts, and finally extravasates into the surrounding areolar tissue; or it may burrow for some time through the substance of the middle coat until it comes in contact wTith an eroded patch situated upon the internal coat, and then the Fig. 28. Plan of a Dissecting Aneurysm. blood again enters the artery ; or it may burrow for some distance and meet no eroded patches in either outer or inner coat, and may thus remain in a small sac formed by the circumscribed separation of the arterial coats. The component parts of an aneurysm are (1) the sac, (2) the contents. The sac is composed of one or all three coats of the artery, unless the aneurysm is traumatic, in Avhich case the walls are formed by lymph and condensed areolar tissue. The sac may be formed by the internal and external coats, the middle coat having been ruptured ; or by the dilatation of the external coat, the internal and middle coats having been ruptured ; or by the dilatation of the internal coat, the middle and external coats having given way. If the latter condition is ever present, which has been denied, the aneurysm Avould be called an aneurysmal hernia. The mouth of the sac is the narrow opening 15 226 AX AMERICAX TEXT-BOOK OF SURGERY. which establishes a communication between the interior of the sac and the lumen of the artery from Avhich the aneurysm develops. In the fusiform aneurysm there is no mouth, as the aneurysm results from a uniform dilatation of the coats of the artery. In the sacculated variety a mouth is present, and its situation relative to the lumen of the vessel influences the amount of fibrin deposited, as well as the groAvth of the aneurysm. The contents of the sac vary according to the stage of the disease. In the first stage the sac is very thin, and contains only fluid blood. In the second stage the Avail of the sac is very thick, and contains fluid blood FlG- 29- in the center and laminae of fibrin (Fig. 29) around the periphery. The blood is in greater proportion than the fibrin at first, but later the coagulum or laminated fibrin is in excess of the fluid blood. These laminae of fibrin van' in firmness and consistency in the different parts of the sac. Thus upon the extreme periphery the layers off fibrin are dry, friable, and opaque, while the layers ap- proaching the center of the tumor are soft and of a red- dish color. LamTnated Coagulum. .In the sacculateo5. variety the fibrin is rapi% de- posited, and the rapidity with which it is formed depends upon the relation of the mouth of the sac to the sac itself. The greater the obstruction to the free flow of blood into the sac, the greater the tendency to the deposition of fibrin. In the fusiform aneurysm, Avhere there is n» retardation in the current of blood owing to the absence of a mouth in the sac, there is no depositian of fibrin, or at least it is deposited in exceptional cases only. The natural terminations of aneurysm are-—(1) spontaneous cureT (2) death. k. The Spontaneous cure of anewrysm is occasionally effected by natuare unaided by the surgeon. Such a case occurs very sel«E©m, but that a cure under certain conditions may thus be brought about is no longer ©pen to dispute. In the cases of spontaneous cure the aneurysm has always beea found solid and firm,—which leads t® the belief that a deposition of fihrin hadi already taken place. A deposition of fibrin takes place m consequenee of the slower current in the sac, and finally fills it. The clot thus formed within the sac may extend into the vessel, and thus add to the permanence of the dure. Occasionally the aneurysm is spontaneously cured by an embolus, when a clot is washed out of the sac into the efferent artery and occludes it, so that the current is completely arrested Avithin the sae; the latter then fills with a firm coagulum. Sometimes a spontaneous cure is effected when the sae becomes large enough by its own weight to cause mechanical pressure upon the artery sufficient to retard, or even to arrest, the circulation in the vessel. Finally, a spontaneous cure is accomplished in some cases when the sac beeomes acutely inflamed and the coagulation of the blood Avithin it is thereby promoted. Death is the other natural termination. There are various Avays by Avhich an aneurysm destroys life: 1st. By rupture of the sac. The aneurysm extends to the surface of the body or to a mucous canal or a serous cavity. When the aneurysm has reached the surface of the body the thin skin over the sac sloughs, and Avhen the slough comes aAvay there is a slight hemorrhage through a small opening. This hemorrhage is arrested by a coagulum, but after a while is renewed, until finally the patient dies from repeated hemorrhages. In case an aneurysm bursts into a mucous canal the process is the same. The rupture SURGERY OF THE VASCULAR SYSTEM. 227 may open into the trachea, oesophagus, intestine, or bladder. Here, again, the sac is first rendered thin by absorption, and when the slough separates the hemorrhage occurs. An aneurysm may destroy life by bursting into one of the pleural cavities, generally the left, or into the peritoneal or the pericardial sac. In this situation the serous membrane gives way in a rent, and death follows instantly. 2d. Aneurysm also destroys life by pressure upon important organs. If the aneurysm presses upon the trachea or the bronchi or the lungs, it produces asphyxia; if upon the oesophagus or the thoracic duct, it causes inanition; if upon the vertebrae and the ribs, absorption of these bones results (Fig. 30), folloAved by spinal irritation and meningitis, Avith severe neuralgia from pressure on the intercostal nerves. Fig. 30. Absorption of the Vertebrae and Ribs from Pressure by an Aneurysm. 3d. Aneurysm, again, destroys life by septicemia and pyemia, due to acute inflammation and suppuration of the sac; also, 4th, by embolism, in which case the small migratory clot is carried by the cerebral arteries to the brain if the situation of the aneurysm is in the arch of the aorta; finally, 5th, by gangrene of the extremity caused by obstruction. In this case the gangrene causes blood-poison and death results from septic infection. Etiology of Aneurysm.—In general terms, any disturbance of the proper relations between the force of the heart on the one hand and the elas- tic resistance of the artery on the other, especially if an increase of the former is combined Avith a diminution of the latter, will give rise to aneurysm. The causes of aneurysm may be divided into I. Predisposing, and II. Ex- citing. I. Predisposing Causes.—(a) Degeneration of the Arterial Coats.—This is the principal predisposing cause, since in some form it is ahvays present except in traumatic aneurysm. The degeneration most commonly associated with the development of aneurysm is the atheromatous and fatty, frequently accompanied by a calcareous deposit that renders the vessels less elastic. As a result of this atheromatous and fatty condition the artery fails to contract after the 228 AX AMERICAX TEXT-BOOK OF SURGERY. systolic action of the heart, gradually yields and dilates, until finally an aneurysm is formed. It is held by Von Recklinghausen and others that the influence of atheroma upon the development of aneurysm has been exaggerated. It is believed that changes in the middle coat, either inflammatory or degenerative, are among the most frequent predisposing causes. (b) Syphilis is a frequent predisposing cause of aneurysm, in consequence of the changes in the arterial walls. (c) Over-action of the Heart.—Hypertrophy of the heart, by increasing the strength of the impulse, drives the blood Avith greater force into the arteries. These are likely to distend under the impulse of an hypertrophied heart if they have undergone the slightest degenerative changes. Hypertrophy of the heart associated Avith chronic nephritis, in Avhich the arterial tension is increased and the vessels are weakened by atheroma, affords another illustration of the combined action of these tAvo causes. (d) Certain violent occupations, as riding and hunting, it has been asserted, predispose a patient to aneurysm. Thus coachmen and postilions, owing to the nature of their occupations, are especially liable to the disease. This clinical fact is explained by the obstruction of the popliteal arteries on account of the constant bending of the knee in horseback riding and sitting on the box, as Avell as by the contractions of the gastrocnemii and solei muscles wrhen the feet are placed firmly against the footboard or the stirrups. The arteries, too, are bent or stretched in these positions, and the jar and motions of the rider or driver must increase the force of the circulation. (e) Age.—This has a marked influence. Aneurysms are most frequently found between the ages of thirty and forty years, because the arteries begin to lose their elasticity at this period, Avhile the heart has not yet lost any of its force or the muscles any of their strength. Aneurysms in very young people are merely surgical curiosities. (/) Sex.—Seven to one of the entire number of aneurysms are found in males, presumably because of their more active occupations. II. Exciting Causes.—(«) A partial rupture of one or more of the arterial coats, produced by external violence, is Avithout doubt a prominent cause of aneurysm. (b) A direct wound of an artery also produces aneurysm, since it leads to extravasation of the blood from the artery into the surrounding tissues. In this case the aneurysm is termed traumatic, because the sac is not formed by the coats of the artery. {c) Fractures and dislocations are exciting causes of aneurysm, since the artery is torn or stretched so as to weaken the coats, thus permitting subse- quent dilatation. (d) Strains have been considered exciting causes of aneurysm, since they produce irregular and forced action of the heart. Strains may also act directly upon the vessel by forcing blood through it while it is under unusual tension, thus causing pressure at right angles to the axis of the vessel, or b}1- stretching the artery in its long axis. The signs and symptoms of aneurysm may be described as belong- ing to two stages : First Stage.—This includes the period from the beginning of the formation of the aneurysm until the tumor is firm from the deposit of fibrin. Second Stage.—This includes the period after the aneurysm has become firm and resisting by reason of the presence of the deposit of laminated fibrin. This stage may be absent, as in some aneurysms no such deposit takes place. First Stage.—(a) Pulsation which is distinct, expansile, and synchronous with the action of the heart. SURGERY OF THE VASCULAR SYSTEM. 229 The pulsation is distinct in the first stage, because the aneurysm contains only fluid blood and the sac is thin. The pulsation is excentric and expansile in character. If both hands are placed upon the sides of the tumor, they Avill be separated from each other with every pulsation. The pulsation in this stage is simultaneous with the contraction of the heart. The pulsation of an abscess lying on an artery would be up and down in mass, and not expansile. (6) Pressure on the artery above the tumor diminishes the size of the latter; when applied below the tumor increases its size; and in both cases causes the pulsation to diminish or cease. If the artery above the sac is compressed, the flow of blood into the sac is arrested, the blood can be squeezed out of the sac, and the tumor disappears. This can be beautifully illustrated in the first stage while the contents of the sac are composed of fluid blood and the walls of the sac are thin. If, after having compressed the artery above the sac and emptied the latter of blood, the hands are placed firmly over the sac and the pressure is removed from above, the blood will rush into the sac, and as soon as the sac has filled pulsation will return and will separate the hands. In abscess, on the other hand, the instant the pressure from the artery above is relieved, the trans- mitted pulsation, or upheaval, is felt. If the artery below the sac is com- pressed, the sac will rapidly enlarge and the pulsation will diminish or cease. If the pulsation in the efferent artery at some distance from the sac on its distal side be felt, it will not be simultaneous with the pulsation of the corresponding artery of the opposite side of the body. Besides the appreciable delay in pulsa- tion as compared with the opposite artery, the force of the pulsation will be markedly diminished. The sphygmographic tracing of the pulse upon both sides of the body will also reveal a wide difference (Fig. 31). Fig. 31. Sphygmographic Tracings of the Radial Pulse of a Patient with Aneurysm of the Right Brachial Artery: 1, Left Radial Pulse; 2, Right Radial Pulse. (c) A bruit is heard over the aneurysm, and also along the artery for some distance from the sac. The bruit is a noise caused by the rush of blood into, through, and out of the sac, the internal lining membrane of Avhich is rough- ened. The bruit is bloAving or loud and rasping like the noise made by a saw. This blowing murmur is not always present, but its absence will not exclude the possible existence of an aneurysm. In malignant vascular tumors the bruit is sometimes present, but is heard only over the area of the tumor, and is never transmitted along the artery leading from the sac, as it is in aneurysm. Second Stage.—This stage includes the period after the aneurysm has become firm and resisting by the deposit of laminated fibrin. (a) Indistinct Pulsation.—When the aneurysm becomes firm and its sac is lined Avith fibrin, the pulsation is indistinct and may even be altogether lost. There are certain points over the sac where the pulsation is felt more distinctly than at others. This is because the fibrin is not equally distributed over the interior of the sac. (b) Pressure.—OAving to the deposition of fibrin, the tumor cannot be effaced by pressure on the artery above the sac, as in the first stage. 230 AX AMERICAN TEXT-BOOK OF SURGERY. Fig. 32. (c) The bruit is generally present, although it is heard with varying degrees of distinctness over the tumor, and also can be heard at a distance from the sac. It will be observed that these symptoms, which Avere so marked and almost pathognomonic in the first stage, are of rather negative character in the second stage. There are, hoAvever, additional signs : (d) Pain.—The pain is sharp and lancinating, like that of carcinoma, or aching or boring, like that of ulceration. It arises after the aneurysm has attained some size and makes pressure upon the nerves. Thus in popliteal aneurysm the pain is intense along the course of the popliteal nerve. The nerve is sometimes flattened out upon the sac. Pain may be at times an early symptom of aneurysm, but it is generally more pronounced later on in the course of the disease. (e) (Edema.—This is produced by the pressure of the sac upon the veins. (Edema of the limb is constant after the tumor has attained a certain size. The oedema, if excessive, produces a great deal of discomfort to the patient, and may terminate in extensive ulceration and sloughing. (/) Gangrene sometimes occurs late in the course of the disease, and gen- erally follows the oedema, but may come suddenly as the result of an embolus. (g) Pressure-effects vary according to the parts pressed upon and the amount of pressure exercised by the tumor. If the aneurysm presses upon bone, it produces a severe aching, boring, gnaAving pain, and finally causes the absorption of the osseous tissue (Figs. 30 and 32); if upon glands, it destroys their function: if upon the trachea, respiration is rendered difficult, and there is an obstinate distressing metallic cough and altered voice produced by pressure upon the recurrent laryngeal nerve. This is termed the brassy cough of aneurysm. If the aneurysm presses upon the oesophagus or the thoracic duct, deglutition or nutrition is interfered Avith and the patient dies from inanition. If the pressure be on the phrenic nerve, hiccough often is produced ; and if on the sympathetic nerve, marked capillary congestion. Diagnosis of Aneurysm.—If the aneurysm has not consolidated, the symptoms which have been enumerated will enable the surgeon to establish a diagnosis. But it often happens that after consolidation of the aneurysm by fibrin many of the signs and symptoms become obscure and a diagnosis is ren- dered someAA-hat difficult. Again, cer- tain other tumors under exceptional circumstances may present signs almost identical with those of an aneurysm. In a case of consolidation the history of the disease, and occasionally the use of the hypodermatic syringe, are the only safe guides for the surgeon. In pulsating tumors Avhich resemble aneu- rysm the diagnosis must be made Avith great care. Absorption and Perforation of the Sternum Pressure by an Aneurysm. from SURGERY OF THE VASCULAR SYSTEM. 231 The different tumors Avith Avhich a surgeon may confound an aneurysm are the pulsating encephaloid, the vascular soft sarcoma, erectile tumors of all kinds, pulsating tumors of bone, an abscess over an artery, and hematocele of the neck. There are also tumors Avhich are not, strictly speaking, pulsating which have led to error in diagnosis and treatment, such as lymphatic enlargement and cystic disease of the thyroid gland, and certain other diseases, as neuralgia and rheumatism, the pain in both of Avhich has been mistaken for that of beginning aneurysm in the thoracic cavity. Duration of Aneurysm.—An aneurysm may grow very rapidly, but this is rare. The groAvth, as a rule, is sIoav, and may extend over several years. The aneurysm is likely to groAV as long as the cause is present. Its duration is influenced by the force of the circulation, its situation, the size of the mouth of the sac, the coagulating tendency of the blood, the nature of the surround- ing parts, the condition of the sac, and the patient's habits and manner of living. Treatment.—The surgeon must aim in his treatment to effect a cure by precisely those means which nature adopts. The essential conditions for suc- cess in any plan of treatment are obliteration of the cavity of the sac and occlusion of the afferent and efferent vessels. There are several Avays in which obliteration of the sac and the vessels can be accomplished, but often the best results will be obtained by a combination of various methods of treatment. In order to occlude the sac it is necessary to diminish the force of the circulation, thus causing; coagulation of the blood in the aneurysmal sac. W hen this has been effected a cure may be expected. The methods resorted to may be either medical or surgical. The medical methods which have met with the greatest success in curing aneurysm are those suggested by Langenbeck and by Tufnell. Langenbeck's method consists in the hypodermatic injection of ergotin. This drug sIoavs the action of the heart, and hence favors deposit of fibrin; it contracts the muscular fibers of the middle coat of the arteries leading into the sac, and produces increase of blood-pressure. All these are favorable to the deposition of fibrin and the consolidation of the aneurysm. Iodide of potassium has also been used in the medical treatment, largely upon the supposition that aneu- rysms are due to the effects of syphilis, but it probably acts as a heart depres- sant. Acetate of lead has been employed to equalize the circulation. Bromide of potassium has been used to relieve the cough and pain. Tufnell's method is a modification of a plan of treatment originally suggested by Valsalva. It is especially applicable to internal aneurysms ; but a brief description of it is proper here, as external aneurysm has been thus successfully treated, and as a list of the different methods of curing aneurysms would be incomplete Avithout reference to this peculiar plan of treatment. In 1875, Tufnell, an Irish physician, published his experience in Avhat may be termed the rest treatment of aneurysm. Tufnell required his aneurysmal patients to assume the recumbent position in bed for several months. The object of the treatment Avas to reduce the watery elements of the blood and to increase its solid constituents. Rest, regimen, and remedial agents were the three means he employed. He showed that in the recumbent position the circulation Avas tranquillized and the action of the heart became regular and sIoav. He maintained that recumbency placed the same check upon the circu- lation in internal aneurysm that mechanical compression does in the treatment of external aneurysm. He demonstrated this proposition in the following Avay : A patient before assuming the recumbent position had a pulse of 9b' a minute; 232 AX AMERICAX TEXT-BOOK OF SURGERY. after a feAv days' lying supine in bed it fell to 66 a minute. Thus there Avas a difference of 30 beats a minute caused by position. Multiplying 30 beats by 60, the number of minutes in an hour, the result is 1800 beats an hour, and this multiplied by 24—the number of hours in a day—gives 43,200 beats per diem; that is to say, a patient suffering from aneurysm and occupying the recumbent position has his aneurysmal sac distended 43,200 times less frequently in a day than it would be if he remained in the standing position. Tufnell held that there was no remedial agent in the Pharmacopeia that Avould produce such an action upon the heart Avithout injury or danger. Recumbency is the secret of cure, but it must be continued for three months. The diet was restricted to 10 ounces of solid and 6 ounces of fluid in the twenty-four hours. This reduction of nourishment diminished the action of the heart and increased the plasticity of the blood, and hence favored the consolidation of the aneurysm. Tufnell also directed certain remedial agents to be combined with rest, such as lactucarium to quiet the patient and induce sleep, and opium to soothe pain. Compound powder of jalap was used at intervals, to reduce the quantity of cir- culating fluid by withdrawing the serum from the blood. He gives an analysis of 10 cases treated by his method: 7 wrere cured, and 3 died during treatment. One of the successful cases was an aneurysm of the popliteal artery, cured in twelve days. The surgical treatment of aneurysm may be subdivided into—1st, those methods which embrace some form of compression ; 2d, those Avhich embrace some form of surgical operation ; 3d, those which may be classed as miscellaneous. 1. Compression.—The treatment of aneurysm by compression was employed over two hundred years ago, but only in cases of traumatic aneurysm. The manner of employing compression in the seventeenth century for the cure of aneurysm was essentially different from that employed at the present time, both in its principle and in its application. The principle upon which surgeons based the treatment of traumatic aneu- rysm by compression in the seventeenth century Avas this: the compression was supposed to prevent the further dilatation of the aneurysm and to squeeze the blood out of the sac into the arteries, as water would be squeezed out of a sponge; the edges of the cut artery were thought to be thus brought into apposition and to become adherent, and the blood to pass through the restored artery as if nothing had happened. From this description it is evident that little was knoAvn of the nature or pathology of aneurysm. That the prin- ciple upon which the treatment Avas based was erroneous will be seen when we study the subject in the light Avhich modern pathology has thrown upon it. In the eighteenth century Heister Avas the first to propose to extend the plan of treatment of traumatic aneurysm by compression from the brachial artery, to Avhich compression had been limited, to the popliteal artery, but he did not carry his plan into execution. It was reserved for Guattani, an Italian surgeon, in the year 1772 to treat the first case of popliteal aneurysm by compression. He applied compression directly upon the sac and also band- aged the entire limb, believing that the aneurysm was cured upon the same principle that has been mentioned. The cases treated by this means usually resulted fatally. By direct compression a circumscribed aneurysm Avas often transformed into a diffuse one; the sac became inflamed and suppurated; the limb became gangrenous, and half of the patients died. This Avas the state of affairs Avhen, in 1785, John Hunter tied the femoral artery in Hunter's canal for the cure of a popliteal aneurysm, and announced a new principle, which changed all the opinions then held as to the way in Avhich compression cured an aneurysm, and was followed by a complete revolution in practice. SURGERY OF THE VASCULAR SYSTEM. 233 Desault ligated the popliteal at some distance above the sac earlier in the same year, and a claim of priority has been based upon this fact. The Hun- terian method is mentioned in this connection only to show the change produced by it in the treatment by compression. In another place it w ill be considered at length. The neAv principle involved was this: that it was necessary to arrest only partially, and not completely, the current of blood through the aneurysmal sac, which, from its own inherent elasticity, tends to diminish in size so soon as the full force of the heart's action is taken off: this contractility of the sac is an important element in the cure of circumscribed aneurysms by any method, and its absence in diffused as in traumatic aneurysms explains the failure of ligation and compression in the majority of such cases. Upon this principle and after Hunter's time compression Avas employed above the aneurysm, instead of, as ahvays before, directly over it, and with greatly improved results. When this method is employed, the cessation of pulsation in the sac after the compression is relaxed, the absence of the thrill and bruit, together with the fact that the collateral circulation is fully established, indicate that the aneu- rysm is cured. The enlargement and pulsation in the collateral vessels do not take place until the aneurysmal sac is obliterated by the deposition of fibrin ; therefore the establishment of the collateral circulation is in itself a reason for supposing that the aneurysm is cured. It is through this collateral circulation that the extrem- ity is supplied Avith blood. This prevents gangrene from attacking the parts below the sac. The collateral vessels soon develop into vessels of important size. The pain which has been recorded in the cases in Avhich spontaneous cure was effected, as well as in those cases in which compression accomplished a cure, has been said to have been due to the sudden enlargement of the anas- tomosing vessels consequent upon the complete solidification of the sac, and may thus occasionally be considered a favorable symptom. Instrumental compression is carried out by the employment of one of the many different varieties of tourniquets or compressors. Whatever instrument is employed for the purpose (Figs. 33, 34), only the artery must be compressed, Fig. 33. Fig. 34. 'WJ.FORD.s.|.cn.N.Y n Signorini's Tourniquet. Skey's Tourniquet. and at no time during the period in which the instrument is applied must the pressure be greatly relaxed. A piece of chamois-skin should be placed over the artery, so that the pressure of the instrument shall not excoriate the skin. The time required to cure an aneurysm by compression varies from one to several days. The instrument must be kept on the artery until the pulsation in the sac has ceased, and then the amount of pressure during the folloAving twenty-four hours can be lessened gradually. This gradual diminu- 234 AX AMERICAX TEXT-BOOK OF SURGERY. tion of the amount of compression after pulsation has ceased is necessary, because otherwise the current of blood might disintegrate the clot in the sac before it is firm and solid. Digital pressure Avas first employed by Jonathan Knight of Ncav Haven, Conn., in 1848. In the same year Dr. Willard Parker and Dr. James R. Wood of Xe\v York City each cured an aneurysm by digital pressure. The pressure is maintained by relays of students or assistants for from one to tAvo days, and this method is preferred by many surgeons to all other methods of compression. The same principle of treatment has been carried out by the use of instrumental pressure instead of digital, with fairly satisfactory success. A bag of shot, suspended over the bed by means of elastic tubing, has been used to secure uniform pressure upon the artery above the sac. Flexion of the joint was brought to the attention of the profession in 1858 by Mr. Hart of England. The principles involved in this method are similar to those involved in compression. The plan is usually applicable only to aneu- rysm at the bend of the elboAv and in the ham, although it has been success- fully employed also in aneurysm of the external iliac. The leg is flexed upon the thigh and the thigh upon the pelvis; or the forearm is flexed upon the arm. The entire extremity is bandaged before flexion. Flexion causes compression directly upon the tumor itself, and also impedes the circulation through the sac, and probably dislodges a small clot which closes the mouth of the sac. This method is not suitable where the aneurysm is large, because of the liability of the sac to rupture, and is contraindicated if there is much oedema of the leg or inflammation of the sac. In ordinary cases it may be tried, since no harm folloAvs if the treatment is unsuccessful. It is especially applicable to cases in Avhich the tumor is small, the sac not inflamed, and the joint not involved. Rapid Cure by Esmarch's Elastic Bandage.—In 1864, Murray, an English surgeon, anesthetized a patient suffering from an aneurysm of the abdominal aorta, and applied an instrument Avhich completely checked the Aoav of blood through the arteries leading into the sac. The treatment resulted in cure. In this the so-called "rapid method" the object Avas to produce complete stag- nation of a mass of blood in the sac until it coagulated. In 1875, Reid of the British navy treated aneurysms successfully by the rapid method by employing Esmarch's elastic bandage. The formation of a blood-clot in the sac is essen- tial in order to effect the cure of an aneurysm by this method. That variety of blood-clot which is formed Avhile blood is at rest is required (the red blood- clot), and not the one that is formed Avhile blood is in motion (the fibrinous or Avhite blood-clot). In order to accomplish the formation of a blood-clot in con- tradistinction to the formation of fibrin there must be a stasis of blood in the sac, followed by coagulation of the blood. This clot does not finally undergo organization, but contracts. Its chief object is to aid in the formation of a thrombus in the afferent and efferent vessels leading into and out of the aneu- rysm. Not all aneurysms are amenable to this treatment. There should be no vascular degeneration except in the aneurysm, likewise no renal disease, and the sac itself should be free from inflammation. The administration of the iodides and restricted albuminous diet are useful adjuvants. The patient should have a hypodermatic injection of morphine before taking ether, and just enough of the anesthetic should be administered to keep him quiet and free from pain during the treatment. The elastic bandage should be firmly applied from beloAV upAvard till the aneurysmal sac is reached, then carried very lightly over the sac itself, and reapplied firmly above it, so as to confine a quan- tity of fluid blood in the sac. The patient must be kept under ether for an hour or an hour and a half. A tourniquet should be adjusted above the aneurysm, SURGERY OF THE VASCULAR SYSTEM. 235 to moderate the blood-current and prevent its disturbing and washing out the clot in the sac and the thrombi in the afferent and efferent arteries. The tourniquet can be kept on the limb for from sixteen to tAventy-four hours after the removal of the bandage, and must be unscrewed gradually, so as to restore the blood-supply in proper quantity. The two dangers to be guarded against are, on the one hand, washing out the clot before it is solid, and on the other the production of gangrene of the limb by too long-continued pressure. The effect of the arrest of the blood-supply must be carefully watched from hour to hour as the tourniquet is gradually unscrewed. The collateral circulation will soon be established. The risks of the sudden rise and fall of arterial tension, the compression of nerves, the rupture of the sac, the development of kidney disease, and the possibility of gangrene, are all to be considered. These dan- gers also accompany other methods, but perhaps are as little likely to occur after this plan as after any other operative interference or after compression applied in any one of the many ways already described. The treatment of aneurysm by any of the different methods of compression is not without difficulties. If the instrument is not adapted to the exigencies of the case, if the patient is irritable and cannot bear pain well, or if the aneurysm is unfavorably situated for the application of an instrument or of digital compression, there will arise difficulties Avhich will discourage the patient as Avell as the surgeon. If, however, after even Aveeks of perseverance no good has been accomplished, both patient and surgeon should remember that no great risks have been incurred involving the life of the patient, and no conditions absolutely contraindicating a trial of operative measures have been produced. Few cases in Avhich the treatment by compression in some form has been faithfully persevered in for a long time have been unattended with improvement. 2. Those methods which embrace some form of surgical operation. The Old Operation of Anty 11 us (Fig. 35).—The earliest recorded treatment of aneurysm is that devised by Antyllus, who lived in the fourth century. At that time it Avas employed only in cases of small traumatic Fig. 35. aneurysms situated at the bend of the elboAv. The method was simple, and Avas as folloAVS. An incision Avas made along the inner aspect of the arm over The Old Operation of Antyllus for Aneurysm. the brachial artery. The ves- sel having been exposed, the aneurysm was laid open and the contents of the sac Avere turned out. The coagula having been removed, the artery just beloAv and just above the sac was sought for and tied. This Avound was then filled with poAvdered myrrh. This arrested hemorrhage, and induced a violent inflammation which led to suppuration. This operation was performed for several hundred years, and it was not until the eighteenth century that any other Avas practised even in idiopathic aneurysm. The great mortality in this form of aneurysm was due to the fact that the artery Avas tied immediately above and beloAv the sac, where the vessel was unsound, and hence secondary hemorrhage and exhaustive suppuration, with ankylosis of the joint, followed. The principle involved in the old opera- tion, with certain omissions and modifications, is still applicable in axil- lary and gluteal aneurysms and in traumatic aneurysm at the bend of the elbow. Anel's Operation (Fig. 36).—Anel in the year 1710 devised and performed 236 AX AMERICAX TEXT-BOOK OF SURGERY. a neAv operation for the cure of aneurysm. He did not open the sac as in the old operation, or tie the artery above and Fig. 36. below the sac, or stuff the Avound Avith myrrh. He thought that the tumor would collapse if the main artery leading into it were tied near the aneurysm. He Avas suc- cessful, and thencefoi'Avard the treatment of aneurysm rested upon a scientific basis. Anei's operation for Aneurysm. Anel, hoAvever, did not apprehend cor- rectly the principle Avhich his operation in- volved. He thought the tumor simply collapsed, and it was not until some years afteiAvard that the true principle underlying this operation of ligaturing the artery upon the cardiac side of the aneurysm was brought to light—not indeed until John Hunter, in 1785, on account of the many failures in the treatment Fig. 37. im»- Hunter's Operation for Aneurysm. of aneurysm by compression, was led to investigate the subject from a patho- logical point of view, and devised the operation for its cure which has made his name immortal. Hunterian Operation (Fig. 37).—Hunter demonstrated by experiments upon dogs that weakness alone was not the cause of dilatation of an artery, but that there must be some previous disease of the coats of the artery itself before the force of the circulation would develop an aneurysm. He proved that the disease was not confined to the artery at the seat of enlargement only, but extended some distance from the sac; and this fact, he thought, explained the cause of failure of treatment by Anei's method, in Avhich the artery was tied at a point where it was diseased, permitting the ligature to come away too soon and second- ary hemorrhage to occur. Hunter proposed, therefore, to tie the artery at a distance from the sac, at a point Avhere the vessel Avas healthy, and thus diminish the risk of secondary hemorrhage. He thought, moreover, that if the force of the circulation were taken off from the aneurysmal sac the disease would be arrested, and the sac and its contents Avould be absorbed. The conclusion which he dreAv from his observations Avas that simply taking off the force of the circulation from the aneurysmal artery is sufficient to effect a cure of the disease, or at least to put a stop to its progress, and enable the processes of nature to restore the parts to a normal state. The conditions under Avhich the Hunterian operation is indicated are as follows: the aneurysm must be of moderate size; it must be of sIoav growth; and the sac must not be inflamed. Slight oedema Avould not contraindicate the operation. Gangrene Avould preclude all operations except amputation. The accidents following the Hunterian operation are—secondary hemor- rhage, return of pulsation in the sac, inflammation and suppuration of the sac, gangrene of the extremity, pyemia, and septicemia. SURGERY OF THE VASCULAR SYSTEM. 237 Brasdor's Operation (Fig. 38) consists in ligating the artery upon the distal side of the sac, so that the circulation upon that side is completely arrested. The cases in which this method can be adopted are aneurysms of the carotid artery, of the external iliac, etc. Wardrop's Operation (Fig. 39) consists in tying the artery or one of its branches upon the distal side of the sac, the principle on which it is founded Fig. 38. Brasdor's Operation. Wardrop's Operation. being the same as that in Brasdor's. It arrests the circulation to a great extent, but still permits the escape of blood through one or more branches. It is applicable only to aneurysm of the innominate artery or of the arch of the aorta. The carotid or the subclavian alone, or both of these vessels, may be tied, and the two operations may be either simultaneous or consecutive. The branches of the subclavian between the ligature and the aneurysm keep up a diminished circulation. Before dismissing the subject of ligation, the advantages of compression over ligation will be considered. These advantages are that— 1st. Compression effects a cure in accordance Avith nature's laAvs. The sac after compression consolidates just as in spontaneous cure; only the sac itself is consolidated, and not all the arteries up to the point where pressure is made, as is the case after ligation. 2d. Compression is less dangerous than ligation. If any danger arises during compression, the treatment can be discontinued and then resumed. Not so with ligation, for then the patient may be in great danger for many days after operation. 3d. Compression is more likely to be attended with success than ligation. There are not so apt to be complications, such as secondary hemorrhage, slough- ing of the sac, phlebitis, gangrene, or pyemia, occurring during compression and preventing a cure. 4th. Compression is more likely to be permanent than ligation. A second aneurysm has been knoAvn to form after ligation, and also suppuration to be set up in the sac; neither of these is likely to occur after compression, though both are possible. 3. Those methods which may be classed «s miscellaneous. Introduction of Foreign Bodies into the Sac.—This method consists in 238 AX AMERICAN TEXT-BOOK OF SURGERY. puncturing the sac Avith a canula and introducing through it several yards of fine Avire. Moore, in 1864, passed tAventy-six yards of fine Avire into an aneurysmal sac. The patient died of pericarditis and inflammation of the sac. Recently, Loreta introduced some silvered copper Avire into the sac of an abdominal aneurysm. A firm clot was formed, but the patient died tAvo months after the operation. Besides wire, other materials have been employed, such as catgut, silk, and horse-hair. Whatever material is used, the operation is attended Avith great danger. Manipulation.—This method was introduced by Fergusson in 1852. The object is to displace some of the fibrin in the sac by manipulating the aneurysm, and thus to block up the artery upon the distal side of the sac. The aneurysm is first emptied by making pressure on the afferent artery, and then the sac is kneaded and rubbed in order to detach a small embolus AA'hich shall be sAvept into the efferent artery and thus obstruct it mechanically. The operation has fallen into disuse, owing to the fact that emboli Avere carried to the brain, causing aphasia, hemiplegia, and even death. Galvano-puncture is a method suggested by Phillips in 1829. The object is to produce coagulation of blood in the sac Avithout the intervention of any foreign body. A galvanic current is passed through an insulated needle Avhich is brought in contact with the point of another insulated needle introduced into the sac about an inch from the point of entrance of the first needle. Suppura- tion of the sac, hemorrhage through the punctures in the sac-wall, and embolism are among the dangers that attend this method. Acupuncture by means of A^ery fine gilded needles has been employed. The needles are introduced into the sac so as to cross each other, and the blood coagulates around them. The needles are left in the sac several days, and then are AvithdraAvn. Extirpation of the aneurysm is an operation that is lately receiving attention. Amputation is required in certain aneurysms. This is necessary if an aneurysm has burst, if hemorrhages are frequent, if a joint is involved, if caries of bone has ensued, or if gangrene of the extremity has occurred. Coagulating Injections.—In this method injections of certain drugs are made into the sac Avith a vieAv of causing coagulation of the blood. Such injections should not be employed in aneurysms situated in the neck, because emboli may be transmitted to the brain and cause instant death. In aneurysms involving the extremities, injections of Monsel's solution of iron, tannin, acetate of lead, and other drugs have been employed. Whatever injection is used, pres- sure should be made for some little time upon both the afferent and the efferent arteries, to prevent emboli from being swept into the circulation. Macewen's Method, Avhich consists in inducing the formation of white thrombi Avithin the sac, is a recent plan of treatment Avhich Avill sometimes be useful. The formation of these thrombi is accomplished by irritating the lining membrane of the aneurysmal sac in such a way as " to induce infiltration of the parietes Avith leucocytes, and a segregation of them from the blood- stream at the point of irritation." The amount of irritation should be sufficient to cause merely a reparative exudation, as any irritation beyond this stage would result in softening of the sac-Avail, Avhich in turn might lead to rupture. The irritation should be evenly applied Avithin the whole surface of the sac, or at least from many foci distributed uniformly throughout its interior. The technique of the operation is as folloAvs. The skin over the sac having been made aseptic, a long, strong cylindrical needle, also rendered aseptic, is introduced into the interior of the sac. The point of the needle should be SURGERY OF THE VASCULAR SYSTEM. 239 alloAved to impinge upon the opposite Avail of the sac, so as to irritate the linino- membrane, or else the needle should be held lightly in this position for a feAv moments, so as to alloAv the impulse of the blood-current to play on it. It should be shifted to other parts of the sac at intervals of ten minutes, until the Avhole sac has been uniformly irritated. The simultaneous use of a second or even a third needle at distant points may be necessary. The time required to irritate the Avhole sac varies from a fe\v hours to forty-eight hours. While the needle is left in situ in the sac, an antiseptic gauze dressing should be applied to the surrounding region. It may be necessary to repeat the operation from time to time for weeks or even for months. This method should not be employed if there is any inflammation in the Avails of the sac, any superficial ulceration, or any erysipelatous induration. Traumatic Aneurysm (Fig. 40).—This variety of aneurysm differs from all the others in the manner of its causation, as Avell as in the condition of the parts involved. In all varieties of aneurysm except the traumatic, the disease is situated in the coats of the arteries. In the traumatic variety the lesion, as its name implies, is the result of a direct injury to the vessel, and an arterial hematoma results. This form of aneurysm is caused by a stab or gunshot wound, or by the giving way of cicatricial tissue which has imperfectly healed a wound of an artery. The blood escapes from the injured artery, and extravasates throughout the tissues until by mechanical pressure the hemorrhage is arrested. The pres- sure of so much extravasated blood in the tissues Avith superadded infec- tion by pyogenic microbes causes an inflammation of the parts, and if not treated, an abscess may possibly form, the opening of Avhich may result in an alarming hemorrhage. The symptoms of traumatic aneurysm depend upon its situation and the size of the vessel wounded. The presence of a tumor suddenly developed after an injury to a vessel, accompanied by severe pain and tension, with pulsation and bruit, and absence of pulsation beyond the aneurysm, is indicative of this form of aneurysm. In addition to these signs, a certain redness of the skin from inflammatory tension soon ap- pears, and unless this tension is relieved sloughing is apt to occur, and in some cases even gangrene of an extremity. Traumatic Aneurysm. 240 AX AMERICAX TEXT-BOOK OF SURGERY. Traumatic aneurysm must not be mistaken for an abscess, Avhich it often resembles. The diagnosis betAveen the tAvo conditions can be made by the history, by the symptoms, and, if necessary, by introducing a hypodermatic needle. Fluid blood indicates an aneurysm, Avhile pus suggests an abscess. The fact that an abscess may be the direct result of a traumatic aneurysm must not be overlooked. The treatment of traumatic aneurysm is based upon the same principles that Avould guide the surgeon in the management of a primary Avound of an artery. If in an extremity, an Esmarch elastic bandage should be applied and the tumor cut doAvn upon until the injured artery is found. The vessel should be completely divided and the tAvo ends securely ligatured. The wound should then be thoroughly disinfected and dressed antiseptically, in order to secure healing by primary intention. In cases in Avhich an elastic bandage cannot be employed—e. g. in the neck—a serious difficulty arises. When this is the case the surgeon should carefully dissect doAvn to the aneurysm, and make an opening sufficiently large to admit his finger into the tumor, by which he should seek for the opening into the artery on the proximal side of the aneurysm, in order to arrest the hemorrhage by pressure. The finger may be guided to the opening in the vessel by feeling the current of Avarm arterial blood impinge upon it. When the opening has been occluded, the surgeon can enlarge the wound so that he may be enabled quickly to turn out the fluid blood and the coagula in the false sac. The vessel is then tied between the finger and the heart by means of a curved aneurysm needle armed with a catgut or silk ligature. The artery on the distal side of the aneurysm must then be secured by a similar ligature, otherwise, if the collateral circulation has been established before the operation is done, very troublesome hemorrhage would arise from this point. If the vessel is in an extremity, is very large, and the traumatic aneurysm is situated near the trunk, an amputation may be necessary, especially if the injury to the vessel has been caused by a gunshot Avound. An Aneurysmal Varix is a communication betAveen an artery and a vein Avithout the intervention of a sac. It may result from unskilful venesection, from the thrust of a sharp instrument, from a pistol-shot Avound, etc. If an artery and a vein have been Avounded by venesection, for example, so that a communication is established between them, an aneurysmal varix is formed. When this accident happens, a pad or compress is laid firmly over the wounded part, so as to arrest the hemorrhage. The Avails of the artery and vein in con- sequence of the slight inflammatory action become adherent to each other at Fig. 41. Plan of an Aneurysmal Varix. the margins of the wound, but the Avound itself does not heal, since at each pulsation of the heart a stream of arterial blood is thrown through the opening into the vein. The blood thus projected from the artery into the vein finally SURGERY OF THE VASCULAR SYSTEM. 241 dilates the latter (Fig. 41). The blood as it enters the vein comes in contact with the opposing venous stream, and so produces a whizzing sound which is pathognomonic of an aneurysmal varix. Once heard, the sound will never be mistaken. It has been compared to many noises. One of the best compari- sons (which is as ludicrous as it is forcible) was suggested by the late Mr. Spence—viz., the noise which a bluebottle fly imprisoned in a thin paper bag makes in its efforts to regain its freedom. Valentine Mott compared the noise to the purring of a kitten. Aneurysmal varix may exist for years and give rise to no serious disturb- ance. There is some alteration in the coats of the vein and of the artery, but none that would offer resistance to the flow of blood, as is the case in an aneu- rysm. There is dilatation of the vein, but not enough to cause ulceration or rupture. The veins beyond the varix are ahvays more or less dilated and enlarged. Treatment.—In some cases of aneurysmal varix no operative interfer- ence is called for. All that is then necessary is to apply an elastic bandage, which prevents further enlargement. The disease, however, sometimes extends and occasions pain and disturbance in the circulation. In these cases pressure by means of a firm compress should be made upon the artery above and upon the vein beloAv, and also directly over the aneurysmal varix. If this does not cure the disease after a fair trial, the tumor should be treated by operation. The aneurysm should be exposed by dissection, a ligature placed above and below the opening in both the artery and the vein, and the aneurysm extirpated. In aneurysmal varix of the carotid and the internal jugular and of the common femoral vessels operative interference should be undertaken only when the reasons are very urgent. Varicose Aneurysm.—A varicose aneurysm is similar to an aneurysmal varix, since in both there is a communication betAveen an artery and a vein ; but in the varicose aneurysm there is a sac between the artery and the vein. The arterial blood is projected into this sac, and from the sac into the accompany- ing vein (Fig. 42). Both aneurysmal varix and varicose aneurysm are often called arterio- venous aneurysm. Varicose aneurysm, like aneurysmal varix, is the result of a wound both of the artery and of the vein; but in the case of varicose aneurysm if not treated, or if the compress which Avas placed over the wound at the time of the FlG- 42- accident was not firm enough, blood Avill have extravasated between the walls of the artery and the vein and separated the two vessels. Inflam- matory lymph has then been depos- ited around this space, and thus a false aneurysm has been formed, communicating with both vessels; its sac consists of condensed effused Varicose Aneurysm: a, the artery ; 6, the vein ; c, the lymph. This intervening sac which intermediate sac. comes from the false aneurysm must not be confounded with an ordinary false aneurysm the result of a wounded artery alone. In the ordinary false aneu- rysm there is no communication with a vein. On account of the slight arterial pressure exerted by the force of the circula- tion upon the Avails of the sac of a varicose aneurysm, the sac is not subject to great enlargement. In an ordinary aneurysm the force of the blood-current 16 242 AX AM ERICA X TEXT-BO OK OF SURGERY. impinges directly upon the aneurysmal sac; in a varicose aneurysm the blood- current finds its way through the aperture into the vein, and thus its force is distributed into the vein instead of impinging directly upon the sac. While, then, enlargement of the sac is not common, yet in vieAV of the liability of the sac to slough, and the danger of gangrene of the limb or of the false aneurysm's becoming diffuse, the indication for surgical interference is plain. The symptoms are nearly the same as in aneurysmal varix, with the exception of the presence of a sac, which sometimes can be made out by pal- pation, and over Avhich can be heard a soft bruit. Treatment.—Varicose aneurysm must not be left to itself, for it will finally ulcerate and become diffuse. Compression is not suitable, as the already dilated and varicosed veins would become greatly enlarged, and finally cause much oedema and expose the patient to the risk of gangrene. In most cases of vari- cose aneurysm, especially if the aneurysm is small, ligature of both vessels above and below the disease, folloAved by extirpation, is a Avell-recognized opera- tion. In cases of varicose aneurysm situated in the neck or in the anterior femoral region, this procedure Avould be attended with great danger. The Hun- terian operation of tying the femoral artery above the sac in healthy tissue has been tried in two cases, and death folloAved in both instances. The reason for the failure of ligation of the artery by Hunter's method is that the conditions in an ordinary aneurysm and in the varicose aneurysm are different. In the ordinary aneurysm the ligation of the artery causes deposition of fibrin in the sac on account of the lessened amount of blood slowly entering the sac; in the varicose aneurysm the communication through the sac with the vein offers an unimpeded passage of the blood into the venous circulation, and the return venous circulation through the sac prevents coagulation, for blood in motion will not coagulate. The late Mr. Spence of Edinburgh devised and carried into successful execution an operation for varicose aneurysm which meets the theoretical as well as the practical indications. To use his own words, he cuts down upon the artery above the sac, and then beloAv the sac, but does not open the sac or disturb the vein. The application of two ligatures to the artery at the places mentioned removes the disturbing influence in the retrograde current of arterial blood, and thus permits the blood in the sac to remain unagitated by the meeting of two currents and to coagulate, causing the consolidation of the tumor. ANEURYSMS OF SPECIAL ARTERIES. Carotid aneurysm is usually situated at the point AA-here the artery bifurcates upon either side of the neck. Upon the right side the aneurysm may develop at the origin of the vessel. It begins Avith the appearance of a small tumor, which may groAV slowly or very rapidly. The symptoms of carotid aneurysm are those common to any other aneurysm, Avith, in addition, dyspnea, difficulty of deglutition, vertigo, hoarseness, brassy cough, and ringing in the ears. The diagnosis of carotid aneurysm is often attended Avith great difficulty. The affections for Avhich this disease may be mistaken have already been con- sidered under the differential diagnosis of Aneurysm. The treatment of carotid aneurysm is best carried out by means of a ligature upon the proximal side of the sac if there is sufficient room, othenvise upon the distal side. Among the accidents that may folloAv ligature of the carotid may be mentioned embolism, cerebral softening, hemiplegia, syncope. secondary hemorrhage, and suppuration of the sac. SURGERY OF THE VASCULAR SYSTEM. 243 H it becomes necessary to ligate both carotid arteries, they should not be tied simultaneously, as this double operation has been attended* by fatal coma. Subclavian aneurysm is found most frequently in the third portion of the vessel. The tumor appears under the clavicular origin of the sterno- cleido-mastoid muscle, the direction of its long axis corresponding with.the direction of the artery. Besides all the symptoms common to aneurysm in general, subclavian aneurysm has some special signs. Among these may be mentioned pain along the nerves belonging to the brachial plexus, if on the right side a brassy cough from irritation of the recurrent laryngeal nerve, a varicose condition of the jugular veins, delayed radial pulsation, and finally oedema of the arm and hand. These symptoms increase in severity as the tumor enlarges. The diagnosis of a subclavian aneurysm in the third portion of the artery from one involving the lower portion of the carotid or the subclavian in its first portion, or even the innominate, must be made. The chief diagnostic points of subclavian aneurysm in its third portion are the simultaneous pulsation of the carotid arteries and the delayed radial pulsation upon the affected side. The simultaneous delay of the carotid and radial pulsations of the right side indicates an aneurysm of the innominate artery instead of the third portion of the subclavian. Treatment.—If the aneurysm is small and limited to the third portion, digital pressure upon the proximal side of the subclavian, although difficult for anatomical reasons, may be attempted in conjunction Avith constitutional treat- ment. Pressure directly upon the sac has been successful in a few cases. If compression fails, the artery should be ligated upon the distal side, since prox- imal ligation has proved ineffectual. It may be necessary, Avhere other means have failed, to ligate the artery on the proximal side as a preparatory step, and then immediately to amputate at the shoulder-joint. Axillary aneurysm may be idiopathic or traumatic. The idiopathic •variety may be developed by the stretching of the vessel in reducing an old dislocation or by a too free movement of the shoulder-joint, or by atheroma of the vessel. This variety of aneurysm grows very rapidly, OAving to the laxity of the surrounding tissues, Avhich permits it to dilate without early mechanical obstruction. It quickly attains a large size, and the situation of the sac renders it especially prone to inflammation. The pressure of the aneurysm soon causes venous obstruction, and oedema of the forearm ensues. The pain is often very severe, on account of the irritation of the brachial plexus. The pulse at the Avrist corresponding to the side of the aneurysm is delayed Avhen compared Avith that of the opposite side. If the sac continues to groAv, the shoulder-joint is invaded, the ribs are eroded, and the correspond- ing lung is compressed. The movement of the arm is soon interfered Avith, and ankylosis of the shoulder folloAvs. This variety of aneurysm may cause a dry pleurisy or a hyperplastic pneumonia. I he treatment consists in applying digital or instrumental compression to the third portion of the subclavian artery, and, in the event of failure, in tying this portion of the vessel. The application of "an elastic bandage to the arm, combined Avith pressure upon the proximal side of the sac, can also be tried. Other methods of treatment in this form of aneurysm are fraught Avith danger, and must not be undertaken without deliberate consideration. In the traumatic variety of axillary aneurysm the injury may be produced by a stab or gunshot Avound, or even, as has been said above, by external vio- lence in attempting to reduce an old dislocation. In the treatment of traumatic aneurysm Mr. Syme has suggested a modification of the old operation of Antyl- 244 AX AMERICAX TEXT-BOOK OF SURGERY. lus. The subclavian is compressed firmly in its third portion, and the axillary sac is then opened, the coagula turned out, the wound found, the artery com- pletely divided, and both ends ligated. Brachial aneurysm may be situated either along the course of the artery or at the bend of the elbow. The most frequent variety of aneurysm is the traumatic ; but aneurysmal varix, and also varicose aneurysm, are found at the bend of the elbow as a result of unskilful venesection. For the treatment of these varieties of aneurysm see pp. 223-242. In idiopathic aneurysm of the brachial artery compression or the modified operation of Antyllus or the Hunterian operation may be employed. In rare cases gangrene of the forearm may result from an aneurysm in this situation. This condition calls for amputation. Iliac aneurysm may involve the common trunk of the vessel, the internal or the external iliac artery, or their branches. In aneurysm of the common iliac artery the treatment consists in compression upon the cardiac side of the aneurysm. The pressure should be made as much as possible over the artery, and not over the sac. The results of ligation of the common iliac for aneurysm show a mortality of nearly 75 per cent. The interned iliac artery is seldom the seat of idiopathic aneurysm. The sciatic and gluteal branches have, however, been the seats of aneurysm both of the traumatic and the idiopathic variety. If the aneurysm is idiopathic, the treatment should consist in proximal compression, and, if this fails, in the injec- tion of remedies with a vieAv to coagulating the blood. Recently, ligation of the vessel by a median laparotomy has been employed. If the gluteal or sciatic aneurysm is traumatic, compression must be made above upon the main artery, the sac be laid open, the clots turned out, and the vessel tied above and beloAv the Avound. The external iliac artery is often the seat of idiopathic as well as of trau- matic aneurysm. In the idiopathic variety the method by compression should be first employed, and if this fails the ligature of the vessel above the sac is indicated. The vessel can be reached by a median laparotomy. If the aneurysm is of the traumatic variety, the modified operation of Antyllus is indicated. Femoral aneurysm may be traumatic or idiopathic. From the exposed situation of the femoral artery, false aneurysms are of frequent occurrence. The treatment should consist in the application of a tourniquet to the artery as it passes over the brim of the pelvis, incision of the sac, and ligation of both ends of the divided artery. If the aneurysm is idiopathic, compression above the sac should be first tried, and in the event of failure the Hunterian operation should be employed. Popliteal aneurysms are usually idiopathic, but occasionally the trau- matic variety is seen. The latter should be treated according to the rules given for the management of this form of aneurysm situated in any other part of the body. The idiopathic variety can be treated by the flexion method, by the Hunterian method, by proximal compression, or by the elastic bandage. section iv.—injuries or the blood-a^essels. Hemorrhage is invariably present Avhen a vessel is wounded. The blood mav escape through the broken skin, or may extravasate beneath the skin and form a hematoma. The occurrence of severe hemorrhage is always attended with great danger to life, and the larger the caliber of the wounded vessel the greater the immediate danger. There is no other emergency which the surgeon is SURGERY OF THE VASCULAR SYSTEM. 245 called upon to meet that requires so much judgment and presence of mind as the proper management of alarming hemorrhage. There are four varieties of hemorrhage: 1. Arterial hemorrhage, characterized by bright-red blood spurting out in jets synchronously Avith the action of the heart. The bright-red color is due to the presence of oxygen in the blood. Arterial blood may be deprived of its characteristic color when the oxygen is greatly diminished and carbonic acid gas is present in excess, as in profound narcosis or when an operation is undertaken to avert death from apnea. During an operation, therefore, the surgeon should always look to the anesthetic if the blood from the wound becomes dark-colored. 2. Venous hemorrhage, characterized by the blood flowing in an unin- terrupted stream and by its dark color. The steady flow of the blood from the veins is due to the fact that the intermittent cardiac impulse is lost. For the same reason blood from the distal end of a Avounded artery also flows in a steady stream. The dark color is caused by the non-oxygenation of the blood and by the presence of carbonic acid gas. The walls of the veins collapse, with the exception of the veins of the liver; the portal system, however, is seldom taken into account by the surgeon. 3. Capillary hemorrhage, characterized by its constant oozing on the one hand, and by its spontaneous arrest on the other. This variety of hemor- rhage is alarming in exceptional cases only, but its persistence often makes it a troublesome variety to treat. The capillaries in the mucous membranes bleed more profusely than those situated in the integument. This is due to the fact that in the former the capillaries are larger and more abundant. Hemor- rhage from capillaries situated in the skin usually ceases owing to the con- traction of the wound. 4. Parenchymatous hemorrhage, characterized by absence of the features which distinguish the other three varieties, and also by the fact that it is found where there is a peculiar anatomical arrangement of the blood- vessels, or among diseased tissues, as when the main vein is thrombosed. This variety of hemorrhage is seen in those organs or parts of the body Avhere the small arteries empty into small veins without the intervention of a capillary system. Such an arrangement is found in the corpora cavernosa and in the erectile tissue of the female genitalia, as Avell as in the spleen. Hemorrhage may be divided upon another basis than an anatomical one— viz. a clinical one. It may be termed—I. Primary ; II. Intermediary; III. Secondary. I. Primary hemorrhage occurs immediately after the Avound in the vessel. The characteristics of a primary hemorrhage vary according as it is arterial, venous, or capillary, as above described. II. Intermediary or reactionary or consecutive hemorrhage occurs shortly after an injury to a vessel or after a surgical operation, during what is termed the period of reaction. This variety of hemorrhage usually takes place within twenty-four hours, and is caused by a ligature's coming away, or by the action of the heart in driving out coagula from the divided end of a vessel, or by some movement of the wounded part. III. Secondary hemorrhage occurs after tAventy-four hours and before organization of the thrombus and cicatrization of the Avound, and most fre- quently betAveen the fifth and tenth days. It usually occurs during suppura- tion, and is caused by disease.of the walls of the vessel, by sloughing of the wound, by ulceration of the vessel, by sepsis, or by the too rapid absorption of 246 ^A- AMERICAN TEXT-BOOK OF SURG a catgut ligature. Secondary hemorrhage is often seen in gunshot injuries and in wounds where there have been extensive contusion and sloughing. The constitutional symptoms of hemorrhage are rapid, feeble pulse; subnormal temperature ; frequent and irregular respiration; convulsive movements; lividity of the lips and blueness of the finger-nails; dilatation of the alie nasi; nausea and vomiting ; pale face and pallid mucous surfaces; great dyspnea; profuse perspiration; muttering delirium; tinnitus aurium ; syncope; collapse ; disturbances of sight and hearing ; unconsciousness. The symptoms just enumerated are present to a greater or lesser degree according to the amount of blood lost, the size of the vessel injured, and the general condition and the age of the patient. Infants and children do not tolerate the loss of blood well, but they recuperate rapidly. Aged people like- wise are seriously affected by the loss of blood, and, unlike children, do not rally quickly. Adults in health endure well the loss of blood, and Avomen during parturition tolerate hemorrhages Avhich under other circumstances would prove rapidly fatal. After hemorrhage has been arrested and the patient has rallied, the symp- toms denoting the existence of hemorrhage change and a slight febrile disturb- ance follows. To this condition the term "hemorrhagic fever" has been applied. The elevation of temperature is due to the nervous irritation conse- quent upon the hemorrhage and to the absorption of the "fibrin ferment," as after operation. (See p. 34.) The pulse is accelerated and often irregular, and its wave is apparently more distinct than normal, OAving to the relaxation of the coats of the vessel due to the absence of the natural stimulus of the blood. The patient is in an asthenic condition from exhaustion consequent upon the loss of blood, and septic processes are likely to develop under these circum- stances. The lowered vitality in hemorrhagic fever predisposes the patient to unhealthy inflammations, and great care must be exercised to guard against the onset of these pathological changes. The mental condition in hemorrhagic fever is characteristic. The patient is affected with a low form of muttering delirium, never becoming maniacal or violent. The intellect is restored in proportion to the general improvement in the symptoms. The distinguishing feature of hemorrhagic fever is that it is not caused by absorption of any septic material, but is due chiefly to an altered nervous condition consequent upon the loss of blood, which fail's to supply the proper nutriment to the great nerve- centers. Spontaneous arrest of hemorrhage may be effected by a combina- tion of several agencies. Contraction and retraction of the divided vessel and eoagulation of the blood are among the means which nature adopts. Cardiac svneope is also sometimes a most important factor in bringing about an arrest of hemorrhage, because this condition of the heart reduces the force of the blood-current, and thus permits coagulation in the Avounded vessel. Con- traction of the middle and internal coats and retraction of the entire vessel Avithin its sheath help to form a barrier to the exit of blood at the divided end of the artery. Coagulation of the blood is brought about by the diminished floAV of blood and also by its exposure to atmospheric influences. The hemor- rhage after laceration of the vessel is controlled by nature, OAving to the fact that the internal and middle coats curl up and the external coat and the sheath are twisted over the open mouth of the vessel. This phenomenon explains the small amount of blood lost in cases where the extremities are torn from the bodv. The diagnosis of hemorrhage is attended with no difficulty when blood makes its appearance externally. When the hemorrhage occurs within the SURGERY OF THE VASCULAR SYSTEM. 247 great cavities of the body, and is therefore concealed, the diagnosis is frauo-ht with uncertainty. Hemorrhage into the pleural, peritoneal, pelvic, or cranial cavity must be diagnosticated upon the special evidences manifest in each case. The general symptoms of hemorrhage are present, but in many respects they are so similar to those found in shock that a discrimination must be made with great care. (See p. 87.) The aseptic hypodermatic needle can sometimes be utilized with great advantage. If the hemorrhage is within the cranial cavity, the study of the nervous phenomena Avill aid in the diagnosis. (See Intra- cranial Hemorrhage.) If it is within the pleural, peritoneal, or pelvic cavity, physical signs will establish the diagnosis AAThen taken in connection with the history of the case. The treatment of hemorrhage is divided into constitutional and local. The constitutional treatment consists in the judicious administration of cardiac stimulants, such as strychnine, tincture of digitalis, carbonate of ammonium, nitro-glycerin, and hypodermatic injections of ether, brandy, or whiskey. As a rule, the remedies to excite the action of the heart should be given hypodermatically in order to secure an immediate effect, and great care should be taken lest the patient be suddenly over-stimulated. Ergot of rye has been used to cause contraction of the involuntary muscular fibers of the vessels. In view of the subnormal temperature, artificial heat should be applied to the surface of the body. This can be accomplished by warm blankets, bottles of hot water, and hot-air baths. In the use of bottles of hot water or hot-Avater bags care must be exercised lest the patient be burned, an accident as unfortu- nate as it is frequent. An enema of brandy, or of turpentine and hot water, can be employed as a valuable adjuvant. The head should be placed Ioav, to prevent cerebral anemia, and the patient kept as quiet as possible. An abundance of fresh air should be supplied to a patient suffering from profuse hemorrhage. The application of Esmarch's elastic bandage to the extremities, elevation of the arms and legs, and raising the foot of the bed should be employed, in order to increase the amount of blood in the brain and internal organs. Galvanism or sinapisms may be applied over the precordial region. Towels wrung out of hot water and applied to the head Avill help to bring about reaction. Warm fluids can be given as soon as the patient is able to swalloAv, and a good nutritious diet as soon as possible. Opium should be administered during reaction, especially if nervous excitement is present. Transfusion after hemorrhage has been resorted to with marked success in cases in Avhich a sudden loss of a large amount of blood has occurred. The operation of transfusion as formerly employed consisted in the injection of blood from a healthy person into the blood-vessels of a patient suffering from hemorrhage. It Avas attended with a high death-rate, and investigation into the causes of death demonstrated the fact that the mortality was due to the presence of emboli. Entrance of air was another source of danger. At present transfusion is employed, but instead of injecting blood a saline solution is generally used. (See Minor Surgery.) The local treatment of hemorrhage consists in the arrest of the bleeding either by compression, ligation, torsion, or acupressure. If the hemorrhage proceeds from an injured vein, compresses should be placed over the wound with uniform equable compression of the limb. This will suffice to control the bleeding in venous hemorrhage. If the hemorrhage is from a wounded artery, the bleeding vessel must be sought for and tied at both ends. The divided end of the artery, Avithout any surrounding tissue, should be seized 248 AN AMERICAN TEXT-BOOK OF SURGERY. with a pair of artery forceps (Fig. 43) or hemostatic forceps, and the liga- ture then be tied by means of the reef knot (Fig. 44). Catgut and sterilized silk are the materials employed for tying wounded arteries. Torsion of the vessel is applicable especially after amputation, as the vessel in this case is completely divided. In a wound in the continuity of the artery the vessel must be divided before torsion is applied. If the wound is a lacerated one, it can be converted into an incised one and the divided vessel caught and ligated or twisted. In applying torsion the vessel should be seized with the torsion forceps as if to ligate it (Fig. 45). A second pair of forceps may be placed upon the artery at right angles with and a short dis- tance above the first pair. The open end of the artery is now to be twisted by the forceps on the long axis of the artery, which is held securely by the second pair of forceps. Only a few turns Application of Ligature to an Artery. Fig. 44. Fig. 45. Trunk *f - Artery, The Reef Knot. Fig. 46. Twisted, end cfArtety. Hverted end of inner Coctta Effects of Torsion on Femoral Artery. Artery laid open to show Turning Up of Inner and Middle Coats from Torsion. should be made or the end of the artery may be twisted off. The effects of torsion on the inner and middle coats of an artery are shown in Fig. 46. Acupressure (Fig. 47) is occasionally useful; one method consists in passing a needle under the vessel FlG- 47- and compressing it pre- cisely in the same manner as the stem of a rose is fastened in the lapel of a coat by a pin. If the hemorrhage is capillary, gentle pressure can be employed. Hot water at 120° F. will act as an astringent, and is one of our most con- Ice is sometimes employed. Different Modes of Applying Acupressure. venient and reliable means of arresting hemorrhage. SURGERY OF THE VASCULAR SYSTEM. 249 Heat and cold both act by stimulating the muscular fibers of the vessels to contract. The actual cautery is a powerful hemostatic, but it has the great disadvantage of causing a slough. Styptic cotton, though generally objection- able, may be useful in hemorrhage from places Avhere the ligature is inadmissible. The position of the part, according to the laws of hydraulics, should be such as to diminish the force of the circulation and to favor venous return. Elevation of the limb Avill accomplish this result if the wound is in an extremity. Comparative Merits of Various Methods of Treatment.—In all cases of hemorrhage the constitutional treatment is the same. The local treat- ment, however, is subject to certain variations. The ligature or torsion is the preferable method. If catgut or sterilized silk is used for ligatures, both ends may be cut short, the wound closed, and primary union obtained. Acupressure possesses no special advantage over ligature or torsion since the principles of antiseptic surgery have been applied to Avound treatment. Transfusion should be employed in any case of hemorrhage in which the symptoms become alarming. A patient may have lost a great quantity of blood, and may even be apparently moribund, but if the heart's action is per- ceptible, transfusion is indicated. It has often saved life even under these extreme circumstances. In the after-treatment of hemorrhage the patient should be kept perfectly quiet both physically and mentally, and all visitors should be excluded. Any tendency to syncope must be combated by lowering the head, and cardiac stimulants should be judiciously employed. The surface of the body should be kept warm by artificial means, and warm drinks be given until the equilib- rium of the circulation is restored. A nutritious diet, fresh air, and hygienic surroundings should be provided. After the alarming symptoms have passed aAvay, attention must be directed to the use of iron in some form, wine in mod- erate quantities, and a free diet. Oxygen may be inhaled several times a day with advantage. If the wound has been antiseptically dressed and drained, union by primary intention should follow. If it has been improperly dressed, or if, owing to some condition for which the surgeon is not responsible, suppu- ration is likely to follow7, the wound should be thoroughly disinfected and free drainage provided, so as to repair the damage with as little constitutional and local disturbance as possible. From what has already been said in regard to the treatment of hemorrhage the following rules may be formulated: 1. (a) If primary hemorrhage is serious and bleeding is actually going on, apply an Esmarch bandage or a tourniquet above the injury to the vessel, open the wound, turn out the blood-clot, find the wounded artery, divide the vessel at this point, unless it has been already divided, and tie the proximal and distal ends with aseptic catgut. (b) If primary hemorrhage is serious, but bleeding is not actually going on and the patient is in collapse, apply a tourniquet above the wound and stuff into it sponges soaked in hot 1: 4000 bichloride solution, administer stimulants, and Avhen everything is in readiness relax the tourniquet and proceed as already described under the first rule. (c) In general oozing apply hot water (120° F.) by compresses. If an artery spurts from the saAvn end of a bone, introduce an acupressure needle and lacerate the vessel or plug it with a strand of catgut. 2. (a) In secondary hemorrhage, if it is slight, open the wound or stump, turn out the coagula, and apply a compress. (b) If the hemorrhage is alarming, apply a tourniquet or an Esmarch bandage, open the wound, and tie the ends of the vessel if possible. If this is 250 AX AMERICAN TENT-BOOK OF SURGERY. not practicable on account of diseased or sloughing tissue, ligate the vessel above in its continuity according to the Hunterian method. (c) If secondary hemorrhage occurs after ligation of a vessel in its con- tinuity, apply a tourniquet, open the Avound, turn out the clots, and tie the artery above and below the bleeding point if the tissues are not too much lacerated. (d) If this fails, tie the artery higher up in its continuity, or amputate. WOUNDS OF ARTERIES. These may be punctured, contused, lacerated, gunshot, or incised. Besides the varieties just mentioned there may also be rupture. A punctured Avound is caused by the penetration of the artery by a sharp or a thin blunt instrument. If the opening is very small hemorrhage may not result, but if the puncture is of any size bleeding occurs. A punctured Avound of an artery usually gives rise to a traumatic aneurysm, and must be treated as such. A contused Avound of an artery may be insignificant, or it may be of suf- ficient magnitude to cause gangrene by obliteration of the vessel or death by secondary hemorrhage. A slight contusion of the arterial wTall may be fol- lowed by an inflammation Avhich leads to a thickening of the walls of the vessel and complete occlusion. This condition may give rise to gangrene. If a thrombus forms in a contused artery which supplies some internal organ with blood, the viscus, having been deprived of its nutriment, will undergo degeneration. The contusion may be extensive enough to destroy the coats of the vessel, so that a fatal secondary hemorrhage follows the separation of the slough. A lacerated wound of an artery deserves special attention, because the results are likely to become serious. If an artery is stretched or torn suf- ficiently, the middle and internal coats snap. In the middle coat the circular fibers separate from each other so as to leave a space, and the separated circu- lar fibers contract upon the internal coat, Avhich is torn completely across and curls up Avithin the lumen of the vessel in the same manner as it does after the application of a ligature. In a lacerated wound of an artery the external coat is draAvn out so as completely to lose its normal elasticity, in the same manner as a piece of rubber tubing will lose its elasticity Avhen it is overstretched. Such an injury to an artery of large or small size may occur without any bleeding. The vessel is, however, permanently injured. A gunshot Avound of an artery derives its special importance from the fact that secondary hemorrhage is likely to occur. The vessel may be only contused by a bullet, and no bleeding occur until some days after the injury, when serious hemorrhage supervenes as a result of sloughing. A gunshot Avound of an artery is often associated Avith injury to the accompanying vein, and an aneurysmal varix is formed. In case an extremity is blown off by shot or shell, the hemor- rhage is often slight, on account of the fact that the vessels are lacerated, the middle and internal coats contract, curl up, and a plug is formed at the open end of the vessel. If, however, a rifle bullet enters the body Avhen it is travelling at great speed, it may cut an artery like a knife, causing immediate and alarm- ing hemorrhage. In addition to the primary or secondary hemorrhage which may be produced by a gunshot wound of an artery, the contusion of the vessel may lead to the formation of a thrombus, AAhich may cause occlusion of the artery and be folloAved by gangrene. Pyemia is also a serious complication in gunshot wounds ; and often a secondary hemorrhage ushers in a fatal septicemia. SURGERY OF THE VASCULAR SYSTEM. 251 An incised wound of an artery is an injury inflicted by some sharp cuttino- instrument. The hemorrhage is ahvays profuse in such a wound, because there is no mechanical obstacle to the outfloAV of blood through the opening, such as is often found at the open mouth of a torn artery, and also because the con- traction of the tAvo ends of the vessel causes the wound in the artery to gape. The direction of the incised Avound may be transverse, oblique, or longitudinal. The hemorrhage is very profuse in a transverse cut of an artery, Avhile it is not so abundant in an oblique incision. If the artery is upon the stretch and is Avounded longitudinally, the bleeding is very slight, but may become very alarming when the artery is relaxed. In case of a partially divided artery the proper rule to follow is to divide the vessel completely and tie both ends. Rupture of one or all of the coats of an artery is an injury that occurs under certain circumstances. The rupture may be partial, for example, Avhen the internal and middle coats are torn and the external coat is stretched. This accident is not followed by hemorrhage, but it is a condition favorable to the production of secondary hemorrhage by sloughing, or to the development of an aneurysm. The same condition may also cause thrombosis or embolism of the vessel, and gangrene of the extremity or part may result. The rupture may be complete, in which case the artery is in the condition of a lacerated vessel. If it is subcutaneous, a traumatic aneurysm develops. If the rupture is partial and a clot has formed sufficient to occlude the vessel, then the pulsation beloAv is lost and gangrene may supervene. The treatment of wounds of arteries must necessarily vary according to the character of the injury. If the opening is of any size, the vessel should be completely divided and both ends tied. In case a traumatic aneurysm has developed as a result of a punctured Avound of an artery, the rules prescribed for the management of this condition must be followed—i. e. it is a Avounded artery, and should be treated as such. If the wound is a contused one, the treatment consists in securing as much physical rest for the artery as possible by tranquillizing the circulation. This is effected by absolute rest and the administration of cardiac depressants. The possibility of the occurrence of secondary hemorrhage must not be forgotten, and measures to arrest it must be instituted immediately if it appears. The area or extremity which may be deprived of blood as a result of a contusion of an artery must be kept artificially Avarm in order to encourage the determination of blood to the part and to stimulate the collateral circulation. If the wound is a lacerated one, the primary hemorrhage is usually slight on account of the curling up of the internal coat and the contraction of the mid- dle coat, and the coagulation of the blood at the torn end of the vessel; but on account of the danger of secondary hemorrhage both ends of the vessel should be diligently sought, by a careful dissection if necessary, and securely tied. If the wound is a gunshot one, the primary hemorrhage must be treated according to the same principles that would guide the surgeon in the manage- ment of an ordinary Avounded artery. If the vessel is one of large size, digital pressure directly upon the artery and in the Avound is indicated for the instan- taneous arrest of the bleeding; in no case should styptics be employed. An Esmarch elastic bandage should noAV be applied, and the surgeon should cut doAvn immediately upon the bleeding vessel, completely divide it at the seat of injury, and tie both ends of the artery with aseptic catgut. If the hemorrhage comes from an artery situated in the neck, or in any other place where the application of an elastic bandage is impracticable, the surgeon must be guided by the rules for the management of traumatic aneurysm. The dressing of such a Avound should be conducted Avith the most rigid adherence to the principles 252 AX AMERICAN TEXT-BOOK OF SURGERY. of aseptic surgery in order to prevent secondary hemorrhage, a danger Avhich is peculiarly frequent after gunshot wounds. The occurrence of gangrene is also a complication of an exceedingly fatal character in gunshot Avounds, since septi- cemia rapidly develops. If the main artery of the limb is injured, and also its accompanying vein and nerve, even without a fracture of the bone, as a general rule amputation is necessary to avert gangrene, which Avould almost surely folloAv. If secondary hemorrhage occurs, it will be during the second or third Aveek— that is, at the time when the sloughs separate. The bleeding should be arrested, if possible, at the site of the hemorrhage; but when this is impossible, a ligature should be applied according to the Hunterian principle—i. e. in healthy tissue upon the proximal side of the wound. If the hemorrhage is alarming and it comes from several points, and the suppuration is extensive, wTith sepsis, ampu- tation of the limb is indicated. The best Avay to prevent secondary hemor- rhage is to keep the Avound aseptic and to provide sufficient drainage. Good nutritious diet is required in order to maintain a high standard of vitality, which conduces to repair of the wound and averts the dangers of exhaustion, suppuration, and septicemia. If the wound is an incised one and involves the neck or axilla, digital pres- sure must be promptly employed, and at once preparations should be made to search for the Avounded vessel. This should be completely severed at the point of injury and a proximal and distal ligature of aseptic catgut or silk should be applied. If the incised artery is in an extremity an Esmarch bandage can be applied in the same manner as already described in the management of primary hemorrhage in gunshot Avounds. The application of the bandage permits the surgeon to make a bloodless dissection and secure Avith certainty and ease the Avounded vessel. In case of a ruptured artery the treatment is practically the same as would govern the surgeon in the management of a contused or lacerated vessel. AVOUNDS OF SPECIAL ARTERIES. The carotid artery may be Avounded as a result of gunshot injury, a stab, or other Avound, or during the performance of an operation upon the neck. The Avound of so large a vessel is necessarily a most serious event. If the vessel is entirely cut across, the patient usually (but not ahvays) expires in a few minutes; but if the carotid is partially Avounded, the hemorrhage may be arrested by compression until the vessel is secured and ligatured. This artery is seldom divided in an attempt at suicide, especially when the head is thrown back, because of its anatomical situation deep in the neck ; but the superior thyroids lying in front and more superficially are often Avounded ; the incision rarely extends deeper than these vessels. In all cases of Avounds of these larger vessels of the neck the treatment is based upon the general principles which govern the surgeon in his management of hemorrhage. A primary hemorrhage should be treated by dividing the vessel at the point of injury, if not already divided, and instantly tying both ends of the vessel. A secondary hemorrhage must be controlled by methods already mentioned. In Avounds of the carotid and its branches the possibility of the occurrence of oedema glottidis must not be overlooked, and a prophylactic tracheotomy should be performed if this occur. The- vertebral artery may be injured in any of the Avays mentioned in reference to Avounds of other vessels. Compression has effected an arrest of the hemorrhage; but, as a rule, a search for the Avounded vessel may be made, SURGERY OF THE VASCULAR SYSTEM. 253 and if possible the artery be divided and tied at both ends. There is dano-er of escape of blood into the spinal canal and compression of the cord when a wound of the vertebral artery occurs. The subclavian artery has been wounded in the various ways that have been described, and possibly by a puncture from a fragment in fracture of the clavicle or of the first rib. A wound of this vessel is most serious on account of its size and its situation. A large traumatic aneurysm is developed, and must be treated after the manner described in the management of such an aneurysm. The axillary artery is subject to the same injuries as other vessels, and is additionally exposed to the danger of rupture in reducing old dislocations of the shoulder-joint. Fortunately, in the wounds of the axillary artery due to complete laceration of the vessel the artery retracts and contracts and the hemorrhage may be spontaneously arrested. In injuries of this artery, as a rule, the vessel should be exposed, completely divided, and both ends secured by a ligature. In rupture from attempts at reducing an old dislocation this procedure has been uniformly fatal, and should be replaced by compression, ligature of the subclavian, or amputation at the shoulder-joint. The femoral artery is often exposed to injury, and on account of its superficial situation the hemorrhage is easily controlled. The same rules govern the surgeon in the management of Avounds of this vessel as in those of other arteries. After ligation of the artery the limb should be elevated and artificial Avarmth should be applied to prevent gangrene. The popliteal artery is seldom Avounded, owing to its deep situation and to the protection which is afforded to it by the joint in front. In case of an injury to the vessel an Esmarch bandage should be applied, the vessel found, and both ends of the divided artery ligated. In case of a wound of any of the other arteries in the body—in the fore- arm, arm, leg, or foot, or upon the trunk—the principle of searching for the bleeding vessel and ligating it at both ends must always be kept in mind. The hemorrhage from an intercostal or from the internal mammary is serious, because generally some of the thoracic viscera are also implicated. It has been suggested to introduce a finger-shaped tampon made of a piece of antiseptic gauze, which is pushed between the ribs with a probe, and then to fill the tampon with strips of iodoform gauze and draw the entire mass outward, so as to make firm pressure against the inner wall of the thorax and the two corresponding ribs. It is, however, best to secure the two ends of the divided vessel by ligatures in the manner already described. A rib may be resected if necessary. WOUNDS OF VEINS. A wound of a vein is in some respects less dangerous than a wound of an artery of the corresponding size; but serious complications may readily folloAv a wound of a vein, unless kept aseptic. The hemorrhage from a small vein is less than that from an artery of the same size, because the vein collapses and the force of the circulation is not so great as in the corresponding artery. A considerable quantity of blood is extravasated in the surrounding tissues, so that external pressure will also contribute to the arrest of the hemorrhage. I he loss of blood from a large vein, hoAvever, is so rapid and excessive as to endanger life in a few minutes. The symptoms of venous hemorrhage upon Avhich the diagnosis is based, are—1st, the escape of dark-colored blood in a continuous stream ; 2d, the special effects of pressure: if applied upon the distal side of the wound, it 254 ^V AMERICAX TEXT-BOOK OF SURGERY. causes the hemorrhage to cease; but it causes it to increase if the pressure is applied upon the cardiac side of the wound. The complications that follow an injury to a vein depend chiefly upon the size of the vessel and upon the septic or aseptic conditions attending the injury. Among the complications are phlebitis, oedema, thrombosis, embolism, ulcera- tion, metastatic abscesses in organs directly connected with the Avounded vein, gangrene, and secondary hemorrhage. The treatment of a Avounded vein depends upon the size and situation of the vessel. If the vessel is small and situated superficially, elevation of the limb, a compress applied upon the distal side, and rest will be all that is neces- sary. If the vein is large and deeply situated, the injured vessel should be found and both ends of the divided vein secured by an aseptic ligature. Of course thorough asepsis of the Avound must be secured. If the wounded vein is Avithin one of the three great cavities of the body, an operation of great magnitude may be indicated in order to reach the bleeding vessel. If a vein is Avounded laterally, the slit can be picked up with a pair of forceps and a ligature applied to it, so that the lumen of the vessel will not be obliterated. In the case of a large vein Avhere the tissues are abundant this method of treat- ing a Avounded vein has many advantages. Wounds of Special Veins.—A AAound of the internal jugular vein is generally quickly fatal from the loss of blood or occasionally from the entrance of air into the vein. The direction of the Avound influences the prognosis, because a longitudinal slit will not gape, Avhile a transverse one is held Avide open by the action of the deep cervical fascia. If the internal jugular is Avounded near its entrance into the skull, besides the dangers arising from the loss of blood and also the entrance of air, there is the additional danger of cerebral septic infection and venous and sinus thrombosis. Injuries of the subclavian and axillary veins are also very serious, for the same reasons that have been mentioned in reference to the jugular vein. A Avound of the femoral vein, besides the loss of blood, has an additional danger—gangrene of the leg—Avhich may follow the ligation required to arrest the hemorrhage. Ligation of the popliteal vein may also be attended with the same complication. After either of these ligations the limb should be elevated to help the venous return, and be enveloped in cotton and hot-water bottles to keep up the temperature of the leg. If gangrene intervenes, amputation must be done. For "Wounds of the Cerebral Sinuses see Injuries of the Head. CHAPTER II. SURGERY OF THE OSSEOUS SYSTEM. As the ossous tissue differs in no material respect from the soft parts except in the added lime-salts that give it firmness, its injuries and diseases are in the main of like character and course, wounds, inflammations, and tumors termi- nating in more or less complete return to the normal state or in constructive or destructive changes. The soft structures in the cancellous and medullary spaces, SURGERY OF THE OSSEOUS SYSTEM. 255 in the Haversian canals, and upon the exterior of the bone, though for con- venience' sake and Avith a seeming anatomical and pathological basis they may be separately considered, are but parts of a common Avhole, a lesion of wrhich may be general or limited according to its nature and intensity. The most numerous and important affections are the inflammations conse- quent upon injury; upon the existence of special diathetic states, as the tuber- cular or syphilitic; upon a general infective disease, as typhoid fever; or upon the presence and action of pyogenic organisms. They may be acute or chronic, and end in resolution, in organization of an exudate, or in destruction, limited or extensive, molecular or in mass, of the part involved. According to the presence or absence of the pyogenic microbes suppuration Avill or Avill not occur. Liquefaction to a greater or less extent is an ordinary effect of the syphilitic invasion, still more of the tubercular. The intensity of the symptoms is ahvays greater in the suppurative than in the non-suppurative affections. The pyo- genic organisms (generally the staphylococcus aureus or, but much less fre- quently, the streptococcus pyogenes) gain admission to the diseased area either through an open AA'ound or by the blood-stream, having been taken up at some distant and often small pus-depot, or by the lungs, or the intestinal canal, to which they have been brought from Avithout the body. These inflammations may be considered under the general heads of osteo- periostitis and osteo-myelitis, since pure periostitis is of very infrequent occur- rence, perhaps is only met with as a syphilitic manifestation, and pure myelitis is equally infrequent. OSTEO-PERIOSTITIS. This condition usually exists in cases commonly thought to be examples of periostitis, in Avhich not only the periosteum, but the superficial layers of the bone also are diseased. It may be acute or chronic, plastic or suppurative, limited or diffused. It is the result of cold, of wounds or contusions, of strains from undue traction on inserted tendons, of contiguous inflammations, as from old ulcers, or of special infections, syphilitic, tubercular, or pyogenic. The more superficial the bone, the more likely is osteo-periostitis to occur, because of the greater exposure to injuries and the action of cold. The perios- teum both in its outer and inner layers is thickened and reddened and its cells increased in number. More or less of the surface of the underlying bone is simi- larly affected, and its blood-supply may be so diminished in consequence of the separation and occlusion of the vessels by the swollen periosteum as superficially to destroy its vitality. When neither suppurative nor tubercular, the disease terminates either in resolution or in permanent thickening writh new formation of bone, or, but much more rarely (and chiefly on the head in cases of syphilis), in thinning and absorption. When suppurative and limited, after evacuation of the pus repair takes place with either little or no thickening, with decided hypertrophy, or with some loss of substance. When diffused, unless very promptly arrested, extensive destruc- tion of membrane and bone commonly folloAvs. These purulent varieties are rarely, if ever, primary, though the antecedent deeper inflammation may be but slight. The symptoms vary someAvhat according to location and cause, being least marked in the traumatic non-suppurative cases, but pain and swelling are ahvays present, the former, as a rule, severe and wrorse at night. If it is a deeply-situated bone that is affected, it is often impossible to recognize the swelling, but if a subcutaneous one, for example the tibia, as is so frequently 256 AN AMERICAN TENT-BOOK OF SURGERY. the case, the spindle-shaped thickening can be readily felt; there is much ten- derness on pressure and the overlying soft parts are oedematous and reddened. In the suppurative varieties constitutional symptoms are present, and are of a high grade in the diffused phlegmonous form. In the chronic syphilitic inflam- mations the pain is, as a rule, not acute. The treatment in the beginning is by rest and the application of either cold or heat as is more comfortable to the patient. If speedy resolution does not take place and the pain is great, subcutaneous punctures of the swelling should be made, or, if pus is present, the parts should be freely laid open. When the disease is due to syphilis, the knife should not be used, but reliance should be placed upon the administration of the ordinary antisyphilitic remedies. OSTEO-MYELITIS. Osteo-myelitis (which includes both osteitis and medullitis—i. e. myelitis of bone) is the more common form of bone inflammation, the cause of Avhich may be either local, general, or septic. As in inflammation of the soft tissues, the parts are congested, the blood- vessels dilated, effusion and exudation take place, and there is increased cell- growth. If the disease is slight and due to traumatism, and if resolution quickly folloAvs, no organic change is produced in the bone-layers; but ordinarily there occurs more or less destruction, either in mass (necrosis) or molecular (caries). These are limited or extensive according to the degree of the inflammation and its exciting cause. It is either acute or, more frequently, chronic. If the inflammation is acute and severe, the resistance of the rigid walls of the central cavity and of the Haversian canals generally causes such compression of the vessels (Avhich often become strangulated by the newly-formed cell-masses) that the vitality of the part cannot be preserved ; necrosis then necessarily results (Fig. 48). Such death in mass in greater or less measure is always to be looked for in the acute infective or suppurative inflammations. When the process is a sloAver one, there may still be an arrest of circulation with resulting necrosis, but generally the death of the bone-layers is a molec- ular one, due in part to the disintegrating action of the excess of fluid, but chiefly to the pressure made by the enlarged vessels and the neAvly-formed cells and to the destructive action of the latter. These are especially abundant in the Haversian canals over the flexures of the vessels, and as a consequence the walls of such canals break doAvn unevenly and are pitted, the depressions being commonly spoken of as the How ship lacuna?. As the result of the softening and disappearance of the bone the cancellous spaces enlarge, the central cavity widens, and the Haversian canals increase in diameter, granulation-tissue becoming more and more abundant and progressively occupying the places from which the bone has been removed. In other words, a condition of osteo- porosis has been developed, and the affection is a rarefying osteitis, which may be, on the one hand, of very limited extent, or, on the other, involve a large part of the bone, even from center to cortex. Outside the area of rarefaction there will often be found a space of greater or less width in which formative changes have occurred, the bone being thicker and denser than normal, osteo- sclerosis instead of osteo-porosis being present. Such secondary changes may affect parts of limited extent previously in a state of rarefaction, which Avhen the inflammation has entirely disappeared will remain unduly hard, with their Haversian canals abnormally narrow. During the rarefying action small pieces of bone may be destroyed and SURGERY OF THE OSSEOUS SYSTEM. 257 Fig separated (necrotic caries). The great majority of the cases of caries, nine- tenths if not more, are of tubercular origin, the deposit taking place readily, as the result of slight traumatisms, in the cancellous tissue, the vessels of which are numerous and thin-walled and the capillaries very large in proportion to the size of their associated arteries and veins. It is during the years of growth in the parts of the bone in Avhich such growth chiefly occurs, as about the epiphyseal lines and in those portions of the skeleton particularly subject to blows, shocks, and the action of cold, that this form of dis- ease is ordinarily observed. Here as everywhere else the bacilli cause soften- ing of the parts immediately about them. If few in number and limited in action, they may be rapidly destroyed or shut in, so that either by cicatrization or encapsulation recovery takes place. This often occurs; in the great majority of cases, hoAvever, the disease is not so arrested, but infected granulation- tissue continues to be developed in the cancellous spaces, in the Haversian canals, and in the central medulla, more and more bone is softened down or pieces of appreciable size are deprived of their blood- supply, and consequently die. Thus the tubercular area groAvs larger with accompanying liquefaction and caseation, and the rarefaction extends farther and farther. When it is the presence and action of the pyo- genic microbes that excite the inflammation the osteo- myelitis may be either acute or chronic, limited or widespread, with accompanying destruction of bone and corresponding intensity of local and general symptoms. Though there are a number of the pyo- genic organisms that may cause these septic diseases of bone, the staphylococcus aureus is the one most commonly met with, and next to it the streptococcus pyogenes. Associated with certain of the acute infectious diseases, especially typhoid fever, there occurs an inflammation, generally superficial, Avhich causes a necrosis commonly of limited extent and with a strong tendency to become symmetritical—e. g. to Necrosis of a e Diaphvsis. follow. simultaneous or consecutive development in like parts ins Acute osteo-myelitis of the on both sides of the body. Whether because the dis- umerus- ease-germ is itself pyogenic or because of a double infection, these typhoid inflammations are as a rule suppurative. Osteo-sclerosis is a very frequent effect of syphilitic infection, but both necrosis and caries often occur, and in different portions of the same skeleton the three forms of osteitis, condensing, rarefying, and hypertrophic, may be observed. In phosphorus-workers severe and extensive necrosis of the jaws is at times, though noAv very rarely, produced by the action of the poison that has gained access to the bone through decayed teeth. Acute osteitis is either simple or septic. Simple acute osteitis is consequent upon traumatism, and occurs in parts protected against the action of the pyogenic micro-organisms either by an 17 258 AN AMERICAN TEXT-BOOK OF SURGERY. unbroken soft covering or by antiseptic treatment. It is of comparatively lit- tle importance, and usually terminates by resolution in a short time. Its symp- toms are feAv. Pain is the most prominent symptom, and is often not severe; it is apt to be deep-seated, boring or gnaAving, Avorse at night, aggravated by the dependent position, and increased by pressure. If it is superficially located— when, indeed, it is an osteo-periostitis rather than a simple osteitis—it may be associated with some oedema of the soft parts and ^discoloration of the skin. Rest, elevation of the limb, fomentations, and moderate compression are the local remedial measures to be adopted, pain being controlled by opiates. If the suffering is very severe and does not quickly subside, the overlying soft parts should be incised, and if this does not relieve, the bone should be asepti- cally drilled at one or more points, thus lessening the tension. Of the septic inflammations of bone there are two varieties: (1) the one associated with an open wound, originating ordinarily in the shaft of a long bone and generally met with in adults; (2) the other, without such associated wound, beginning in the parts near the epiphyseal line. The latter is pecu- liarly a disease of childhood. It may, however, occur later in life, and is then in the great majority of instances a recurrence of a similar inflammation of early life, some of the causative germs of which had been encapsulated. Boys are attacked three times as often as girls, and nearly half of the patients are adolescents between the ages of thirteen and seventeen. The first variety, since the introduction of antiseptic surgery, is compara- tively rare. Typical examples in former years were often seen in cases of compound fracture, especially gunshot fractures, and after amputations, infec- tion of the wound having taken place at the time of injury, during the opera- tion, or later. The severity of the inflammation varies, from that in which there are but little suppuration and limited destruction of bone to that in Avhich the parts quickly become putrid; the whole bone is destroyed, and the patient dies early of septicemia or pyemia, even Avithin tAventy-four or forty-eight hours, in the most malignant of the latter cases. When associated with a compound fracture, in addition to the ordinary conditions, such as congestion, extravasations, and cell-development, following an injury of this character, pus is present, with the general symptoms com- monly attendant upon suppuration. Since the great danger lies in the develop- ment of septic infection, the local treatment should consist in securing free drainage and in rendering the diseased area aseptic. When the disease arises after amputation, the medulla appears discolored by extravasated blood, and in the severer cases bleeds upon slight pressure and protrudes beyond the level of the sawn surface, at times to a large extent, covering the end of the bone with a fungous mass. The discharge is abundant and sero-purulent, often having a very offensive odor.' As the result of the inflammation, when the constitutional infection is not such as to cause early death, the bone about the medullary cavity necroses, and after a time is sepa- rated in the form of a tubular sequestrum (Fig. 51), much worm-eaten on its exterior, of greater or lesser length, thick at the base, irregularly thinning out higher up, and ending in sharp points. The constitutional symptoms, increase of temperature, acceleration of pulse, mental hebetude, etc., are of varying intensity. The local treatment should consist in the free removal of the infected medulla and in curetting the Avails of the cavity, followed by its thorough dis- infection and drainage and by antiseptic dressing of the stump, thus limiting, as far as possible, the extension of the septic inflammation. When the dead bone has been loosened fronj the living, chiefly by a process of rarefying osteitis SURGERY OF THE OSSEOUS SYSTEM. 259 Fig in the latter, it should be promptly removed, since, its extrusion unaided by surgery Avould be effected sloAvly, and while in progress there would be liability to extension of the suppurative inflammation, Avith further destruction of bone. The second variety arises when the pyogenic organisms have not found entrance through an open wound, but have been brought to the affected area in the blood-stream. The effect then produced is very variable. In a com- paratively small proportion of cases intense and rapidly destructive inflammation of the bone folloAvs. It is this variety of osteo-myelitis that is most frequently met with at the present time, Avounds involving bone, however produced, being protected in the great majority of cases against the action of the pyogenic cocci by aseptic and antiseptic treatment, provided they come under the care of the surgeon before infec- tion has taken place. As has been stated, it is a disease of childhood and adolescence, and has its starting-point in the tissues near an epiphyseal line, due to the frequency of juxta-epiphyseal strains, the femur and the tibia being the bones most commonly affected. Fig. 49 shoAvs arrest of development of the ulna followed by deformity of both ulna and radius consequent upon such an inflammation near the epiphyseal line of the ulna. The symptoms are, in the beginning, high fever (with often, but not always, an initial chill) and great pain, gnawing or boring in character and located ordinarily near the end of a long bone, with a pe- culiar helplessness of or inability to move the limb by its own muscles. The attack comes on suddenly, generally at night, after exposure to cold and damp- ness, combined sometimes with unusual exertion. Sitting on a stone doorstep and unduly prolonged swimming are common causes, even in summer. If the inflammation is at first deeply seated in the can- cellous tissue, no change in the overlying soft parts, either in thickness or in color, will be observed for a number of days, even in the graver cases, though there is from the first sensitiveness to pressure over the affected area, and frequently the superficial veins are abnormally distinct. Before long, however, the external layers of the bone and periosteum become involved, and SAvelling of the soft parts and redness of the skin occur, with quickly-folloAving fluctuation, indicating the presence of pus. When the disease originates near the surface, these latter symptoms will be noticed early, the rapidly-forming and widely-spreading pus lifting the periosteum off the shaft for a variable distance, in the graver cases from end to end and around the Avhole circumference of the bone. The temperature continues high, Avith daily fluctuations of two, three, or more degrees, and the pain is excessive until ten- sion is relieved by the spontaneous opening of the abscess or by operation. As soon as there is such an opening, probing Avill almost certainly reveal the presence of dead bone. The neighboring joint generally soon becomes inflamed, Avith resulting effusion into its capsule, the fluid often becoming purulent after Arrest of Development of the Ulna following Osteitis near Epiphysis; continued Growth and Deformity of the Radius. 260 AX AMERICAN TEXT-BOOK OF SURGERY. a time, either from direct communication with the suppurating area in the bone or from transmission of the pyogenic cocci through the blood-vessels or the lymphatics. In young children the acute epiphysitis that at times occurs is very apt to cause separation of the epiphysis, folloAved by suddenly produced displacement, resulting in shortening and deformity (Fig. 49). This variety of bone-inflam- mation is usually located at the hip, knee, or shoulder. At times, though not often, the pyogenic organisms are carried from one end of the bone to the other Avithout involvement of the intervening shaft, two entirely distinct areas of inflammation being produced in the same bone. The intensity of all the symptoms will vary according to the character and number of the infecting organisms. In the most severe cases, fortunately very rare, only pain and the temperature and typhoid state of an acute septicemia are observed, death occurring quickly. Generally, swelling and abscess-forma- tion are added. These abscesses are extensive and developed early in the graver cases, but are limited and appear more slowly in the milder ones, the latter being those more commonly met with. In certain cases the attack may be so mild that pus is not formed, but a synovia-like fluid, chiefly subperiosteal, the nature of which is not discovered until after its evacuation ; or perhaps pus is found and undergoes a later mucoid degeneration. This periostitis albuminosa has been observed only a very few times. The diagnosis in the earlier hours or days may be uncertain, the affection being often regarded as a typhoid fever or an acute rheumatism, or, as in the periosteal variety, because of the redness of the skin, as an erysipelas. But if due regard be had to the age of the patient, the location of the pain close to but not in the joint (commonly the knee, the ankle, or the hip), its peculiar gnawing, boring character so indicative of bone-inflammation, and the sud- denness of appearance and severity from the start of the constitutional symp- toms, with the absence of the progressive daily rise of temperature that belongs to typhoid fever in its first Aveek, there will seldom be any doubt as to the nature of the disease. The prognosis as respects both part and life is grave. Death from sep- ticemia in a few intensely infective cases takes place so soon (within one, two, or three days) that its osteo-myelitic origin is not recognized. When it origi- nates superficially, the disease is less dangerous than when of central origin, as the pus more readily and rapidly reaches the surface and is more quickly evacuated. Though the prognosis is much affected by the intensity of the inflammation, it is more influenced by treatment. This to be effective must be operative, and the sooner the diseased area is cut doAvn upon and the bone drilled or trephined, the greater the likelihood of arresting the inflammation and lessen- ing the local destruction. The application of heat, pressure, tincture of iodine, etc. will not stop the disease; tension must be relieved, pus evacuated, the bone trephined and the bone cavity scraped, and the parts irrigated with a sublimate solution in order to kill the staphylococci. When the medulla is extensively involved, much benefit will follow tre- phining at two different levels or at many points, scraping out the intervening infected tissue, even to the removal of the whole medulla of a long bone, such as the tibia, and thoroughly irrigating Avith antiseptic solutions. In the super- ficial variety (even in the so-called acute phlegmonous periostitis), Avhen the periosteum has been extensively separated, it may regain attachment to the bone to a large extent after early free incision and irrigation, and the vitality of the shaft in the main be preserved. PLATE X. \\ A& " «%*■*?* *ii*% SEQUESTRUM OF ENTIRE SHAFT OF FEMUR, INVOLUCRUM RIDDLED AVITH CLOAC.E; THE RESULT OF ACUTE OSTEO-MYELITIS. SURGERY OF THE OSSEOUS SYSTEM. 261 Fig. 51. Fig. 50. &'■ If, as is generally the case, from neglect of treatment or in spite of it, necrosis has resulted, the dead bone should be removed as soon as it has become detached; but often in the more severe cases, in order that the profuse discharge and pro- gressive exhaustion may be stopped, an early opera- tion will be required at the end of four, five, or six weeks, even at the risk of taking aw7ay too much or too little of the shaft and having little or no regeneration of bone folloAv. Sequestra—The dead piece of bone, Avhether large or small, is called a sequestrum ; when upon the exterior it is superficial (Fig. 50); in the interior it is central; when of limited thickness, but involving the entire circumference, as after amputation, it is tubular (Fig. 51) or ring-shaped according as it extends for a considerable distance up the bone or is confined to the sawn end; Avhen it embraces the whole shaft, Avith or Avithout the epiphysis, it is complete. For a long time the frag- ments in a compound fracture have been spoken of as sequestra—primary when completely separated at the time of the injury, secondary when for a time held by periosteal or muscular attachments, and tertiary when later destroyed by inflammation ; but the term should be restricted to the latter, since the others are not at first dead nor in a large proportion of cases will they die if suppuration be prevented. When not exposed to the air, sequestra are almost always of a dull-white color ; when so exposed, they are generally black. When struck by a probe, the note is clear and high-pitched, altogether different from that given out by healthy or by carious bone. The orifice of a sinus communicating with the sequestrum is more or less open, the granulations are pouting, and the bony rim is firm to the touch. When the periosteum Avith its deeper layer is not destroyed, and especially when the external layers of the bone are living, if sufficient time is afforded for the production of neAv bone an osseous envelope is formed, called the invo- lucrum. This more or less completely shuts in the sequestrum, the outer sur- face of Avhich is either smooth if the new formation is of periosteal origin, or rough and Avorm-eaten if the separation has been produced by a rarefying osteitis. Where there has been ulceration through the periosteum and bone-layers outside the sequestrum, no such re-formation occurs at these points, and the involucrum is pierced by openings of a size corresponding to the parts destroyed ; these openings are called cloacae. Plate X shoAvs on the exterior the involucrum pierced by numerous cloacae and on the interior the sequestrum of the entire shaft of the femur, the result of an acute osteo-myelitis. When the necrosed piece is central, the living bone about it often becomes so sclerosed that it can be cut through only with difficulty. Occasionally, though rarely, this condensed bone is not perforated by even a single sinus and the sequestrum is completely enclosed. (PI. XI, Fig. 1.) The separation of the dead bone from the living is a comparatively sIoav process, occupying tAvo, three, or more months, but it should nearly always be waited for Avhen removal by operation is to be effected, so that only the Superficial Sequestrum. Ch Tuhular Sequestrum. 262 AX AMERICAX TEXT-BOOK OF SURGERY. dead bone may be taken awTay and time be afforded for the formation of a firm involucrum: the only exception to this rule is found in those more severe cases of acute osteo-myelitis in Avhich an early removal is demanded in order that fatal exhaustion from profuse suppuration may be prevented. That such separation has taken place may generally be recognized by the mobility of the sequestrum when pressed upon through one or more of the cloaca;, though occasionally movement is prevented by the firm hold of the granulations upon the dead piece. Detachment from the living bone must then be inferred from the length of time that has elapsed. Though a non-infected sequestrum may in very rare instances be absorbed or remain shut in and innocuous for a long time, dead bone, as commonly met Avith, is an irritating foreign body, which must be got rid of either by spontaneous extrusion, by chemical solvents, or by operative removal before a healthy condition of the affected region can be secured. Small sequestra, especially superficial ones, may make their way to the surface and be thrown off, but the process is a very slow one. Treatment by the application of a dissolving fluid, such as dilute nitric or hydrochloric acid, is uncertain, tedious, and to be advised only in those rare cases in which the sequestrum is so placed that it cannot readily and safely be got at by operation. In the great majority of cases the removal of the seques- trum will be by operation—sequestrotomy. Sequestrotomy.—When practicable, the parts should be rendered blood- less by the Esmarch bandage, or, better, when the disease involves an extremity, by elevation for four or five minutes, followed by the application of the rub- ber band. If there is a cloaca large enough to permit of the introduction of a forceps, the dead bone is seized through it, and if of small size is dragged aAvay. When necessary the opening should be enlarged and the sequestrum divided before removal. When the necrosed piece is a large one it will generally be necessary to cut away with chisel or gouge a portion of the involucrum, it may be for nearly the entire length of the bone. The dead bone having been lifted out, the granulations in Avhich it has rested are to be thoroughly scraped awray, the parts well irrigated, the cavity stuffed with iodo- form or other antiseptic gauze, an antiseptic dressing applied, and the limb immobilized. When the involucrum is quite thin or imperfectly developed, it may be broken in the removal of the sequestrum, but repair, as a rule, readily and rapidly takes place after immobilization. Usually the progress of the case is very satisfactory: the cavity more or less completely fills up by the formation of neAv bone, and after a few weeks the patient can begin to use the part if, as is generally the case, the operation has been done on one of the extremities. Only rarely, and Avhen there has been great general Aveakness or Avhen the wound becomes infected, is the result a fatal one. If the gap in the bone is long and deep, much of the involucrum having been cut away, an effort should be made to fill it up, either by an organizable blood-clot, by bone- chips, by breaking doAvn and bending in the edges of the involucrum, or by skin-flaps turned in and attached at the bottom; preferably the first or second. In order that success may folloAv the adoption of any of these methods the wound must be made aseptic and kept so. THE CHEONIC INFLAMMATIONS OF BONE. The chronic inflammations of bone are generally such from the begin- ning. They are of much more frequent occurrence than the acute, and, like them, are of pyogenic, syphilitic, malignant, or tubercular origin. They are very rarely traumatic and unassociated Avith pyogenic infection, though, as is SURGERY OF THE OSSEOUS SYSTEM. 263 seen in the vertebrae pressed upon by an aneurysm, ulceration from prolonged, frequently-repeated injuries may take place. The prevailing type is the rarefying. Molecular death occurs to some degree in all cases; death in mass results chiefly in those due to syphilitic or pyo- genic infection; often extensive neAv formation, both in length and thickness, takes place in the syphilitic, and, to a certain extent, in the pyogenic. The diseases induced by the different causes are located by preference in different parts of the skeleton: thus, syphilis infects chiefly the long bones and those of the head and face; sarcoma and carcinoma, the long bones, the pelvis, and the jaws; pus infection, the long bones; tuberculosis, the bones of the hands and feet and the spongy tissue in close relation with the hip-, knee-, and elbow-joints. Children and adolescents are the ordinary subjects of osteo-myelitis, tuber- culosis, and inherited syphilis ; young adults, of sarcoma, acquired syphilis, and the relapses of the inflammations of youth; persons of middle and advanced life, of syphilis and cancer. Symptoms.—Pain is the most common symptom, its intensity, however, being very variable even in cases having a like origin. As a rule, it is worse at night, the increased fulness of the veins and capillaries due to the more sluggish circulation making greater the tension-pressure upon the nerve-fibers. It is aching, gnawing, boring, or, in tubercular cases in which there is inflam- mation of the subarticular layer of osseous tissue, starting. With or without the development of an abscess a sinus may form, through which more or less discharge may take place, the discharge being often gritty or having in it small yet readily detected spicules of bone, showing, as does the bone itself, that the affection is truly a caries or decay of the osseous tissue. When the inflammation is located upon the surface, examination by the eye, the finger, or the probe, or of the cleaned and dried specimen, shows that the process is an ulcerative one, producing an ulcer with all the characteristics of an ulcer of the soft parts; and the same is true, certainly as respects the process, when it is centrally developed. The granulations may be numerous and moist, as is commonly the case, or large and abundant with little fluid (fungous caries), or very feebly developed with no discov- erable fluid (dry caries), as in a few cases of syphilitic or tubercular origin. This caries sicca is frequently observed upon the skull and in the upper ends of the humerus (Fig. 52) and femur. The bone-destruction is often extensive, and in the long bones is due in a measure to the wearing effect of the pressure of contiguous parts. Not seldom its ex- istence is indicated only by impairment of function and by severe pain, very persistent, and irremediable except by removal of the diseased part. This form of osteitis, if left to itself, (1) may terminate in arrest of formation of the granulations, absorption or elimination of the dead tissue, and sclerosis of the new layers and of the parts around, with or without over- groAvth of the affected bone, Avhich when it occurs causes permanent alteration even to the extent, it may be, of marked deformity; or (2) may continue for a long time without material local change or the development of vis- ceral lesions; or (3) may often slowly but steadily advance, destroying more and more widely the bone, involving other portions of the skeleton, causing marked Caries Sicca, resulting in Absorption and Deform- ity of the Head of the Humerus. 264 AX AMERICAN TEXT-BOOK OF SURGERY. general debility, and inducing grave disease of internal organs, especially the lungs, the kidney, and the intestine. The treatment, in general, is made up of measures calculated to relieve irritation and to hasten the elimination of dead tissue—measures therapeutic and operative, considered in detail under the separate heads of the various classes of bone-inflammations, septic, specific, malignant, and tubercular. Tubercular Inflammation of Bone.—The most frequent and most typical of these inflammations is the tubercular, and is often secondary to some distant primary focus of the disease. Infected granulation-tissue forms more or less rapidly, showing, as a rule, comparatively few bacilli, and these chiefly in the new growths farthest from the point or points of original deposition; such tissue, by its pressure and after-caseation with its associated fluid, produces wast- ing of the osseous trabeculas. Caseation and liquefaction so affect the cells of the growth that, together with the altered layers of bone, they may be scraped away as grayish-yellow masses saturated Avith fluid. At times little or no fluid is to be seen, though the bone has become so soft as to be easily cut with a knife. Cavities, larger or smaller, few or many, filled with fluid degenerated cells and bone detritus, are of frequent formation (PI. XI, Fig. 2). In the long bones infiltration of the medulla of the central canal may occur throughout its length or be limited to a few distinct areas. Usually, however, the new growth is in the cancellous spaces of the extremities and in the Haversian canals, pushing toward the exterior of the bone. After the bone itself is involved, there is subperiosteal neAv forma- tion, which, if caseation has not occurred, may remain for a considerable time as a semi-solid mass, the adjacent bone and periosteum undergoing thickening and hardening. Sooner or later, and quite rapidly as a rule Avhen caseation has taken place, the periosteum is infected and destroyed, the adjacent soft parts become tubercular, and by one or several tortuous channels following the lines of least resistance the disease reaches the skin, the piercing of which com- pletes the formation of the sinus or sinuses. The Avails of such sinus, from its mode of formation, are necessarily tubercular, and its outlet is filled with granu- lations more or less exuberant, more or less dark-colored, readily bleeding when torn, and at times quite sensitive. A probe being introduced, often Avith much difficulty because of the flexures of the canal, softened, easily-penetrated bone may be felt, but its presence may escape detection because of the heavy granula- tion-layer covering it. The difference in the appearance of the external granu- lations, in the resistance to the probe offered by the bony Avails, and in the percussion note elicited by the probe (Avhich is here flat), enables one readily to distinguish caries from necrosis. When a circumscribed area of bone has broken doAvn and liquefaction of the caseated granulation-tissue in it has taken place, such a collection of fluid has long been spoken of as an abscess; and the same is true of the similar collections betAveen the periosteum and bone and in the overlying soft parts. But, though accumulations of a fluid in appearance much like pus, they are not, properly speaking, abscesses, since true pus is not present (unless it be a fact that at times the bacillus is a pyogenic organism) except Avhen a double or mixed infection has taken place. This is not often the case until a communica- tion with the external air has been established by the spontaneous or operative opening of the sinus. When such an opening has been made, the previously pent-up liquid, Avith its associated characteristic cheesy, curdy material, escapes, and the continuous development of similar fluid, now probably become puru- lent, keeps up the discharge. This varies in amount from a feAv drops to many ounces a day, and lasts indefinitely, Avith occasional temporary stoppages SURGERY OF THE OSSEOUS SYSTEM. 265 from blocking up of the canal at one point or another. Its complete arrest can be secured only by destruction of the infected area. This prolonged sup- puration, by the exhaustion and amyloid visceral changes which it induces, often has much to do with the production of a fatal termination. In consequence of plugging of the vessels necrosis may take place, the pro- duced sequestrum being often of considerable size. If centrally located in the cancellous tissue, it is surrounded by the infected granulations, and remains until removed by art or until, after a long time, it has broken dowm, when it may be discharged piecemeal. Often in the extremity of a long bone, because of the arrangement of the vessels which have been plugged by a tubercular embo- lus or by a thrombus resulting from the mural implantation of tubercle bacilli, it is conical in shape, its base directed toward the articulation; and to its presence may be due rapid involvement of the articulation in the morbid action. In its earlier stages the progress of tubercular osteitis is ordinarily insidi- ous, often the only symptoms of its existence being impaired function of the part, rigidity of the muscles about the neighboring joint, and pain in the affected area. The pain may be spontaneous or exist only as tenderness on pressure over the diseased spot, but it can ahvays be developed by such pres- sure. By the thermometer slight increase in the heat of the region may at times, or possibly always, be detected ; but a long-recognized peculiarity of this form of inflammation is the absence of any decided elevation of temperature. The appearance of the overlying skin is generally unchanged, even after infection of the superficial soft parts ; though, because of interference with the circulation by pressure, there may be some general discoloration or certain of the veins may become unduly prominent. Even up to the time of the establishment of a communication Avith the exte- rior the symptoms are far from severe, pain, SAvelling, and impairment of func- tion being present, but no decided constitutional symptoms, and the patient may go about as if in health. But Avhen septic infection has taken place all the local symptoms are aggravated and the constitutional ones become decided. The only disease with Avhich the affection is then likely to be confounded is protracted osteo-myelitis of pyogenic origin; and this, though more common than is often supposed, is far less frequently met Avith than tubercular osteitis, and seldom if ever attacks the parts of the skeleton Avhich are so often the seat of the latter disease—the vertebrae, the tarsus and carpus, the upper end of the femur, and the bones of the elbowT. It is largely to the prevention of sec- ondary pyogenic disturbances that the present favorable course and prognosis, as compared with those of but a few years ago, are to be attributed. Under any treatment, and especially under inefficient or no treatment, the course of the affection is ordinarily sIoav, occupying many Aveeks, it may be months. At any stage it may be arrested spontaneously (1) by removal of the diseased tissue, which is folloAved by condensation of the surrounding bone Avith or Avithout cicatricial obliteration of the cavity; or (2) by encapsulation of the infected tissue, Avhich permanently or temporarily protects the part. Aery often it is temporary, since recurrence frequently takes place. The treatment is mechanical, therapeutic, or operative—more frequently the first and second, but often all three methods, are employed either simultane- ously or successively. Mechanical treatment may be held to include all measures adapted to ensure rest of the diseased part, whether by position, immobilization, or the applica- tion of fixation apparatus of one sort or another. Rest is of prime importance at any stage of the affection, and is especially valuable in the earliest, Avhen it may be sufficient to bring about arrest of morbid action and more or less 266 AX AMERICAX TEXT-BOOK OF SURGERY. complete restoration to health. Simple confinement to bed may be all that is needed, or an immobilizing dressing—e. g. the plaster-of-Paris or a properly constructed and applied splint—may be required. Under such treatment, even when there has been much destruction of bone and "cold abscess" has formed, the symptoms may subside. This will be by absorption and contraction, it may be by calcification, of the tubercular masses, condensation in and around the carious area, and resumption of functional action; though, as a rule, there Avill be more or less impairment, more or less deformity, and an ever-existing danger of a recurrence of the disease. The therapeutic treatment is general and local. The former consists in the administration of remedies serving to improve nutrition and increase the general strength; and of these cod-liver oil has long been regarded as the most valu- able. The local treatment consists in the injection into and around the dis- eased center of agents calculated to destroy the infecting germs and produce condensation of the surrounding bone and of the uninfected new-formation layers, thus bringing about cicatrization. The remedies of this class that have proved of decided value are the acid phosphate of lime, the chloride of zinc, and iodoform; the latter of Avhich in ethereal solution, or, better, suspended in glycerin (10 per cent.) or in oil (5 to 25 per cent.), has been found of great value as a substitute for the operative removal of the morbid tissue, or em- ployed after it. These solutions are carried down by means of a syringe to and into the diseased area, and injected in small quantity, the injections being repeated every three, seven, or ten days according to circumstances. The real value of injections of Koch's tuberculin the future will determine. Operative treatment consists in the removal of the diseased area by scrap- ing or excision. Amputation is rarely demanded, at least in properly treated cases. Scraping, to be effective, must be thorough, and special care must be taken to clean away the walls of sinuses, to remove infected deposits in the medullary canal of a long bone, and in the foot and hand to leave no part of a softened bone (unless it be perhaps the shell of the os calcis, and this, as a rule, should be taken away). No associated tubercular growth in the tendon sheaths, the synovial pouches, or the superficial fascia or skin should in any case be allowed to remain. Ignipuncture by means of the thermo-cautery has been practised by a few surgeons with good effect. Cases of visceral tuberculosis are generally much benefited, and not seldom cured, by change of climate and altitude, and strumous children often rapidly improve at the seaside. Much good would unquestionably be effected, in the earliest stages especially, by sending patients Avith chronic bone disease to the coast, the highlands, or the pine Avoods. Chronic pyogenic osteitis is almost always the sequel of an acute osteo- myelitis that occurred, it may be, many years before, and is the cause of two very different conditions—abscess and overgrowth. It is usually circumscribed, and may be located in the medullary canal, or, much more often, in the can- cellous extremity of a long bone, especially in the head of the tibia or the lower end of the femur. It probably is due ordinarily to the neAvly-aroused activity of long-latent pyogenic organisms left over from an osteo-myelitis of childhood; but at times it may be consequent upon a new infection attacking parts less resistant than others because of their having previously been the seat of a septic inflammation, Rarefaction of the bone takes place in a limited area; condensation goes on around it, though rarely to the extent of producing necrosis, except, it may be, of very limited amount; pus may be almost altogether absent or may PLATE XII. Fu.. 1. ABSCESS IX THE GREAT TROCHANTER. FlG. 2. IMPACTED FRACITRE OF NECK oF FEMUR. SURGERY OF THE OSSEOUS SYSTEM. 267 be present in considerable quantity and form a chronic abscess in the interior of the bone (PI. XII, Fig. 1). This is especially frequent in the cancellated tissue in the lower end of the femur or in either end of the tibia. The most characteristic symptom is pain, severe, often intense, gnaAving or boring decidedly worse at night, limited to a small space, pressure over which is usualfy painful, sometimes because of associated periostitis, at times disappearing for weeks or months to reappear again, often without any apparent cause. °The bone is frequently decidedly enlarged as the result of its early inflammation or of the hypertrophying effect of the long-continued secondary osteitis. No treatment is of value except drilling or trephining, by which exit is afforded the pent-up pus, thus taking off the tension. Careful exploration with a long pin or fine drill, carried in various directions through different openings or from the sides of the trephine-well, should be made before deciding that pus is not present. Even if no pus can be found, relief is afforded and the so- called neuralgic condition is removed. Not seldom the pierced bone is abnor- mally dense. When pus is found it is wise not to be content Avith simple evacuation of the matter, but to scrape away the softened bone, letting the resulting cavity fill up or contract as it may, or, better, endeavoring to secure its rapid and complete closure by means of a blood-clot or bone-chips, for the success of which attempt complete asepsis is required. The overgroAvth from irritation resulting from this form of osteitis may affect a part or the whole of a bone. At times it is very great, producing marked deformity. Although a chronic process, it is very generally the result of the early osteo-myelitis, and the process never having been altogether arrested, it can hardly be considered a part of the phenomena of chronic pyo- genic osteitis unless there is joined with it the limited suppuration already con- sidered. OvergroAvth in length consequent upon the irritative action of a tubercular osteitis is at times observed, and has occurred after excision, par- ticularly of the lower articulating extremity of the femur, the region of the epiphyseal line not having been removed. Much more often after both tubercular and septic inflammations, Avhether an operation has been done or not, there is arrest of development, and as a result shortening, which in children is apt to be progressive up to the time of full maturity. Atrophy, evidenced by lessened solidity, thickness, or length, or by all of these conditions, is the necessary result of long-continued defective nutrition due to feebleness of the general circulation or to disturbed innervation of the part. It is a common phenomenon of chronic osteitis. It may be temporary, as after fracture, or permanent, as in infantile paralysis and in old age. It causes more or less impairment of the functional value of the bone and strongly predisposes to fracture. No special treatment is of value, unless it be the production of hyperemia, as by frequent applications for a limited time of the Esmarch bandage or by drilling the bone. RHACHITIS. (See Chapter xv., p. 81.) OSTEO-MALACIA (MOLLITIES OSSIUM, MALACOSTEON). This is a disease of adult life, and is very rarely met with in children or old persons. In the great majority of cases it affects Avomen, chiefly those Avho are pregnant or Avho have borne children. It is characterized by progressive soft- ening of the various parts of the skeleton, Avith resulting deformities (Fig. 53), usually goes on from bad to Avorse, and after it may be a number of years causes 268 AX AMERICAN TENT-BOOK OF SURGERY. the lungs. It has been attributed to the action of many causes, such as defective nutrition, excess of lactic acid, disease of the trophic nerves, ovarian and uterine changes, etc., but the real excit- ing cause is uncertain. The bone lesions are great increase of vascularity Avith re- sulting hemorrhages, degenera- tion of the medulla and its ulti- mate conversion into a pulp re- sembling splenic tissue, absorp- tion of the lime salts, destruction of the trabeculse, formation of cavities or more rarely tumor-like enlargements, and absorption of the cortical layers. The perios- teum is ordinarily thicker and more vascular than normal, and serves as a pro- tective envelope to the broken-down bone. Fracture from muscular action or from slight movement is of frequent occurrence, and deformity to a greater or lesser extent is sure to be produced in other than the mildest cases, the distor- tion at times becoming excessive and most peculiar. Until such deformity has occurred, or until at least the softening has advanced so far as to permit of bending of the bone, the diagnosis is difficult and uncertain, since the progress of the disease is for a considerable time an insidious one. The early-developed and persistent pain ordinarily causes the affection to be regarded as rheumatic, but the multiplicity of the painful areas, the sex of the patient, the existence of pregnancy, and the presence of large quantities of the lime salts in the urine, should direct attention to the probable existence of osteo-malacia. Though commonly for a time not exerting any unfavorable influence upon life, and occasionally ceasing to advance, even being recovered from, though very rarely, its prognosis is grave, the disease usually ending fatally. Medi- cal treatment by the use of phosphorus and the phosphates, the lime salts, cod- liver oil, etc. has proved of little or no value. The best possible hygienic surroundings should be secured and the patient kept quiet and free from pain. Proper retentive dressing should be applied to prevent fracture and lessen deformity. Of late in a feAv cases the ovaries and uterus have been removed Avith reported decided benefit. When this operation is not done, pregnancy should be prevented, as childbearing exerts a powerful and deleterious influence upon the progress of the disease. FRAGILITAS OSSITJM. Abnormal brittleness due to rarefaction and predisposing to the occurrence of fracture upon the infliction of slight violence is sometimes observed in cases of syphilis, of malignant tumors, and of trophic disturbances after injuries of bones and joints necessitating long confinement. It is also seen in the earlier stages of rickets, in general paralysis, and in tabes. But, besides this condition, which is a sequel of disease, there is at times seen a pure and simple fragility, accompanied, so far as can be discovered, by no pathological clianges, general or local. This fragilitas ossium is. as a rule, an inherited peculiarity manifest- Deformed Pelvis from Osteo-malacia. SURGERY OF THE OSSEOUS SYSTEM. 269 ing itself in infants (even in the foetus in utero), in children, and in adolescents, and ceasing to exist when full maturity is reached. Fracture after fracture in one or in several bones or in many parts of the skeleton occurs, presenting the usual Fig. 54. symptoms and followed by rapid recovery. As the cause is unknown, nothing can be done further than to protect the individual from inj ury as much as possible, and to treat the fractures in the usual Avay. SYPHILIS OF BONE. (See Syphilis.) TUMORS OF BONE. Bone tumors, like tumors of other parts, are benign or malignant; the former being commonly exostoses, fibromata, or chondro- mata, the latter sarcomata or carcinomata. Exostoses are homologous outgroAvths differing from hypertrophies in that but a limited part of the circumference of the bones is involved. They are either spontaneous, and appear first during the period of devel- opment, or are symptomatic of osteitis, trau- matic or non-traumatic, usually syphilitic. They are located chiefly upon the long bones, the skull, or the maxillae, and are generally cancellous in structure, but at times compact, even of ivory hardness ; this is particularly true of the syphilitic exostoses of the skull. When developmental, originating in child- hood, though the outgroAvths may be found upon any part of the skeleton, even upon many and generally symmetrical parts at the same time (Fig. 54), they are commonly in connection with a long bone near its epi- physeal line. If primarily upon the dia- physeal side of the cartilage of conjunction, they may apparently be carried upAvard as the shaft elongates, so as ultimately to occupy a level much above the articular extremity. They may be either broad-based or pedun- culated, and not seldom the free extremity is covered by a bursa resulting from friction or the separation of a part of the synovial sac in the outgroAvth of an originally subsynovial spur. Their growth ceases, as a rule having few exceptions, at or before the twenty-fifth year. The diagnosis is commonly easy, the tumor being hard and fixed and readily felt or seen. Pain is seldom present, and whatever local damage results is from pressure causing atrophy or ulceration of the overlying soft parts (and this is not of common occurrence) or from position interfering with the free use, especially with flexion, of the limb, as in sitting or riding. In a large Exostoses of Various Dimensions. 270 AN AMERICAN TEXT-BOOK OF SURGERY. proportion of cases no serious inconvenience is experienced. When the mass is upon the inner side of the skull (of diploic origin, as a rule), a resulting compression of the brain may give rise to serious cerebral disturbances, but often no appreciable effect is produced, and the existence of the tumor is not discovered until after death. The only effective treatment is operative, removal of the growth, or the breaking of it off, the former being preferable, the latter practicable only Avhen the attachment is by a pedicle. In many cases no treatment is required. Fibromata.—Springing from the periosteum or, much less frequently, cen- tral in origin, the fibrous tumors of bone are found generally in connection wTith the maxillge and the base of the skull, though they are occasionally located upon the vertebrae, the pelvis, or the long bones. When of long standing they are likely to undergo degeneration, fatty, cystic, or, particularly, calcareous, rarely becoming ossified. Not seldom they are either primarily or secondarily mixed in character—fibro-sarcomata, fibro-chondromata. Their development is slow, and they often cease to enlarge about the time Avhen the skeleton has reached full maturity, after wThich they may atrophy, or even completely dis- appear. If superficially placed they can generally be readily diagnosticated by their more or less irregular contour, their firmness but not bony hardness, their evident close connection with bone, and their gradual enlargement. The most common of these growths are the naso-pharyngeal polyp and epulis, both of which are often decidedly sarcomatous. The former is a disease of adolescence. It originates from the under surface of the sphenoid, fills up the naso-pharynx, pushes into the nasal fossa? and the antrum on one or both sides, and, it mav be, outAvardly through the spheno-palatine foramen, causing extensive destruction of the bones of the face by pressure. It is dangerous because of the attending hemorrhages, which, as a rule, are profuse and frequently recurring. The cha- racter of the central tumors, which are often cystic, will not be recognized so long as they are surrounded by a bony envelope, and usually is not determined until after their removal. Treatment.—Extirpation, preferably by enucleation or, when this is not practicable, by excision of the portion of the bone to which the growth is attached, is the proper treatment, though, as has been stated, nature some- times affords relief through atrophy. The naso-pharyngeal polyp, if not rapidly growing or often bleeding, may be let alone in the hope of spontaneous disappearance when the patient shall FlG 55 have reached the age of tAventy- P.^^ jga five years or a little more; but jWPjQfBLa^ m the majority of cases the risk djL SyStfjwJIk 0I" death from exhaustion conse- 'T-w-J^eJik jBKMMWfkn^m °iuent upon repeated hemorrhage T|T'"IM BJUbwmm^^ #\jpr w*^ forbid such delay. (See f,,. „ ,^^-^^\|wQ \ JPH|| he expected, the cartilaginous are \[ W^y^^^ the most common of the benign nr„iHr^ Phm^mm„*. t >u rr * osseous tumors, their chief places Multiple Chondromata of the Hand. ' . \ of election being the long bones (in their extremities) and those of the hands and feet (Fig. 55). They may be either peripheral or central, and are not seldom mixed in character, the addition of sarcomatous elements being particularly frequent. Even when microscopical examination has apparently shoAvn them to be pure chondromata SURGERY OF THE OSSEOUS SYSTEM. 271 they have at times the characteristics of malignant groAvths, in so far as they recur after removal and by transference of their cell-elements develop visceral disease in the lungs, the liver, or the spleen, especially the first. It is possible, however, that these are examples of mixed tumors, all portions of which had not been subjected to examination. The more nearly their histological struct- ure approaches that of embryonic cartilage, the greater is the liability to sec- ondary manifestations. Traumatism is often an exciting cause. Their groAvth is generally slow; they frequently become cystic, and always tend toAvard destructive changes both in their own tissues and in the part in which they are developed. The overlying skin may be unaffected for a long time, but ulti- mately becomes ulcerated, and a sinus is established communicating with the breaking-down tumor-mass. As a rule, they are not painful except when there is involvement of or pressure upon adjacent nerves, either of which is comparatively rare; but by their presence they may interfere Avith free muscular or articular movements. If externally located, as upon the hands or feet, their diagnosis is easy: when upon the long bones it can be made as a strong probability if regard is had to their position, their slow growth, their elastic firmness, Avhich though decided is not that of bone, and their irregular contour. When softened or cystic their nature may be misunderstood until after incision or puncture. When of mixed sarcomatous character, because of rapid growth and associated consti- tutional weakness they may be readily mistaken for osteo-sarcomata—a mistake, however, of no practical importance, since the treatment of the tAvo affections is the same. The central growths cannot be recognized until they have reached considerable size, and even then their character will not generally be deter- mined before removal. The only treatment of value is operative, the growth being removed either by itself when it is external and pedunculated, or with a part or the whole of the bone in which it rests; in other words, by taking it out and scraping away Fig. 56. Osteo-sarcoma of the Femur. the tissue immediately about it, by excision of the diseased portion of the bone, or by amputation. Malignant Tumors.—The malignant bone-tumors are either carcinoma- tous or sarcomatous. The former are comparatively rare and always secondary ; the latter are of frequent occurrence and primary, except when following upon 272 AX AM ERIC AX TEXT-BOOK OF SURGERY. like disease of the adjacent soft parts or upon melanotic sarcoma. Unlike osteo- carcinoma, osteo-sarcoma is a disease of early life, even of infancy and childhood, only a very small proportion of the cases observed occurring in individuals over forty years of age. Histologically, it is of three varieties—round-celled, spindle-celled, and giant-celled; locally, there are two varieties—central and peri- osteal. Its malignancy structurally is in inverse proportion to the size of the cells, being greatest in those tumors made up of small round and spindle cells, least in those composed chiefly of giant cells. As respects location, Avhen originally external it progresses more rapidly, has earlier and more frequently secondary visceral manifestations, and is more certainly fatal than wrhen inter- nal. It especially affects the maxillae and the long bones; of the latter, those of the lower extremities much oftener than those of the upper. The adjacent ends of the femur and tibia are the most common sites (Fig. 56). Local injury is a strongly predisposing cause. Osteo-sarcoma affects a neighboring joint comparatively seldom, even at times passing outside the articulation from one bone to another. Often the bone in Avhich it is situated is so weakened by it that spontaneous fracture occurs, and this is occasionally the first indication of its existence. Its rate of growth is variable, though with rare exceptions it is rapid as compared Avith that of the benign tumors. The size Avhich it may attain is usually not great, but is occasionally enormous. The central growths, AAhich, speaking generally, are giant-celled at the extremities of the long bones, and round- or spindle-celled in their shafts, have for a time an osseous envelope, so thin in some cases as to yield and crepitate on pressure, and later a complete or partial osteo-periosteal capsule. This is not the case Avith the external growths, the lim- iting Avail of which is periosteum until that membrane has become involved and the disease has pushed through it into the adjacent soft parts. The vascularity of the internal tumors may be so great as to render them pulsatile, apparently aneurysmal. Without doubt nearly all the reported cases of aneurysm of bone have been sarcomata of this character. Hemorrhage into the substance of the tumor is of frequent occurrence, and degenerations, fatty, cystic, and, especially in the periosteal growths, calcareous or to a greater or lesser extent bony, commonly take place. Dissemination, Avith resulting disease of remote parts, bony or visceral, is chiefly by Avay of the blood-vessels, affections of the lymphatic glands being infrequently observed. When present it is in large measure only irritative in character. The chief symptoms are pain, Avhich is seldom absent, and at times is intense; SAvelling, Avhich is recognized early in the external, but much later in the internal variety; it is globular, pear-shaped, or conical near the end of a. long bone, spindle-shaped upon the shaft: and increased heat, as determined by the hand or the surface thermometer. There is little or no impairment of the joint motions for a considerable time. The diseases Avith Avhich it is most likely to be confounded are rheumatism, because the pain is usually in the neighborhood of a joint, and tubercular dis- ease, because of the location of the SAvelling. But, taking into consideration the age of the patient, the non-existence of other evidences of any diathetic affection, the absence of joint disease, the firmness of the growth, especially in its earlier stage, the rapidity of its enlargement, and the local temperature- changes, a strongly probable, if not absolute, diagnosis can usually be readily established. Puncture or exploratory incision may be made if necessary. It may also be mistaken for an abscess. The treatment to be effective must be radical, the affected bone being removed, or in an extremity amputation being done at or above the nearest FRA CTURES. 273 joint rather than in the continuity of the bone, except in cases of central giant- celled growths in the loAver end of the bones of the leg or of the femur. When necessity seems to demand disarticulation at the hip, it is very questionable if any operative interference should be resorted to, in view of the risks of the amputation and the almost absolute certainty of an early recurrence of the disease in the stump or viscerally. After amputation other than at the hip the probability of reappearance is strong: even in the least malignant variety, the central giant-celled, it occurs in about one patient out of five. ACTINOMYCOSIS. (See p. 131.) CHAPTER III. FEACTURES. Definition.—The sudden, forcible destruction of the continuity of a bone, in whole or in part, except when done Avith a cutting instrument, is called a fracture. A simple fracture, in the common use of the term, is one that is not compound (see below); a spontaneous fracture is one produced by very slight violence; a pathological fracture is one made easy by partial destruction of the bone by disease; an ununited fracture is one in which bony union has not yet taken place after the lapse of a period of time that is usually sufficient for repair. The injury is a common one ; it occurs about three times as frequently in males as in females, but the proportion varies at different ages: in infants and between the ages of fifty and seventy years both sexes are about equally affected; in middle life fractures are ten times as frequent in men as in women ; and after the age of seventy women are much more frequently affected than men, the commonest fracture then being that of the neck of the femur. The majority of fractures occur in the first and third decades of life, but if the number of people living at the different ages be considered, the greatest rela- tive frequency will be found at about the age of sixty years. The following table shows the relative frequency of fractures of the dif- ferent bones. The italics mark bones with more than 10 per cent.: Fractures Treated in the London Hospital, 1842-77. Hospital Skull....... 730 Face....... 732 169 139 5 Ribs....... 4784 Sternum..... 45 Scapula..... 135 382 1064 Forearm .... 709 856 Thigh .... 3072 Patella..... 649 8067 Foot....... 965 22,503 18 Out-' patients. Total. Per cent. Number by Regions. Per cent. 27 757 1.457 \ Head, "» ( 2,002. / 3.854 513 1245 2.397 3 172 0.331 ] 3 142 0.273 10 15 0.028 1 Trunk, ) [ 9,067. \ 3477 8261 15.905 17.457 7 52 0.100 290 425 0.818 7458 7840 15.094 1 3020 4084 7.863 I Upper extremity, \ |" 27,119. / 52.214 8731 9440 18.175 4899 01 -)0 11.080 J 171 3243 6.243 1 15 664 1.278 1 Lower extremity, \ 0« ATi 256 8323 1H.024 f 13,750. / " 555 1520 2.926 J 29,435 , 51,938 274 AX AMERICAN TENT-BOOK OF SURGERY. Varieties.—The varieties of fracture are numerous, the differences depend- ing upon the extent, direction, and seat of the fracture, the number of bones involved, the associated injury of the soft parts, and the character or mode of action of the causative violence. They may be grouped as follows : 1. Incomplete fractures. (a) Fissure. (b) True incomplete fracture, "green-stick" fracture. {c) Depressions. {d) Separation of a splinter or of an apophysis. 2. Complete fractures, subdivided, according to— {a) Direction of the line of fracture, into transverse, oblique, longi- tudinal, toothed, V-shaped, T-shaped; {b) Seat of the fracture, into fracture of the shaft, neck, condyle, etc., separation of the epiphysis; (c) Relations to neighboring joints, into intra-articular, extracapsu- lar, intra-capsular; (d) Mode of production, into fractures by direct violence, by indirect violence, by muscular action ; (e) Number of fractures or of bones fractured, or the extent and character of the crushing, into multiple, comminuted, impacted, and fractures with crushing. 3. Compound fractures, including, as a special class, Gunshot fractures. 1. Incomplete Fractures.—This class includes fractures of long bones in which the continuity of the bone has not been entirely lost, and fractures of the flat bones in which the line of fracture does not extend completely across the bone or through its entire thickness. Fissure, ox fissured fracture, is a split or crack of limited extent; the most frequent examples are in the bones of the cranium and in connection with complete fractures of other bones. True incomplete, or "green-stick," fracture is one involving part of the thickness of a long bone, and accompanied by some longitudinal splitting and by a permanent bending of the unbroken portion. Possibly Fig. 57. in some cases there is only permanent bending Avithout visible fracture. It occurs in the young, and especially in the clavicle and forearm (Fig. 57). In correcting the deformity, which is best done by bending the bone in the opposite direction, the fracture is frequently made complete. Depression is the crushing of a portion of the thickness of a bone; it perhaps belongs more properly among " wounds of bone'' than among fractures. The class also includes certain rare "fractures by depression," in which by the forcible bend- ing of a flat bone a fragment is broken from the side toward which the bone is bent, as in isolated fracture of the inner table of the skull: it does not include " depressed fractures of the skull," in AAhich the entire thickness of the bone is broken. Separation of a Splinter or of an Apophysis.—Direct violence, as by a bullet or a swwd, may break off a piece Pastick fracture witnout completely fracturing the bone, "or the violent con- of the Radius. traction of a muscle or a strain exerted through a ligament may tear off a scale of bone or an apophysis to which the tendon or ligament is attached. FRACTURES. 275 Fig. 58. Fig. 59. 2. Complete Fractures.— (a) Subdivided according to the Direction of the Line of Fracture.—The fracture is termed transverse (Fig. 58) if its line is exactly or nearly transverse to the long axis of the bone and regular; longitudinal (Fig. 59) if it runs for a considerable distance more or less ex- actly parallel to the long axis; oblique (Fig. 60) if its direction is intermediate betAveen the two preceding. The divis- ion is of course someAvhat arbitrary. The fracture is termed toothed or dentate (Fig. 61) if its line is broken by sharp points and depressions, which may con- stitute a serious obstacle to complete reduction. V-shaped fracture of the tibia (Fig. 62) is characterized by a prominent triangular projection at the lower end of the upper fragment on its inner aspect; its especial importance, other than the occasional difficulty of reduction, is due to a fissure which may extend from the cor- responding re-entrant angle on the lower fragment dowm to the ankle-joint. T- shaped fractures are found at the loAver end of the humerus and femur, and are sometimes termed intercondyloid (Fig. 63): there is a transverse line of frac- ture above the condyles, and a longitudinal one running from the transverse line downward between the condyles. (b) Subdivided according to the Seat of the Fracture.—The fracture receives a name indicative of the portion of the bone involved in it: thus, fracture of the shaft, of the neck, of a condyle, or of a specific process, as the Transverse Frac- ture of the Fe- mur. Longitudinal Fracture of the Tibia. Fig. 60. Oblique Fracture of the Clavicle. malleolus, greater tuberosity of the humerus, olecranon. The term separation of an epiphysis also indicates that the fracture lies wholly or mainly at the cartilaginous junction betAveen the epiphysis and the shaft; this variety is found, of course, only in persons Avhose growth is not yet complete; that is, as a rule, only in those who have not yet reached the age of twenty-four or tAventy-five years; the date of consolidation of the epiphysis Avith the shaft varying Avith the sex, the individual, and the different bones. Separation of the epiphysis is more easily effected than a fracture of the same bone by cross- strain : the periosteum is usually stripped up from the shaft for a considerable distance, varying Avith the displacement, and remains attached to the epiphysis. 276 AX AMERICAX TEXT-BOOK OF SURGERY. The injury is of especial importance because of frequent difficulty of reduction, and because the irritation of the traumatism may lead to premature ossification of the cartilage, with consequent local arrest of growth. This consideration is Fig. 61. of most importance at the knee, the upper end of the humerus, and the lower end of the radius and of the ulna, where the principal growth in length of the respective bones occurs. (c) Subdivided according to the Relations to Neighboring Joints.—The term intra-articular indicates that the line of fracture extends into a joint—a complication that is important because of the possible inflammation of the joint and of possible change in the relations of the fragment, either of which may permanently restrict the mobility of the joint. Intracapsular and extra- capsular are terms used almost solely in connection with fractures of the neck of the femur to ihdicate the position of the line of fracture within or Avithout the attachment of the capsule to the femur. (d) Subdivided according to the Mode of Production.—Fractures by direct violence are those in which the fracture takes place at the point where the blow is received; fractures by indirect violence are those in which it takes place at a distance from that point; fractures by muscular action are those in which the fracture is produced by the action of the patient's muscles. (e) Subdivided according to the Number of Fractures or of Bones Fractured, or to the Extent and Character of the Crushing.—The term multiple indicates two or more separate fractures of a bone, or the fracture of two or more bones other than the tibia and fibula or the radius and ulna of the same limb. A comminuted fracture (Figs. 64 to 67) is one accompanied by considerable splintering of the FRACTURES. 211 Fig. 65. Fig. 64. Fig. 66. Comminuted Gunshot Fracture of the Head of the Humerus, with Impacted Ball. Comminuted Perforating Gun- shot Fracture of the Head of the Humerus. Comminuted Fracture of the Lower End of the Radius, palmar aspect. An impacted fracture is Fig. 67. bone, which is broken into several small fragments. one in which one main fragment is driven into and firmly fixed in the other, Avhich is commonly the expanded spongy end of the bone; the spongy portion into which the other fragment is driven is necessarily more or less crushed thereby, and if the crushing and splintering are such that the entering piece is not firmly impacted, the fracture is said to be one with crushing (Fig. 69). Both conditions are more common in advanced life, and, as the crushing amounts to an actual loss of sub- stance, some deformity must persist. 3. Compound Fractures.—A compound fracture is one Avhich communicates with the exte- rior through a Avound of the overlying soft parts. The latter Avound may be directly caused by the same violence that produces the fracture, as in the passage of a wheel of a Avagon across the leg, or it may be made from wdthin outward by the forcible projection of the end of one of the fragments through the skin; or a simple fracture may become compound through sloughing of the soft parts occasioned either by bruising inflicted at the time of the accident, or by the pressure of a displaced fragment, or through careless handling, or by the movements of the patient while delirious. The injury is much more serious than a simple fracture, because of the possibility of infection of the wound, with its train of consequences—suppuration, necrosis, failure of union, septicemia, and loss of limb or life. Excluding the hand and foot, compound fractures, accord- ing to Gurlt, are most frequent in the leg, being 17.96 per cent, of all com- pound fractures; those of the forearm form 11.68 per cent.; those of the femur, 7.05 per cent. ; those of the humerus, 6.66 per cent. The prognosis is serious in compound fractures by direct violence, because the soft parts are usu- ally so bruised and lacerated that primary union cannot be obtained ; A\Thereas in fractures by indirect violence in which the wound of the skin is made by the end of a fragment the prognosis is much better, for the Avound is generally small Comminuted Fracture of the Neck of the Femur. 278 AX AMERICAN TEXT-BOOK OF SURGERY. and clean, and if properly treated will usually unite promptly, and the fracture will thus be transformed into a simple one. The diagnosis of the compound character of a fracture, when in any doubt, may be made in case of necessity by careful exploration of the wound Avith the purified finger, but usually, and especially whenever the wTound is small and bruising or laceration is absent or slight, it is better to abstain from completing the diagnosis by any measures that may increase the chance of infection, and to direct all efforts to obtaining the prompt disinfection and closure of the wound. Gunshot fractures (Figs. 64, 65,68) constitute an especially severe form of compound fractures because of the usually extensive comminution and Assuring of the bone, the bruising of the soft parts along the track of the bullet, and the greater frequency of associated injury of important blood-ves- sels and nerves. A small bullet may make a clean perforation with but little splintering; a large one literally smashes the bone at the point of contact and produces fissures that may extend to a great distance; the bullet may pass completely through the bone or may lodge in it. In fractures produced by a charge of shot the associated laceration of the soft parts is usually the dominant feature of the case. Amputation and excision have been the rule in the past, and discussion has turned mainly on the respective merits of primary and second- ary operations. Antiseptic surgery has not yet been put to a sufficient test in war to determine fully the extent to AAhich it will modify previous rules of treatment, but it will undoubted- ly avail to save a much larger proportion of limbs and lives. In civil practice it has been clearly shoAvn that suppuration and infection can be prevented in a large proportion of bullet wounds, and that the removal of the bullet is not a necessary preliminary to successful treatment. The guiding principle is to abstain as far as possible from exploration of the Avound with probe or finger, to disinfect it thoroughly by antiseptic washing, and to seek its prompt healing under a single dress- ing combined with measures to immobilize the fracture: this failing, counter-openings, drainage, and irrigation to meet the needs created by suppuration. Displacements.—The folloAving six classes comprise the common changes in the relations of the principal fragments,— the name indicating, in all but the fifth, the direction in which the change has taken place: 1, transverse displacement; 2, Gunsnot Fracture of _„„i„„. o ,„j.„„ .1 -i- r • ■• 1 • the Humerus. angular; 6, rotary ; 4, overriding ; 5, impaction or crushing; 6, direct longitudinal separation. Commonly two or more are associated in any given case. Transverse or lateral displacement may take place in any direction at right angles to the long axis of the bone, and may be complete or partial. In angular displacement one fragment deviates obliquely from the line that represents the normal relation of its long axis to that of the other fragment. In rotary displace- ment one fragment has been separately turned about its long axis. In overriding, the upper and loAver ends of the bone are brought nearer to each other by the passage of the broken surfaces past each other: it is common in oblique frac- tures, and is necessarily associated Avith some transverse displacement, and usu- ally Avith angular displacement. In impaction or crushing (Fig. 69) the bone is shortened by the forcing of one fragment into the other, or in spongy bones an angular displacement is effected by the crushing of the bone at the angle on FRACTURES. 279 the side toward AvTiich it is bent. Direct longitudinal separation is most com- monly seen after fracture of the patella and olecranon, and is then due to the contraction of the attached mus- cle ; but it may be produced after fracture of the humerus by the unsupported Aveight of the lower part of the arm and the forearm. Displacement may be caused at the time of the accident by the force which produces the frac- ture, or subsequently by the ac- tion of gravity or of the attached muscles upon the fragments. The tonicity of the muscles and their contraction Avhen excited by pain habitually tend to produce angu- lar displacement, and overriding when the character of the displacement per- mits it. (See Figs. 58 and 60.) Etiology.—1. Predisposing Causes.—These are of two kinds, normal and pathological. Normal predisposing causes are found in the shape, struc- ture, and functions of the different bones, with such modifications as are pro- duced by advancing years. A long bone is exposed by its very length, as well as by the uses Avhich that length subserves, to fracture by indirect violence, by cross-strain, or by torsion ; length is to that extent a predisposing cause. A short bone or the spongy end of a long one is fitted by its texture and its breadth to receive and transmit violence with the minimum of damage to the bone Avith which it is in contact, but the same texture and breadth expose it to easy crushing and splintering when the violence is unusually great or is abnor- mally directed. To that extent its spongy texture is a predisposing cause. The normal curves found in so many long bones, and the transformation of the segments of a limb into the equivalent of a single sharply-bent bone by the rigidity of the strongly-contracted muscles, tend to diminish the risk of dangerous violence to the trunk and viscera in a fall, but in thus protecting vital organs they become themselves more exposed to fracture. As age advances the bones become more fragile by rarefaction of their spongy and compact tissue: the change is an actual diminution of the amount of bone-tissue in the bone, not an alteration in the proportions of the different elements that compose that tissue; there appears to be no increase in the amount of the earthy matter, either actually or relatively. As an habitual incident of advanced age this senile atrophy may be deemed a normal predisposing cause, but Avhen it appears prematurely or in an excessive degree it is patho- logical. Such premature and excessive fragility, dependent upon causes that are not always understood, may be inherited or acquired. Cases have been reported in which successive generations have shoAvn remarkable liability to fracture from infancy; in one instance a child received fourteen fractures before he Avas thirteen years old. In other cases some or all of the children of a family have shoAvn it, the parents being free from it; thus, a girl suf- fered thirty-one fractures betAveen the ages of three and fourteen years, and her sister nine betAveen the ages of eight months and six years, Avhile tAvo brothers and a third sister shoAved no such predisposition. The cases are much more numerous in which a similar liability to fracture has developed later in life, the bones breaking tinder the slightest violence or muscular effort. Such fractures commonly unite within the usual time. Post-mortem examina- Fig. 69. Fracture of the Calcaneum, with crushing. 433732 280 AN AMERICAN TEXT-BOOK OF SURGERY. tion has shown great thinning and rarefaction of the bone. Fragility may be developed by disuse, as in limbs that have remained dislocated, and in conjunc- tion with certain diseases of the nerve-centers. Rhachitis is a predisposing cause in childhood, through the incomplete development of the bone-tissue to wThich it leads, the bone remaining spongy instead of developing a firm, com- pact, cylindrical formation. Syphilis, cancer and other tumors, and caries may predispose to fracture by destroying a portion of the bone. Rheumatism has been alleged to be a predisposing cause, because some patients have suffered aching pain in certain bones for some time before they have broken under slight violence or, more commonly, by muscular action. The widespread disposition to call such pains "rheumatic " accounts for the supposed connection. Fracture of the patella is not infrequently preceded by such pain, which seems possibly to be evidence of previous slight injury or partial fracture. 2. Immediate or Determining Causes of Fracture.—The immediate cause of a fracture may be violence received at some point upon the surface of the body, or exerted upon the bone that is broken by the muscles that are attached directly or indirectly to it. The former are termed fractures by external vio- lence, the latter fractures by muscular action. The latter class does not include cases in which, while the causative force originates in the contraction of the patient's muscles, an additional and essential factor is created by external resist- ance, as in the breaking of the leg by a sudden turn or fonvard movement of the body while the foot is held fast, or of the arm by striking it against some obj ect. Fractures by external violence are divided into two classes which have important clinical differences—those by direct and those by indirect violence. Fractures by direct violence are those in which the bone is broken at a point corresponding to that upon the surface where the blow is received; fractures by indirect violence are those in Avhich the bone is broken at a distance from the point where the bloAv is received. An important clinical difference is that in the former the overlying soft parts are contused, and often to such an extent that the fracture is or soon becomes compound, and primary union of the wound is difficult or impossible; in fractures by indirect violence the injury to the soft parts is habitually less, and if the fracture is compound the edges of the wound in the skin are not so contused that primary union is difficult to obtain. Fractures by muscular action are most common at the patella, the bone being broken by the powerful contraction of the quadriceps; in other cases the muscles produce the fracture by exaggerating the normal curve of the bone, as the humerus or femur in spasmodic or voluntary contraction, or the ribs in coughing, or the sternum in straining during labor; or by tearing off an apophysis to Avhich the muscle is attached, as the coracoid process or the pos- terior end of the calcaneum; and in others by creating in portions of the body conditions of momentum Avhich act in the same manner as external violence, as in fracture of the humerus by throwing a stone, of the femur by kicking at, but not striking, an object, of the neck in throwing the head back. Symptoms and Diagnosis.—Before proceeding to the examination of the injured region inquiry should be made into the circumstances connected with the injury, and the question should always be asked if the part has been pre- viously injured, in order that an old deformity may not be mistaken for a recent one. 1. Objective Symptoms.—Deformity.—Under this term are included changes in the appearance of the injured region, in the dimensions of the limb, and in the relations of different bones or parts of bones to one another. Swelling occurs promptly, and is often associated with heat and redness. FRACTURES. 281 Ecchymoses appear rather tardily in fractures by indirect violence, and usually at some distance from the seat of fracture. Large blebs, containing a liquid that is at first yellow and later bloody, sometimes appear during the first or second day, especially in fractures of the leg and forearm. Most of the various displace- ments that have been above described may be readily recognized by the eye or finger when the bone is not thickly covered by soft parts; angular displace- ment is often shoAvn by a change in the direction of the segments of the limb ; and overriding or impaction is demonstrated by measurement of the length of the bone or of the limb. When the tAvo ends of a bone can be readily recog- nized, as those of the forearm or leg, its length can be directly measured, but in fractures of the femur or the humerus it is necessary to measure from points on other bones, the ilium and the acromion respectively; and then it is essential to accuracy that the injured limb and its felloAV with which the comparison is made should be symmetrically placed with reference to the bone on which one of the fixed points is taken. 'Two other possible sources of error in measuring should always be borne in mind : one is previous injury or disease that may have affected the length of either limb ; the other is the normal inequality in the length of the limbs Avhich exists in many people; this rarely amounts to more than a quarter of an inch, although it may reach an inch or more, and its existence is usually unknoAvn to the individual until revealed by measure- ment. By abnormal mobility after fracture is meant the independent mobility of the fragments of a fractured bone Avhich is normally one unbroken structure, or the mobility of a joint in an abnormal direction or to an abnormal extent in consequence of the fracture of a portion of the end of one of the bones that constitute it. It is usually present and recognizable with great ease when the fracture occupies the shaft of a long bone, but it may be absent or unrecog- nizable when the fracture is close to the end of the bone. It is habitually accompanied by a sensation of grating which may be heard or felt, and which is technically knoAvn as crepitus. This is produced by the rubbing of the broken surfaces upon each other. Abnormal mobility and crepitus are pathognomonic of fracture, but it must be remembered that in not a feAv fractures either or both are absent or unrecognizable, and that failure to obtain them is not a proof of the non-existence of a fracture. Furthermore, the manipulations necessary to recognize them are, in some cases, actually harmful, and the diagnosis must be made on other symptoms. 2. Subjective Symptoms.—These are chiefly diminution or loss of func- tion, and pain. The history of the case is also of much value. The extent of the interference with function depends upon the importance of the broken bone to that function, the relations of the fragments to each other, and pain or fear of pain. After fracture of the thigh or leg the patient is, as a rule, entirely unable to walk or to lift the limb from the bed when he is recumbent, but, on the one hand, the disability may be much less, and, on the other, equal disability may be caused by a simple contusion. Pain, either spontaneous or aroused by pressure or movement, is a constant accompaniment of fracture, and when limited to a small area and invariably aroused by pressure with the end of the finger or by slight movements communicated to the limb, is a valuable sign of fracture—one upon Avhich a diagnosis of fracture in certain regions can be safely made Avhen the history of the accident indicates that such a fracture may have been produced. The examination should be made quietly and systematically; movements communicated to the bone in the search for abnormal mobility and crepitus should be slight and gentle, and if the muscles are spasmodically contracted, 282 AX A3IERICAX TEXT-BOOK OF SURGERY. or the patient timid, or the injury obscure and of doubtful character in the neighborhood of a joint, an anesthetic should be employed. Repair of Fracture.—In simple fractures there is at first some rise of temperature, the limb SAvells promptly, blebs sometimes appear on the surface, ecchymoses and yellow discoloration of the skin extend to a considerable dis- tance : then the SAvelling subsides, and a firm ovoid mass, which is tender on pressure, can be felt about the seat of fracture. This gradually groAvs smaller and harder and the abnormal mobility diminishes. After a lapse of time, the length of Avhich varies Avith many conditions, abnormal mobility entirely disap- pears and the fracture is said to be united. The length of time requisite for such union is greatest, as a rule, Avhen the fracture is of the shaft of the femur in an adult, in which case it is usually from six to eight Aveeks; it is least at the spongy ends of the bones, less in children than in adults, and greater Avhen there is much permanent displacement. After final healing the limb sloAvly regains its usefulness, the muscles fill out, and the skin becomes soft, but for many weeks the limb may show a tendency to venous congestion and oedema and the movements of its joints be restricted. In compound fractures that do not promptly become simple, if left to itself the wound suppurates, the pus bur- rows, neighboring abscesses form, union of the fracture is delayed, and even after it has taken place the wound may be kept open for Aveeks or months by suppuration about a loose or attached necrotic fragment. The lesions of a fracture comprise the breaking of the bone into tAvo or more fragments, the tearing of the periosteum, and the laceration of the soft parts. A portion of the periosteum habitually remains untorn, although stripped up for a greater or less distance from one or both fragments, and con- stitutes a remaining bond, a "periosteal bridge," between the fragments. This plays an important part in the repair of the fracture. The periosteum thickens, and on its under surface appears a layer, at first soft, then cartilaginous, which extends along the periosteal bridge from one fragment to the other, as well as under the periosteum that remains adherent; the portion belonging to the periosteal bridge thickens and spreads between the fragments, and ultimately becomes bony and continuous Avith the granulations coming from the bone itself. This is the only portion of the callus which passes through a carti- laginous stage. The bone becomes rarefied by enlargement of its Haversian canals, and at its broken edge and on the adjoining surface of the medullary canal granulations appear Avhich increase until they meet those coming from the periosteal bridge and from the other fragments, and fill the space between them, and also usually the medullary canal at the seat of fracture. These granulations become fibrous and finally bony, and thus is formed the callus, Avhich, Avhen complete, fills the gap betAveen the fragments, occupies the medullary canal for some distance, and forms a layer on the outside of the bone for a greater or less distance above and beloAv the fracture. As time passes this callus becomes smaller, and the portion that forms the medullary plug may entirely disappear, and thus the continuity of this canal may be restored. If there is much permanent displacement, or if the fragments are not effectually immobilized during repair, the callus will be larger than under other circumstances, and tendons and fibrous tissue attached to the bone near the fracture may be included in the area of irritation and become ossified. Such ossification at a distance may be destructive to the functions of the limb, as Avhen a fracture is in the neighborhood of a joint, or in the case of the radius and ulna, Avhich may become united to each other with consequent loss of rotation of the forearm. Sometimes a neighboring joint becomes entirely obliterated by bony union of its opposing articular surfaces. FRACTURES. 283 Fragments that are entirely detached, even from the periosteum, may regain their vital connection with the body, apparently by the groAvth of neAv vessels into their Haversian canals, and again form an integral part of the bone. Others may remain imbedded in the callus, but Avithout vascular connection, and be tolerated for years: under the influence of various causes they may ultimately lead to suppuration. Occasionally the evolution of the callus is arrested at the fibrous stage, and union is then said to have failed or to be fibrous. Fibrous union may be so close and firm or so Avell supplemented by the interlocking of the different parts of the callus that have ossified that the limb is very useful. The common causes of fibrous union are separation of the fragments and insufficient immobilization. Complications and Late Consequences.—With the healing of the fracture the limb is not immediately restored to a normal condition; it is shrunken, the skin is dry and rough, the limb SAvells on use, and its joints are more or less stiff. Most of these abnormal conditions gradually disappear, but in the aged the limb may long remain sensitive to free use and to changes in the Aveather, and the stiffness of the joints may persist. The latter is due in great part to the inflammatory conditions that have existed in and about the joint as a direct consequence of the fracture, or to the implication of neigh- boring tendons ; but in the joints of the fingers it may be due to the immobili- zation, and is much more likely to arise when the fingers have been kept extended. It has been clearly shoAvn that prolonged immobilization of the large joints, per se, is not a cause of permanent stiffness, and that passive motion of the joint is not necessary, or even desirable, during treatment of the fracture, to prevent it. If the joint is inflamed, the best means of reducing the inflammation and restricting its results is to keep the joint at rest. Per- sistent swelling of the limb, especially of the leg, is apparently the result of interference Avith the venous Aoav, and may be the cause of or be associated with much trouble and annoyance, especially if the callus is large and adherent to the skin. The nutrition of the limb is interfered Avith, persistent ulcers form, and eczema torments the patient. Persistent paralysis of one or more groups of muscles may appear as a consequence of injury of a nerve-trunk at the time of the accident, or of its later inclusion in the callus; the latter has been observed only in the musculo- spiral nerve after fracture of the shaft of the humerus. Exuberant and Painful Callus.—Excessive size of the callus may cause trouble by interference Avith the circulation, or by stretching the skin, or by pressure on a nerve. The second cause is not uncommon in the leg, and may call for relief by chiselling aAvay the bone. Pressure upon a nerve may occur at any point where a nerve lies in close proximity to the bone, as in the case of the ulnar nerve at the back of the elboAV. Persistent pain in the callus may be due to an inflammatory process, as suppuration about a sequestrum, or to a non-inflammatory condition of unknoAvn character which has been termed osteo-neuralgia; occasionally it has been traced to inclusion of a nerve-filament in cicatricial tissue. The other complications to be described are those that arise during the earlier period of the case and put the patient's life in danger. Most of them are extremely rare. Embolism.—The thrombus of the small veins that have been torn may extend to the large ones, and a portion may be detached and lodge in the heart or in the pulmonary artery. For the symptoms and course the reader is 284 AN AMERICAN TEXT-BOOK OF SURGERY. referred to the section on Thrombus and Embolism (p. 56). Fat embolism (see p. 90) has been recently recognized as an occasional cause of death in the first feAv days after the receipt of a fracture. Liquid fat set free by the crushing of the marroAv passes into the open veins and lodges in the pulmonary capillaries. The symptoms are not constant or characteristic ; there may be sudden dyspnea Avith subsequent oedema of the lungs, or there may be only prostration Avithout dyspnea, but Avith cyanosis, quick, feeble pulse, and coarse rales. In some cases the symptoms resemble those of shock, from Avhich the affection is to be distinguished by its antecedent period of comparative well-being. Rupture of a large artery may be caused by stretching or by perfora- tion ; the blood escapes freely until the resistance of the soft parts checks it, and then a traumatic aneurysm forms. The general practice is to postpone active treatment of the injury of the artery, if possible, until repair of the fracture has taken place. The bruising of an artery may be followed Avithin a feAv hours by the formation of an obstructing thrombus Avithin it. Gangrene may be the result of direct bruising of the soft parts or of interference with the circulation in the large vessels arising from their injury or compression by a displaced fragment or from the pressure of a bandage. It may be partial or may involve the limb as far up as the seat of the fracture. Septicemia and pyemia occur, as a rule, only after compound fracture, and, if the fracture is treated antiseptically, are very rare. Tetanus is a rare complication, and is seen most frequently after com- pound fracture of the fingers. Delirium tremens is a frequent complication of fracture in adults addicted to the use of alcohol. It is, as a rule, milder than the delirium tremens that develops Avithout an injury. Warning of its approach is given by agitation and insomnia, and it can often be aborted or arrested by the vigorous use of sedatives. The outbreak seems generally to be due to the cutting off of the daily ration of alcohol, which is usually the result of the accident and the admission to a hospital; and this indicates the advisability of continuing mode- rate stimulation for the first Aveek or tAvo in patients Avho are habitual drinkers. Treatment.—By the reduction or setting of a fracture is meant the res- toration of the displaced fragments to their normal position, or at least to that in which it is desired that reunion shall take place. The manipulations com- monly employed are traction upon the lower fragment to correct overriding or angular displacement, and direct pressure to correct lateral displacement or longitudinal separation. Reduction should be made as completely and as promptly as circumstances Avill permit, having regard to the condition of the patient and of the limb. If there are severe associated injuries and the shock is great, it is Avell to wait for reaction, and meanAvhile to immobilize the parts in partial reduction with simple dressings ; if the limb is greatly SAvollen it may be impossible to restore it to its full length without causing dangerous pressure. An anesthetic may be required to overcome the opposition of the muscles; and in the case of a fracture near to or involving a joint anesthesia is doubly valuable, both to recognize the details of the fracture and to facili- tate the complete and accurate readjustment of the parts. Usually no greater force is required to effect reduction than that Avhich can be exerted by the hands of the surgeon or of an assistant, but in some impacted fractures the fragments are so firmly Avedged together or one is so small or inac- cessible that reduction cannot be made. Traction is made by grasping the loAver segment of the limb and pulling firmly and steadily upon it; coaptation is made by the direct pressure of the fingers and thumbs upon the fragments close to the fracture; angular displacement in "green-stick " fracture, and in FRACTURES. 285 others where it is not combined with overriding, is corrected without traction by forcibly bending the bone back into line. If there is so much crushing of the spongy end of a bone that the restoration of the fragments to their normal position would leave an important gap between them, the restoration should not be made, but the fragments should be left in contact. Permanent dressings have for their main object the prevention of dis- placement of the fragments by the action of the muscles or by external forces, especially gravity. The means by which this object is to be attained vary greatly in the different fractures, but in most cases they consist of some form of lateral support, often combined with permanent traction upon the lower seg- ment of the limb. Dressings applied circularly about a limb expose it to the danger of constriction, and consequent gangrene, if swelling should occur after the dressing has been applied, and therefore, as a general rule, such should not be used during the first few days, or if used should be frequently inspected. If applied Avhile the limb is swollen, they are liable to be made too loose by the subsidence of the swelling and to need renewal or readjustment. As a general rule, a roller bandage should not be applied to the limb under the splints; it will rarely do good, and may do great harm. Another rule is to include in the dressings the joints at either end of the broken bone. The simplest form of lateral support is that furnished by wooden splints: they should be longer than the broken bone, of such breadth and thickness that they will not yield under the weight of the limb, and should be thickly padded Avith cotton to fit the contour of the limb or placed over detached cush- ions made for the purpose; they are made fast, one on each side, with strips of adhesive plaster, straps, or a roller bandage; they should be so wide that the enveloping bands will not circularly constrict the limb. Projecting bony points should be protected by thick padding about them, not on them. Carved wooden splints made to fit average limbs rarely have advantages commensurate with their cost. Gooch's flexible wooden splints (Fig. 70) made of thin strips of wood fastened close together on a muslin backing are com'enient in some cases. They can be easily made by fastening the strips upon a sheet of adhesive plaster. Fracture-boxes are essentially a combination of lateral and pos- terior splints, and are used only for fractures of the leg. They consist of a long rectangular piece of wood with two hinged sides and a movable foot-piece. The central posterior piece is first well covered with cotton, oakum, or bran ; the limb is laid upon it and the foot bound to the foot-piece; then the sides are turned up, Avith interposed padding, and bound to each other across the front of the leg by cords or bands running through holes made for the purpose. To avoid troublesome pressure upon the heel the foot may be sus- pended by a long and not too narrow strip of adhesive plaster run- ning from the middle of the calf along the back of the leg to the heel, and up past the sole of the foot to the top of the foot-piece. After application of a fracture-box or any equivalent apparatus suspension from a horizontal bar held up by two vertical side-pieces is often of great advantage. Volkmanns splint is a convenient substitute for a fracture-box, and very useful as a temporary dressing for fractures of the leg. It is a shalloAv gutter of tin with a foot-piece and a movable support by Avhich the loAver end is held at a convenient height above the bed. Wire gauze is a convenient dressing for fractures, since it is flexible enough to adapt itself to the varying dimensions of the limb under the pressure of a Fig. 70. Gooch'.s Flexible Wooden Splint. 286 AX AMERICAX TEXT-BOOK OF SURGERY. roller bandage, and can be bent to fit the elboAv or ankle by cutting it partly through on the sides. Moulded splints can be made of any material that can be temporarily soft- ened so as to be fitted to the limb and will then harden and retain the shape that has been given to it. For the lighter splints plaster of Paris, pasteboard, leather, felt, and gutta-percha are used ; for the heavier ones plaster of Paris is the most convenient. To make a, plaster-of-Paris splint (Fig. 71) the surgeon Fig. 71. Fig. 72. Posterior Plaster-of-Paris Splint or Gutter. Plaster-of-Paris Dressing, made of coarse sackcloth. cuts strips of gauze, coarse muslin, or thin blanketing of the desired length and width, and soaks them Avith freshly-prepared plaster of the consistency of thick cream ; he then squeezes out the superfluous water, covers the limb thickly with vaseline, applies the splint, and secures and at the same time moulds it to the limb with a roller bandage; after it has hardened he removes the roller and secures the splint by circular turns at tAvo or three points. If sharp angles are made, as at the elbow or ankle, the fit can be improved by notching the splint Avhile it is still soft and slipping one edge of the cut under the other. Such splints are very useful in the treatment of fractures of the leg, but are not strong enough for those of the femur; they may be applied Avhile the injury is still recent, and permit inspection AAithout having to be removed. The plaster-of-Paris bandage for complete encasement of the limb is most conveniently made by using gauze rollers that have been prepared by thorough filling Avith dry plaster. The limb is enveloped in cotton or other soft material, and then the prepared roller bandages, after having been thoroughly Avet. are applied in the usual manner. Or strips of some coarse material soaked in plas- ter cream may be applied, as shown in Fig. 72. They can be fenestrated at any point by cutting out a piece after the plaster has hardened, or may be "interrupted," the two segments being attached to each other by iron bands FRACTURES. 287 ____n-----set into the dressing. Similar dressings can be made with sili- cate of soda, dextrin, starch, or glue. In order that such a dressing shall prevent shortening of the limb within it, it is essential that it should have a bearing against bony prominences or a flexed segment of the limb above and beloAv the fracture : such points of counter- pressure are easily found in the leg and forearm, but with difficulty in fractures of the arm and thigh. The methods for applying continuous traction to the lower segment of the broken limb include the double inclined plane, suspension, Buck's exten- sion, and india-rubber bands in combination with side-splints. The double inclined plane (Fig. 73) is sometimes used in fractures of the Fig. 73. Esmarch's Oouble Inclined Plane. thigh; it is made of a short thigh- and a long leg-piece hinged together at the knee, and hinged at the upper end of the thigh-piece to a long underlying third piece, as shown in the figure. Traction is made by the Aveight of the pelvis as it sinks in the bed. In Buck's extension, a very popular method of treating fractures of the femur, the traction is effected by a weight attached to the leg by a cord Avhich runs over a pulley at the foot of the bed. This attachment is made by adhesive plaster, the introduction of which constituted an immense improvement in the treatment of these fractures. It is applied as folloAvs: A strip of stout adhe- sive plaster, four or five inches wide and long enough to reach from well above the knee loosely around the sole of the foot and back to the same height above the knee, is cut as shown in Fig. 74; a piece of wood five by three inches and Fig. 74. perforated at its center is placed at the middle of the strip, the edges of which are turned do\vn over it and over each other, as shoAvn in Fig. 75; a Fig. 75. stout cord is then passed through the hole in the piece of wood and its end is tied in a knot. A roller bandage is applied to the foot and the lower third of the leg; the adhesive plaster is then applied to the sides of the leg and thigh above it, and secured by continuing the bandage upward (Fig. 76). The cord is then carried over a pulley at the foot of the bed and attached to the Aveight, ten to twenty pounds according to circumstances. The foot of 288 AN AMERICAX TEXT-BOOK OF SURGERY. the bed must be raised, to obtain the counter-extension by the weight of the body. Outward rotation is prevented by securing the limb to a long Fig. 76. Adhesive Plaster applied for Extension. side-splint having a cross-piece at its lower end that rests on the bed, or, better, by placing the leg on a Volkmann's sliding rest (Fig. 77) which Fig. 77. Volkmann's Sliding Rest for Fractures of the Thigh. is composed of two side-pieces about two feet long and eight inches apart, on which rest by two cross-pieces a posterior splint and foot-piece, to which the foot and leg are attached in the usual manner. Instead of the weight and pul- ley an india-rubber cord may be used. The attachment to the limb is made by Fig. 78. ImULJilierAajimMlator Cripp's Splint. adhesive plaster. Fig. 78 shows such an apparatus in use for fractures of the thigh. Vertical suspension of the limb by a rubber cord attached to the limb FRACTURES. 289 by adhesive plaster is sometimes useful in fractures of the humerus close to the elbow, and is common in the treatment of fractures of the thigh in young children. Nathan R. Smith's anterior splint (Fig. 79) acts like the double inclined Fig. 79. is— a rr-n Nathan R. Smith's Anterior Splint. plane when the suspension is vertical, and like Buck's extension when it is oblique. Hodgens splint (Fig. 80) acts on the principle of Buck's extension, and has the additional advantages of slight flexion of the knee and of greater facil- Fig. 80. Hodgen's Splint. ity in moving the patient in bed. It is attached to the leg by adhesive plaster in the same manner as in Buck's extension, and the traction is greater or less according to the deviation of the supporting cords from the vertical. The inclination shown in Fig. 80 is very much more than can be tolerated in practice. The foot of the bed must be raised, to supply the counteracting force. Treatment of Compound Fractures.—One of the chief advances made possible by antiseptic surgery is in the results now achieved in the treatment of compound fractures. Formerly they were excessively dangerous accidents 19 290 AX AMERICAX TEXT-BOOK OF SURGERY. from septic infection; noAv this danger has been almost entirely eliminated. But all depends on the proper and thoroughly antiseptic character of the first dressing. This dressing of a compound fracture is often equivalent to a major surgical operation, requiring the aid of anesthesia, the use of instruments, and the protection of antiseptic measures. After anesthetization, the surface of the limb all about the Avound is thoroughly washed, shaved, and purified. By "purifying" is meant securing the most thorough antiseptic cleansing of the entire interior as Avell as exterior of the wound in every nook and corner of possible infec- tion. This is a sine qud non. If covered with machinery grease, etc., thorough rubbing Avith SAveet oil or with turpentine and alcohol before scrubbing with soap and Avater greatly facilitates the proper cleansing. Blood-clots and loose splinters are removed, Avounded vessels tied, divided nerves and tendons sutured, the ends of the fragments sparingly trimmed if necessary, contused tissues cut aAvay, counter-openings made for drainage, and the cutaneous Avound sutured. A thick antiseptic dressing is applied, and over all is placed such' retentive apparatus as is suitable. The main indication is to secure early union of the cutaneous Avound: Avhile this is taking place it is desirable that the fragments should remain properly reduced ; but this is, in a measure, of secondary import- ance, for a final readjustment can usually be made in the second or even the third week. But if the wound in the skin is small and clean, it is advisable to limit interference to its irrigation, to the setting of the fracture as if it Avere simple, and to the application of an antiseptic dressing, and then after the lapse of a week, when the wound will probably have healed, to remove the dressing and make permanent reduction and retention if it has been impossible to effect this at the primary dressing. The use of metallic sutures and similar devices to maintain the fragments in contact Avith each other is rarely advisable, since sufficient support can usually be given by an external apparatus, and the presence of the foreign body appears somewhat to retard bony union. If suppuration follow from prior infection, the limb must be placed in a splint that will permit the removal of the dressings with the minimum of dis- turbance of the fragments. Some form of interrupted plaster or suspended splint may be applied, and later indications met as they arise. Concerning the propriety of primary amputation or excision of a joint definite rules cannot be laid doAvn ; each case must be judged according to the extent of the injury, the probable usefulness of the limb if saved, and the ability to protect against suppuration and septic infection. The protection afforded by attention to the modern principles of treatment of wounds is such that in doubtful cases the patient may safely take the benefit of the doubt and be given an opportunity to show Avhether or not the limb can be saved. Pseud arthrosis and Delayed Union.1—When abnormal mobility hi.s not ceased after the usual lapse of time, the condition is described as delayed union ; if this condition persists after some additional Aveeks, it is termed pseudarthrosis, or failure of union, or ununited fracture. Delayed union is not very uncommon, but failure of union is relatively rare; most of the cases occur in middle life, and most frequently in the humerus, tibia, and femur in the order mentioned. In proportion to the number of fractures of the respect- ive bones, delayed union and failure of union occur more frequently after frac- ture of the shaft of the femur than after that of the tibia. Anatomically, two distinct varieties exist: in one the fragments are more or less closely bound 1 The fibrous union with persistent mobility which is the rule after fracture of the patella and of some apophyses will not be here considered. FRA CTURES. 291 together by solid bands of fibrous tissue, sometimes enclosing nodules of bone; in the other similar fibrous bands enclose a central cavity containing a viscid synovia-like liquid, into Avhich the ends of the fragments may project; and these ends may be smooth and eburnated or even covered by hyaline cartilage —a complete new joint. The clinical difference between the two varieties°is important, as will appear when their treatment is considered. The reason of delay or of failure of union, in the great majority of cases, lies in the arrest of the evolution of the callus before it has entered upon the stage of ossification—i. e. its persistence as fibrous tissue; in others the separation of the fragments is so great and the gap so broken by interposed muscle that a continuous callus, formed by granulations springing from the bones, has never existed, and the fibrous bond is composed solely of the thick- ened surrounding connective tissue. The ends of the fragments are variously affected in accordance with the extent of the rarefying and productive pro- cesses which folloAv the injury; according as one or the other predominates the ends are diminished in size, sometimes to slender conical points, or enlarged by the formation of irregular masses of bone upon them. In a very fewT cases the rarefying process has gone so far that a large portion, or even the Avhole, of the shaft has gradually disappeared. This tendency to excessive rarefaction, when present, is a serious obstacle to the success of operations undertaken to secure union, and it has seemed to some Avriters to be increased by the presence of metallic sutures binding the fragments together. Occasionally the fragments are in close apposition by their broad surfaces, the fibrous bond is short and complete, and the fragments are enlarged by peripheral productions of bone, and yet ossification of the short fibrous bond fails. The resultant disability varies with the amount of abnormal mobility and the uses to which the limb is put: thus, failure of union in the leg or thigh may make the limb Avholly useless, while in the arm or forearm it may interfere but slightly with its usefulness. \j With respect to the cause, certain general conditions have seemed at times to delay repair, such as syphilis, pregnancy, and acute general diseases, but the common causes are local. Advanced age is not a cause. The local causes are separation of the fragments (by displacement or by loss of substance), the interposition of a foreign body or of a portion of muscle, disease of the bone, defective blood-supply, defective innervation, inflammation on the surface of the limb, and faulty treatment. The first three act mechanically by creating a gap that cannot be filled by the granulations, and, in addition, in the third the surfaces may be so modified by the disease (syphilis, caries, cancer, etc.) that they are unfit to furnish the necessary granulations. Defective blood-supply, the result of injury to the nutrient artery of the bone or to the main artery of the limb, has often been alleged as a cause, but satisfactory proof is lacking and theoretical con- siderations do not furnish much support. The influence of defective innerva- tion has been shown in some fractures of the lower limb combined with injury to the lower part of the spinal column ; it appears to arise not from the same cause that produces the paralysis of motion, for such delay does not occur in paraplegia due to injury at the upper part of the spinal column, but from injury to trophic centers in the loAver part of the cord. The influence of surface inflammation has been occasionally shown in the delay of repair or in the soften- ing of a firm callus coincidently Avith the appearance of an erysipelas or a phlegmon of a limb. Excluding incomplete reduction, the fault in treatment which is most likely to delay or prevent repair is insufficient immobilization. Its influence is 292 ^V AMERICAN TEXT-BOOK OF SURGERY. unquestionable, although of course it is known that union may take place in spite of it. It is thought that the relative frequency of failure of union after fracture of the humerus is largely due to this cause. The local applica- tion of cold is also thought to retard union. It has been asserted also that treatment by complete encasement of the limb in a plaster-of-Paris bandage is followed by a larger proportion of delays and failures than is the case where other methods are employed, and that the increase is due to the shutting out of air and light from the limb : a more probable explanation of the frequency, if it actually exists, is defective immobilization. Premature use of the limb may be followed by a gradual return of the abnormal mobility, as well as by distinct refracture; and a similar occurrence has been observed under the influence of intercurrent diseases weeks or even months after union appeared to be complete. Treatment.—If a general cause exists, such as syphilis or malnutrition, measures should be taken to remove it, Avhether the case is one of delayed union or of failure of union. In delayed union of short duration, and with only slight mobility and displacement, much is to be hoped from time, aided by accurate immobilization by splints that will permit the patient to leave his bed. A gratifying number of successes in fractures of the leg and thigh have been obtained by the use of orthopedic splints. In a number of cases of delayed union of the leg union has gradually become complete while the patient was using the limb under the protection of a suitable splint: it is thought that the slight irritation caused by bearing the weight upon the limb favors ossifica- tion. On the same theory percussion of the bone at the fracture has been used. If the case is of longer standing and the mobility greater, a more decided local irritation is required—one that will bring the parts more nearly to the condi- tion of a recent fracture and start the process of repair afresh. Under anesthe- sia the limb is forcibly bent at the seat of fracture, care being taken not to injure main vessels and nerves. The bending should be nearly or quite to a right angle, and the laceration should be sufficient to permit a fairly complete reduction if there has been previous displacement. The fracture is then treated as a recent one. Direct irritation of the ends of the bones can be produced by subcutaneous drilling, but it seems better, and, if antiseptically done, is equally safe, to expose the bone by incision and apply the drill under the guidance of the eye and finger: it should be forced into the end of each fragment at several points. This plan is, in the writer's judgment, more efficient than the permanent intro- duction of metallic, bone, or ivory pins. Excision of the fibrous tissue and of the end of each fragment is the only means that will cure old cases and those in Avhich a joint-cavity has formed between the fragments. Under the protection of antiseptic treatment of the wound it has become a popular method, and has proved safe and efficient. The bones should be freely exposed, and their surfaces freshened and fitted to each other—preferably by a transverse section, if that does not require the removal of too much tissue—and the periosteum should be stitched together as exten- sively as is practicable. Buried or temporary sutures of silver Avire or of strong silk are sometimes used to bind the fragments together and prevent displace- ment ; as are also long, narrow metal plates on each side of the bone, crossing the line of fracture and secured to the fragments by long pins that are left pro- jecting beyond the skin and are removed after two or three weeks, the plates being left to heal in. The attempt has been successfully made in a few instances to obtain union, when there was a considerable gap betAveen the fragments due to loss of substance, FRACTURES. 293 by filling the gap with small pieces of sterilized decalcified bone or of fresh bone taken from animals : the intermediate fibrous tissue is removed, the ends of the fragments freshened, and the skin closed over the inserted Fig. 81. pieces ; perfect asepsis is neces- sary to success. Finally, amputation may be required to rid the patient of a useless and troublesome limb. Faulty Union.—An opera- tion may be required to relieve a disability due to union Avith deformity or to exuberant cal- lus : thus, the femur may have united Avith an angular displace- ment that causes effective short- ening of the leg in such man- ner that the foot does not rest squarely on the ground or is outside the line of support; or the bones of the forearm may unite Avith a callus that prevents rotation ; or an exuberant callus may compress a nerve. Fig. 81, from a photograph, is an example of union Avith extreme deformity. The measures employed are subcutaneous refracture, osteotomy, and chiselling away of exuberant bone. (See Operations on Bones.) Faulty Union after Fracture. SPECIAL FRACTURES. FEACTURES OF THE SUPERIOR MAXILLA AND MALAR BONES. These are caused only by direct violence, are generally comminuted, and unite AAdth great rapidity. Displacements may often be corrected by direct pressure, and, except in the case of the alveolar border, require no retentive apparatus. When a portion of the alveolar border, with more or less of the adjoining bone, is loosened, it may need to be retained by Aviring its teeth to the neighboring ones or by keeping the lower jaAv pressed against it. feactuee of the nasal bones. This is produced by direct violence, and is often compound, either through the skin or through the mucosa. The fracture may extend to the superior maxilla or to the cribriform plate of the ethmoid; the latter is a dangerous complication because of the possibility of septic meningitis. Cellular emphysema of the face and eyelids, due to the forcing of air through the lacerated mucosa by efforts to clear the nostrils, may appear. Repair takes place so rapidly that it is necessary to recognize and reduce displacements promptly. Reduction is best made by pressure with a small stiff metal rod, like a director, passed into the nostril, Ordinarily there is but little tendency to recurrence of the dis- placement, but it may sometimes be necessary to oppose it. A plan that has yielded good results is to transfix the nose close beneath the fragments wTith a 291 AN AMERICAN TEXT-BOOK OF SURGERY. stout pin, and steady them Avith a piece of india-rubber or adhesive plaster crossing the bridge of the nose and caught upon the ends of the pin. Suppuration may be folloAved by necrosis of the fragments. Possibly it could be prevented by irrigating the nostrils Avith an antiseptic solution and plugging the passage Avith iodoform gauze. This should always be done very carefully if injury to the cribriform plate is suspected. (See Fractures of the Base of the Skull in the section on Injuries of the Head.) Fig. 82. FEACTUEE OF THE LOAVEE JAW. This may be single or double: single fractures are most common at or near the median line; those of the ramus and condyloid process are much rarer. Double fractures may occupy one or both sides, or one of the fractures may be in the median line. They are quite common. Fractures of the body of the bone are usually compound; those of the coronoid process are extremely rare, and have been found only in connection with fractures of the condyle, zygoma, and malar bone. The displacement in fractures of the body is almost invariably such that the level of the teeth on one side of the fracture is lower than on the other, and with this is often associated an antero-posterior or lateral displacement accord- ing to the position of the fracture; sometimes there is overriding. In fracture of the ramus there is usually little or no displacement. The common cause is violence received upon the chin or cheek. The diagnosis is readily made in fractures of the body by recognition of the change in the relations of the teeth, of abnormal mobility and crepitus, and usually of looseness of the adjoining teeth and bleeding from the gums. In fracture of the ramus the only symptom may be pain on pres- sure or on tightly closing the jaws. The pain should be sought for by making pressure with the finger within the mouth as Avell as on the cheek. The course is marked by swelling of the face and gums, and often by suppuration at the seat of fracture, the pus escaping into the mouth alongside the teeth, and also often open- ing through the skin near the loAver border of the jaAv. Suppuration may be maintained for a long time by necrosis, and may lead to a considerable loss of bone with consequent fail- ure of union and great disability. /^»^\ Reduction can almost ahvays be readily v\\\\ effected by direct pressure, but the prevention of recurrence may be very difficult. In sim- ple cases treatment consists in the application of a "four-tailed bandage" (Fig. 82); in the more difficult cases recourse has been had to a great variety of interdental splints and methods of wiring the bones or the teeth together. For the con- struction of most of these the surgeon will require the services of a dentist. FEACTUEE OF THE HYOID BONE. This is exceedingly rare, and in the feAv recorded cases has been caused by direct violence and has almost always involved one of the greater cornua. "Four-tailed Bandage" for Fracture of the Jaw. FRACTURES. 295 The symptoms are sharp pain, swelling, marked dysphagia, and sometimes bleeding from the mouth due to perforation of the mucous membrane by the fragments. Death from oedema of the glottis may occur. FEACTUEE OF THE STEENUM. (See also Dislocations.) This fracture is rare ; it may be incomplete, multiple, transverse, longitu- dinal, or oblique, but the common form is transverse and situated at or near the junction of the manubrium and body of the bone. As a complete joint sometimes exists between the manubrium and body, it may be impossible to say whether a separation exactly following the line of their junction is a frac- ture or a dislocation. Displacement may be absent, or may be angular or transverse Avith or without overriding, either piece lying in front of the other. The periosteum on the posterior surface appears habitually to remain untorn. When the fracture takes place at the junction of the first and second pieces, the second rib usually remains in contact Avith the manubrium. Fractures of the body are most common in its upper half; those of the ensiform process, including its separation from the body, are extremely rare. The fracture has been caused in several cases by straining during labor and by lifting heavy objects ; external violence may cause fracture directly, as in a blow upon the breast, or indirectly by bending the trunk backward. The diagnosis is made by recognition of the displacement when it is present, localized pain, and the history of the case. There is sometimes irreg- ularity of the heart with dyspnoea. The treatment consists in reduction by direct pressure, aided, if there is overriding, by extension of the trunk and by deep inspiration by the patient, and in retention by a broad band of adhesive plaster around the chest. FEACTUEE OF THE EIBS. This fracture is of frequent occurrence; it may be partial or complete, single or multiple. Incomplete fractures are rare, whether by bending or by fracture of a piece from one border of the bone. Complete fracture may involve one or several ribs, or one or more ribs at two points each ; the ribs most frequently broken are the fifth to the ninth ; fracture of the floating ribs is almost unknown, and that of the upper ribs apparently very rare, although there is some reason to think that fracture of the first rib is not infrequent, but usually passes unrecognized. Unless two or more adjoining ribs are simultaneously broken, there is little or no displacement; if they are thus broken, the displacement may be angu- lar, with the apex directed inward or outward, and overriding may be produced by the sinking in of the chest-Avail. If a rib has been broken at two places, the intermediate piece may move in and out as the patient breathes. Associated injury to the lung by the point of a fragment is common, as shown by emphy- sema or bloody expectoration ; and extensive laceration of the lungs or heart may be produced when the violence is great. Serious hemorrhage from a Avounded intercostal artery is rare. The common cause of the fracture is external violence, but it may also be caused by muscular action, especially in coughing. External violence may produce the fracture directly, or indirectly by exaggerating the curve of the bone. The symptoms in the less extensive cases are pain on deep inspiration or coughing and Avhen pressure is made upon the broken rib ; abnormal mobility can often be recognized by placing a finger on the rib on each side of the 296 AX AMERICAN TEXT-BOOK OF SURGERY. fracture and noticing that movement communicated to one fragment is not transmitted to the other: during this manipulation crepitus may be perceived, or it may sometimes be heard by listening with the ear upon the chest while the patient breathes deeply. Bloody expectoration is frequent. The presence of cellular emphysema, in the absence of a Avound or other sufficient cause, is pathognomonic. In the severer cases, in which several adjoining ribs are broken, the fracture is readily recognized by the deformity; associated symp- toms due to laceration of the lung may be very urgent. The treatment is habitually limited to immobilization of the chest by means of a broad band of adhesive plaster placed about it. Angular displace- ment outward can be corrected by direct pressure upon the projection; it has been proposed to raise a depressed rib by cutting down upon it or by passing a sharp hook under it, but it is unlikely that such a measure would ever be neces- sary. For the treatment of associated injuries of the thoracic viscera, pneumo- thorax and hemothorax, the reader is referred to the chapter on Injuries of the Thorax. FEACTUEE OF THE COSTAL CAETILAGES. This may be caused by direct or indirect violence or by muscular action; it appears to occur more frequently near the junction Avith the rib than at other points, and to involve the seventh and eighth cartilages more frequently than others. Marked symptoms, when present, are due to associated lesions, injury of the heart or lungs, or other effects of the crushing violence that has caused the fracture. The diagnosis is made on the local pain and the deformity. The treatment is the same as that of fracture of the ribs. FEACTUEES OF THE CLAVICLE. The clavicle is broken more frequently than any other one bone, with the possible exception of the radius, and the injury is very much more common in the young than in adults, about half the cases occurring in children under five years of age. The fracture may be partial (green-stick) or complete, simple or compound, single or multiple. The partial (in the very young) and simple complete (in the adult) of the middle third of the bone are the common forms; fracture of the outer third is second in order of frequency ; that of the inner third is infrequent. The division of fractures into those of the inner, middle, and outer thirds is justified by important anatomical and resultant clinical differences, the chief of Avhich arise from the firm ligamentary attachments of the outer third to the coracoid process of the scapula. Fracture of the middle third (Fig. 60,), the most common variety, may be oblique or transverse, the latter form being found mainly in children; the line of oblique fracture runs from above dowTmvard and inAvard, so that the point of the outer fragment underlies that of the inner one—an important element in the production of the usual displacement; the seat of fracture is usually in the outer half of this third. The loss of support occasioned by the fracture is folloAved by the falling of the shoulder downward, forward, and inward, which presses the outer fragment under the inner one, and thus raises the broken end of the latter—a movement which is sometimes aided by the contraction of the cleido-mastoid. If the line of fracture is so nearly transverse that over- riding cannot occur, the displacement is transverse or angular with the apex directed upAvard and usually backward. In fracture of the outer third, Avhich is much less frequent than the pre- ceding, the line of fracture is more often transverse than oblique, and the dis- placement is usually angular with the apex directed backward, but it may be very marked and irregular. FRACTURES. 297 In fracture of the inner third, Avhich is quite rare, the line is commonly oblique, and the displacement of the outer fragment is imvard and doAvnward, the inner fragment either being pressed upward, as in fracture of the middle third, or accompanying the other, thus producing an angular displacement. When the bone is broken at two points, the intermediate piece, especially if it is part of the middle third, is liable to be greatly displaced. Complications of simple fractures are very rare, but injuries to the large vessels, to the nerves, and to the lung have been reported, including one or tAvo cases of aneurysm following fracture, several cases of fatal injury to the subclavian vein or the internal jugular, several of persistent or temporary paralysis of the arm, and several of perforation of the lung, shoAvn by cellular emphysema. Simultaneous fracture of both clavicles has been caused by direct vio- lence, as the kick of a horse, each hoof striking one bone, or, more frequently, by indirect violence, the force acting upon both shoulders to press them together. Marked dyspnea, attributed to the Aveight of the shoulders resting on the tho- rax, and relieved by dorsal decubitus, Avas observed in some. The causes of fracture of the clavicle are indirect violence, as in a fall upon the hand or shoulder; muscular action, as in lifting or striking; and direct violence. The symptoms are pain, deformity, abnormal mobility, and loss of func- tion : pain is caused by pressure on the bone or by pressing the shoulder inward ; deformity varies with the extent of the displacement, and is shown not only by the change in the relations of the fragments, but also by the falling forward, inAvard, and doAvmvard of the shoulder, Avith a reduction of the distance between the acromion and the sternal end of the clavicle; abnormal mobility can be recognized by manipulation of the fragments, and is usually accompanied by crepitus; loss or diminution of function is shoAvn especially in abduction of the arm. The course is uneventful, and union is usually complete within a month in adults, but some persistent deformity due to shortening and angular displace- ment is the rule; excessive size of the callus has in a feAv instances produced pressure-effects on the nerves of the brachial plexus or on the skin. Treatment.—Reduction is made by draAving or pushing the shoulder upward, backward, and outward to its normal position, aided Avhen necessary by pressure upon the projecting angle at the point of fracture. The subsequent indication is to maintain the shoulder in this position, for, as has been said, the unsupported Aveight of the shoulder is the cause of the displacement. This indication has been met, more or less satisfactorily, in a great many wrays. In the transverse or incomplete fracture of children a simple sling for the fore- arm is often sufficient; but in the oblique fracture of adults a perfect result can rarely be obtained. Dorsal decubitus, Avith a firm narrow cushion between the shoulders and the forearm resting on the chest, meets the indication by remov- ing the cause, but the confinement is too irksome to be endured except Avhen the importance of avoiding any irregularity in the bone is great. Suyre's dressing (Figs. 83, 84) is in very general use ; it requires two strips of adhesive plaster, each three inches Avide and long enough to go once and a half around the chest. The end of one strip is fixed loosely about the arm of the injured side just beloAv the axilla, and the strip is carried around the back and the opposite side to the chest in front, so as to hold the elbow a little behind the axillary line; the second strip is then carried from the top of the shoulder on the uninjured side, across the back, to the opposite elbow, and up along the flexed forearm to the place of beginning, meanAvhile pressing the elbow for- 298 AX AMERICAX TEXT-BOOK OF SURGERY ward, inward, and upward. It is well to leave the hand uncovered by the second strip. A feAv turns of a roller bandage about the arm and chest will give additional support. In this and all similar cases care must be taken not Fig. 83. Fig. 84. Bayre's Adhesive Plaster Dressing for Fracture of the Clavicle, first piece. The Same, second piece. Fig. 85. to allow the bare skin of the forearm to rest on that of the chest, in order to prevent retention of moisture, maceration of the epidermis, and even ulceration. Cotton Avadding, linen, or other similar material should ahvays be interposed between the two cutaneous surfaces. Velpeaus dressing (Fig. 85) is made with a roller bandage; the hand is placed on the opposite shoulder, the elbow pressed upward, and a series of turns Avith the roller applied, which, beginning at the opposite axilla, pass upwTard across the back, over the injured shoulder, downward in front of the arm, and under the elbow to the point of beginning: after several turns have been thus made the bandage is carried circularly about the body, covering in the arm from beloAv upward. A figure-of-8 bandage of plaster of Paris, passing in front of each shoulder and crossing at the back, meets the indication very Avell, but is liable to inter- fere Avith the circulation in the arms. Short crutches fastened to the chest by adhesive plaster or bandages have been in occasional use for many years to main- tain the shoulder in the desired position. When the fracture is at the extreme acromial end, and the displacement is like that of dislocation of the acromial end upAvard, the method of treatment of the latter injury by a strip of adhesive plaster passing under the elbow and crossing on top of the shoulder is equally efficient. Velpeau's Dressing for Frac- ture of the Clavicle. FRACTURES. 299 FEACTUEES OF THE SCAPULA. These fractures may be grouped as—1, of the body ; 2, of the inferior angle ; 3, of the upper angle; 4, of the spine; 5, of the acromion ; 6, of the coracoid process; 7, of the neck ; 8, of the glenoid fossa. Fractures. of the body are caused by direct violence, and may be partial, complete, or comminuted; when there is a single line of fracture crossing the body directly or obliquely, either fragment may project outwardly and over- ride the other. The diagnosis can usually be made by recognition of the displacement by touch, especially along the vertebral border of the bone; by independent mobility, recognized by grasping and moving the loAver angle; and by crepitus. The treatment consists in immobilization of the shoulder and arm ; if suppura- tion ensues in consequence of bruising of the soft parts, early opening of the abscess is required, Avith especial attention to the drainage of the portion Avhich lies on the costal surface of the bone. Fracture of the inferior angle is caused by direct violence or by muscu- lar action; the small lower fragment is displaced forward and upward by the attached muscles, and even if it can be restored to its place it cannot be main- tained there. Fracture of the upper angle is very rare, is caused by direct violence, is followed by but little displacement, and is to be treated by immobilization of the arm. The entire spine, including the acromion, may be separated from the body of the bone, or a portion may be broken off, leaving the acromion attached to the body. The cause is direct violence ; the displacement is slight; the treat- ment is immobilization. Fracture of the acromion process may be caused by external violence acting either directly or through the humerus; or by muscular action (contraction of the deltoid). The line of fracture is in most cases in front of the articulation Avith the clavicle, less frequently at the root of the process. The symptoms are localized tenderness, abnormal mobility, and crepitus. Non-union of the epiphysis at the external extremity of the spine, which is not very uncommon, may, if combined Avith a contusion, be mistaken for a fracture. Bony union is apparently the exception, but the failure to secure it creates no disability. The treatment consists in immobilization of the arm at the side of the body, Avith the elboAv a little fonvard, and Avith the humerus pressed well upward against the acromion (the Yelpeau position). Fracture of the coracoid process may be caused by external violence or by muscular action, and has been observed both alone and in combination with other injuries. The symptoms are abnormal mobility, with or Avithout crepitus, obtained, where present, by pressure with the finger against the tip of the pro- cess. Displacement downward by the action of the attached muscles is the rule, as is also fibrous union. The treatment consists in immobilization of the arm upon the side of the chest Avith the elbow directed a little backward. Fracture of the surgiced neck includes all cases in Avhich the detached fragment comprises the attachment of the long head of the triceps. The upper portion of the line of fracture may end in the suprascapular notch, or in front of the coracoid, or in the glenoid fossa. The symptoms are flattening of the shoulder, due to the sinking of the humerus in consequence of the loss of support by the triceps (this is less Avhen the fracture passes through the supra- scapular notch, because the fragment is then supported by the coraco-clavicular ligament); its prompt disappearance when the arm is pressed upward, and its 300 AX AMERICAX TEXT-BOOK OF SURGERY immediate return Avhen the pressure is removed; the presence of a movable hard lump deep in the axilla, felt by following with the finger the axillary border of the scapula upward; and crepitus, obtained by pressing it upward and backward. Bony union with some displacement appears to be the rule. The indication for treatment is to prevent the sinking of the humerus. This can be effected by bandages or a strip of adhesive plaster passing under the flexed elbow and over the top of the shoulder. Fracture of the rim of the glenoid fossa is a complication of dislocation of the shoulder. Some authors speak of stellate fractures of the fossa, appa- rently the result of crushing violence acting through the head of the humerus. Ftg. 86. FEACTUEES OF THE HUMEEUS. These, which constitute about 8 per cent, of all fractures, may be con- veniently grouped clinically as fractures of the upper end, of the shaft, and of the lower end. Fractures of the upper end include those of the head; of the anatomical neck, with or without part of the tuberosities; of the tuberosities; separation of the epiphysis; and fracture of the surgical neck. Fracture of the head is very rare, if from the group are excluded those indentations which are sometimes associated Avith dislocation (q. v.). It cannot be recognized clinically. Fracture of the anatomical neck is rare: the majority of cases probably occur in connection Avith anterior dislocation, the head being split off by the inner lip of the glenoid fossa acting as a wedge along the line of the neck. In other cases it appears to have been caused by external violence acting upon the elbow to press the humerus against the scapula, or by a fall upon the shoulder. When associated with dislocation the diagnosis can be made by recognizing the independent mobility of the head, but Avhen not so associated it cannot be grasped- by the fingers so as to permit the recognition of this fact, and the diagnosis cannot be made with certainty. The symptoms then are crepitus on rota- tion of the arm, with continuity of the tuberosities Avith the shaft. The head may be subsequently displaced inward and downward by the movement of the shaft upAvard under the traction of the attached muscles, and the condition may then be mistaken for an old unreduced dislocation. The treatment is immobili- zation of the arm, with traction to pre- vent such ascent of the shaft. Many surgeons use the same treatment as for fracture of the surgical neck, by a folded towel in the axilla and the shoulder cap. Fracture through the tuberosities (Fig. 86), the line of fracture running partly along the anatomical neck, and usually through the greater Impacted Fracture of the Humerus through the Tuberosities. FRACTURES. 301 tuberosity, is apparently less rare than pure fracture along the anatomical neck : the fragments are commonly impacted with comminution, and in some cases the upper one has been turned completely over. There is the same tendency to late displacement of the head as after fracture of the anatomical neck, and the treatment is the same. Fracture of the greater tuberosity, complete or partial, is rarely seen except in connection Avith anterior dislocation; it may be caused by direct violence or by the forcible contraction of the attached muscles. The line of fracture runs along the anatomical neck adjoining the tuberosity, down the bicipital groove, and through or below the tuberosity; the fragment may remain partly attached by untorn periosteum or may be entirely separated and draAvn backward. The symptoms are loss of voluntary outward rotation, pain, crepitus, and swelling. Of fracture of the lesser tuberosity only three examples have been reported, two of them in connection Avith the very rare dislocation of the shoulder upAvard, the third Avithout history. (Fig. 87) is caused by external violence, by traction upon the arm or in the axilla Fig Separation of the epiphysis and quite frequently in the neAV-born during delivery. The displacement when not complete is transverse and angular,-the apex of the angle directed forward and upward; when the dis- placement is complete the loAver frag- ment lies on the inner side of the upper. The epiphysis includes the tuberosities, and is so shaped that the upper end of the shaft has the form of a low cone or wedge. The symptoms are commonly very characteristic in this respect, that a distinct prominence can be seen and felt on the front of the shoulder about an inch beloAv the acromion, and that a false point of motion can be recognized by grasp- ing the head and gently rotating the shaft; when the displacement is in- ward this prominence is found beneath the coracoid. Reduction is difficult because of the smallness of the upper fragment, but may be effected by carrying the elbow fonvard and upward, as the posterior portion of the capsule attached to the upper fragment prevents it from sharing in the movement. In a few cases recourse has been had to open incision. Occasionally the growth of the limb at this point is arrested in consequence of the injury, either because the displacement persists or because the epiphyseal cartilage ossifies prematurely. Fracture of the Surgical Neck (Fig. 88).—The surgical neck of this bone is the part betAveen the upper expanded end and the insertion of the pectoralis major and latissimus dorsi. This is by far the most frequent fracture at the upper end ; it is commonly caused by a blow upon the upper part of the arm or by a fall on the hand or elboAv. The line of fracture is usually oblique and the displacement marked, the loAver fragment lying oftenest on the inner side of the upper one, draAvn thither by the latissimus dorsi and pectoralis major. Symptoms.—Abnormal mobility and crepitus are recognized by grasping Separation of the Upper Epiphysis of the Humerus; Displacement Forward of the Lower Fragment. 302 AN AMERICAN TENT-BOOK OF SURGERY. the head of the humerus Avith the thumb and fingers of one hand and gently rotating the elboAv Avith the other. Treatment.—Reduction is made by traction and coaptation and slowly bringing the lower fragment into line with the upper one, and, if the deformity obstinately returns, may be maintained by permanent traction Fig. 88. with Aveight and pulley combined Avith the support of a plaster- of-Paris gutter on the back and sides of the shoulder and arm. If the line of fracture is such that the tendency to displacement is slight, or if confinement to bed is very undesirable, splints or encasement in plaster of Paris may be used. In such a case the forearm should be flexed, and supported only at the -wrist by a sling, in order that the Aveight of the limb may make traction while the patient is erect, or occasionally an additional weight of not more than five pounds may be hung from the elbow. A dressing consisting of a folded towel placed against the side of the chest and extending into the axilla and a little above its borders, a shoulder cap, and a sling at the wrist, Fracture of the gives most excellent results. The arm should be bound to the mfmerus. ° the side by circular turns of a bandage, and the shoulder cap should be held in place by a spica. A splint may be used on the outer side, resting against the acromion and the elbow, the loAver fragment being secured to the splint by a bandage: it opposes the displacement of the latter inward by its counter-pressure against the acromion, but does little or nothing to prevent shortening. The scapular muscles attached to the upper fragment tend to tilt its lower end forward and outw^ard, and Avhen this tend- ency is manifested it must be met by keeping the lower fragment in a corre- sponding position, either by traction in bed Avith the arm abducted or by a triangular splint or cushion placed betAveen the arm and the side and maintain- ing the arm in the desired position. When the fracture is complicated by simultaneous dislocation of the head, the latter may sometimes be reduced by direct manipulation under an anesthetic; if this fails, the surgeon has his choice between securing union of the fracture and making a subsequent attempt to reduce the dislocation and the establish- ment of a false joint. Fracture of the shaft may be caused by direct or indirect violence, or by muscular action; all the varieties of fracture and displacement seen in the shafts of other long bones have been seen here. Among observed complica- tions are rupture, thrombosis, and aneurysm of the brachial artery and injury of a main nerve, especially the musculo-spiral, either at the time of the accident or subsequently by inclusion in the callus. The diagnosis is readily made by attention to the common signs of fracture, all of Avhich are usually present. Union takes place in from four to six AATeeks, but it is to be remembered that failure of union is more frequent after fracture of the shaft of the humerus than after that of any other long bone. The treatment is by an internal angular splint, a shoulder cap, and a sling at the wrist; by moulded splints; or by encasement in plaster of Paris, Avhich should include the forearm (flexed at a right angle) and the shoulder. Unless measures are taken to prevent it, this latter dressing will shoAV after a feAv days a distinct gap above the shoulder, due to the shortening of the arm—a gap that will admit one or tAvo fingers: this may sometimes be prevented by adding a spica about the chest, but more surely and conveniently by a weight attached to the elboAv. If the skin is so bruised that a permanent dressing cannot be applied, the limb must be supported on cushions in a suitable position or bound to the side of the chest. FRACTURES. 303 Fractures of the Lower End of the Humerus.—In this group are included fracture close above the condyles ; above and between the condyles; of either condyle; of either epicondyle; and separation of the epiphysis. In fracture above the condyles, or supracondyloid fracture, the line of fracture passes through the expanded lower end of the humerus, and may open into the joint through the olecranon and coronoid fossae; the line may be transverse or oblique, either laterally or antero-posteriorly, and in a few cases has been almost vertical and transverse—i. e. parallel to the anterior sur- face, crossing the bone close behind the trochlea and capitellum. Symptoms.—The usual displacement is of the lower fragment backward, and the injury is often compound because of perforation of the skin by the sharp end of either fragment, especially the upper. The brachial artery or median nerve may be dangerously stretched across the end of the upper fragment. When the usual displacement is present the general appearance of the region resembles that of dislocation backward of the elbow. The diagnosis is then made by attention to the relations of the olecranon and head of the radius to the epicondyles. Treatment.—Reduction, Avhich is sometimes very difficult, is made by trac- tion and coaptation with the elbow flexed at a right angle or fully extended, and is maintained by posterior and anterior rectangular splints or by a moulded posterior splint or trough that extends well around to the front on both sides; occasionally vertical suspension for a fortnight Avith the elbow fully extended is the best, especially if the fracture is compound; and this attitude has the advantage of being followed by less primary stiffness of the joint than is usual after treatment in flexion. In compound fractures excision of the end of one or both fragments may be needed to secure permanent reduction. Intercondyloid fracture, sometimes called T- or Y-fracture, differs from the preceding by the addition of a line of fracture running from the transverse one doAvnward through or between the condyles; it is usually caused by direct violence, a blow or fall upon the elbow, and is often comminuted or compound. Symptoms.—It may closely resemble a supracondylar fracture, the condyles preserving their relations Avith each other, or the latter may be widely sepa- rated, with the lower end of the upper fragment and the olecranon interposed between them. Treatment.—Complete reduction, in attempting which the aid of anesthesia should always be had, is very difficult, as is also its maintenance. It is to be expected that the movements of the joint after recovery will be seriously restricted, and it is well, therefore, to keep the limb during treatment, or at least during the later weeks of treatment, in the attitude Avhich will be the most useful if ankylosis ensues. A broad, heavy, posterior moulded splint reaching from the shoulder to the wrist, with the elbow flexed at a right angle, extending well around to the front of the limb, and allowed to harden while anesthesia is maintained, is probably the best; it may be aided by permanent traction at the elboAv in the direction of the long axis of the arm. Full exten- sion during the first two weeks with the arm in a padded anterior splint is thought by many surgeons to prevent the displacement upward and backward which often occurs. Whatever method of treatment is first employed, after ten days or two Aveeks it is desirable to flex the elbow and to change the angle of flexion from time to time, in the hope of increasing the range of motion. In compound fractures advantage may sometimes be taken of the wound to pin the fragments together with steel drills passed through them; in other cases excision of the loAver end of the humerus is advisable with the object of obtaining a movable, though weaker, joint. 304 AX AMERICAX TEXT-BOOK OF SURGERY. Fracture of the internal epicondyle may be caused by direct violence or by forced abduction of the extended forearm ; in the latter case dislocation of the elbow usually folloAvs in consequence of the continuation of the violence, and the fracture becomes a complication or an incident of the more important injury. The diagnosis in the pure cases is made by recognition of the mobility of the small fragment, possibly with crepitus: in those in which it complicates a dislocation backward the diagnosis is made in the same manner; but in dis- locations outward the fragment is liable to be drawn down below the trochlea, where it cannot be felt, and the diagnosis must then be" made upon its absence. The treatment is by immobilization of the joint in flexion at or within a right angle, to diminish the effect of the attached flexor muscles upon the frag- ment. Fracture of the external epicondyle is very rare; the diagnosis must be made upon the recognition of a small movable fragment at the seat of the epicondyle. Fracture of the Internal Condyle (Fig. 89).—The line of fracture ex- tends from a point on the inner side of the humerus above the epicondyle down- ward and outward into the joint at the center of the trochlea Fig.JS9. Qr between the center and the capitellum. The usual displace- ment is of the fragment upward and backward, and, even if it is but slight, the persistence produces marked deformity by changing the relations of the long axis of the arm and making the external condyle unduly prominent. The toni- city of the triceps appears to favor recurrence of this dis- placement, as does also pressure upon the upper part of the ulna when the elbow is flexed. This undesirable pressure may be readily exerted by a supporting sling, with or with- out a splint, and consequently the arm should be supported only at the Avrist. Treatment.—If care be taken to avoid such pressure and to make complete reduction in the first instance, satis- factory results can usually be obtained by treatment in a posterior rectangular or moulded splint or trough, or even Fracture of the inter- in a plaster-of-Paris dressing, but it is advisable to examine Hum^ras,yldisplace^ ^e J0mt at ^e en(* 0T' a wee^ or ten ^aJS aT1(^ correct me ment upward and in- displacement if it has recurred. Treatment Avith the joint in full extension enables us more surely to avoid this dis- placement of the condyle upward, and has given many excellent results, but the attitude is not so convenient to the patient as that of flexion, and in some cases there is a tendency to displacement forward or tilting of the fragment in the extended position. If it is employed at all, it is perhaps sufficient to employ it during the first fortnight, and then to substitute flexion. The ulti- mate result in the young may be greatly impaired by excessive formation of callus. A complication occasionally seen is coincident dislocation of the radius backward; that is, both bones of the forearm and the internal condyle are displaced backward, the ulna preserving its relations with the latter and with the radius. Recurrence after reduction is best avoided by keeping the elbow flexed at less than a right angle. Fracture of the External Condyle.—In this the line of fracture runs from a point on the supinator ridge downward and inAvard through the capitel- lum or the outer part of the trochlea. Ordinarily the displacement is slight, FRACTURES. 305 but it may be considerable, with coincident displacement of the ulna from the internal condyle outward or backward, the head of the radius maintaining its relations with the capitellum and ulna. The treatment is immobilization in a posterior rectangular splint or immovable dressing. Separation of the epiphysis is not a frequent accident, and there have been but feAv opportunities for direct examination of specimens. The lower fragment usually comprises the entire epiphysis, which is composed of several distinct pieces, but it is possible that either or both epicondyles may remain attached to the upper fragment. The symptoms and treatment are in the main the same as those of supracondylar fracture, of which the injury may be con- sidered a low form. In order to prevent angular displacement Mr. Hutchinson has recommended treatment with the elbow fully flexed. After-treatment of Fracture just above the Elbow.—When union after fracture above the elbow is complete and the splints are laid aside, the elbow is usually very stiff, and much anxiety may be felt concerning its "future usefulness; but in the great majority of cases the range of motion will rapidly increase under natural use of the limb, and the surgeon can do but little to hasten it. Daily forcing of the joint is more likely to do harm than good, and the best results are obtained by simply encouraging the patient to make as much use as possible of the limb, and perhaps aiding him by elastic traction from the Avrist to the shoulder to increase flexion, and making him carry a weight in the hand to increase extension. FEACTUEES OF THE EADIUS AND ULNA. Fracture of the olecranon may be caused by the contraction of the triceps or by external violence received upon the olecranon or upon the ulna near it, the commonest cause being a fall or blow upon the elbow. The line of fracture may be at right angles to the long axis of the bone in both planes, or oblique in either plane, or irregular. The displacement may be slight, the periosteum being in great part untorn, or the fragment may be drawn one or two inches upward by the triceps. The symptoms are localized pain, independent mobility, and crepitus when there is but little displacement, and the absence of the olecranon from its proper place and its presence at a higher point when there is much displacement. Treatment.—If the displacement is slight and the olecranon accompanies the ulna in the flexion of the elbow, no other treatment is required than immo- bilization of the limb in a sling or an immovable dressing; but if the olecranon is completely detached and drawn upward, the elbow must be immobilized in full extension by a long anterior splint, and the fragment be held down by strips of adhesive plaster or india-rubber traction or the turns of a roller bandage. Of these various methods, one of the simplest and most effective is a U-shaped strip of adhesive plaster the curve of which lies on the back of the arm close above the fragment and the sides are carried down upon the forearm. In a few cases the fragments have been exposed by incision and wired together, but except in old cases Avith failure of union and much disability this is hardly jus- tifiable. Union may be bony or fibrous, and even when union fails active extension is not entirely lost. Fracture of the coronoid process is almost unknown except as a complication of dislocation of the elbow backward; the tendency to displace- ment is not great, for the only muscle that is attached to the process, the brachialis anticus, is also broadly attached to the front of the ulna below it, and this broad attachment must be broken before the muscle can draw the 20 306 AX AMERICAX TEXT-BOOK OF SURGERY. fragment upAvard. The fragment can sometimes be felt as a small movable body in the flexure of the elbow. The treatment is by immobilization of the joint flexed at a right angle. Fracture of the head of the radius has been observed mainly in con- nection with fracture of the coronoid process of the ulna as a complication of dislocation of the elbow; it is partial, the fragment being the inner or anterior portion of the head. Of fracture of the neck of the radius afeAv cases have been recorded: it may be followed by suppuration of the joint or by bony union. The clinical histories are not sufficient to permit a systematic description: possibly the diagnosis could be made by localized pain and by recognition of the failure of the head to share in rotatory movements of the shaft of the radius. Fracture of the Shaft of One or of Both Bones of the Forearm. —Fracture of both bones is frequent in the lower and middle thirds, rare in the upper third. Usually the radius is broken at a somewhat higher point than the ulna. They may be broken by direct or indirect violence, and rarely by muscular action. Partial, "green-stick," fractures are not uncommon in the young. Fracture of the ulna alone is commonly due to direct violence, a blow upon the raised arm, but it may be caused by a fall upon the hand, and is then occasionally complicated by dislocation of the head of the radius fonvard and upward. Fracture of the radius alone is less frequent than that of the ulna, and may be caused by direct or indirect violence. The displacement may be angular or lateral or with overriding, and is of especial importance because of its effect, if unreduced, upon the function of rotation of the forearm. Rotatory displacement of the upper fragment of the radius occurs especially Avhen FJO- 90. the fracture is above the in- sertion of the pronator radii teres; the unopposed action of the biceps supinates it, and the result, if uncorrected, is to limit supination of the limb : a study made by Cal- lender of the specimens in the London museums shoAved Fracture of the Forearm^anguto displacement, and union be- guch displacement varying be- tween six and forty degrees. The action of the biceps may also produce angular displacement by flexing the upper fragment. Rotation of the forearm may be lost in consequence of excessive formation of callus, of the union of the callus on the tAAO bones (Fig. 90), or of ossification of the interosseous ligament. The diagnosis of fracture of both bones is easy, that of either bone alone may be more difficult: independent mobility in the radius may be recognized by observing that the head of the radius does not share in slight rotatory move- ments communicated to the lower end; in isolated fracture of the ulna there is localized pain, often a corresponding irregularity in outline that is easily rec- ognizable, and sometimes independent mobility can be obtained. The position of the head of the radius should ahvays be verified in case of fracture of the ulna alone. Treatment.—Reduction is made by traction, writh or Avithout pressure upon the projecting angle when one exists, pressure being necessary in "green- stick " fractures; and by deep pressure with the fingers in front and behind to press the bones apart if they have been approximated. Anterior and posterior FRACTURES. 307 Fig. 91. Fig. 92. padded splints, long enough to reach from beloAv the palm to the elbow and wide enough to prevent circular constriction of the limb by the bandage that secures them in place, are usually sufficient to maintain reduction. The fore- arm should be midway between pronation and supination. Frequent inspection is necessary at first to detect dangerous constriction. Gangrene has occurred from pressure of the upper end of the palmar splint against the brachial artery at the bend of the elbow. This splint may, therefore, with advantage be made from one to three inches shorter than the posterior one. For the same reason it is well to apply the splints while the forearm is flexed upon the arm. The supporting sling should not rest against the ulna. If there is reason to guard against supination of the upper fragment by the biceps, the wrist must be correspondingly supinated; this position is someAvhat irksome, and has the disadvantage of bringing the bones nearer together at the center than they are when the limb is in the midway position. After two or three weeks a moulded plaster-of-Paris dressing may be substituted for the splints. In simple fracture of the radius or ulna alone without displacement moulded plaster of Paris may be safely used even earlier. If dislocation of the head of the radius forward and upward has occurred in connection Avith fracture of the ulna alone, the limb should be dressed after reduction, Avith the elbow flexed at less than a right angle. Fracture of the Lower End of the Radius (Colles's Fracture).— This is one of the most common of all fractures; it is seen at all ages, but with the greatest frequency in the old. It is generally produced by a fall upon the palm of the hand. The line of fracture is usually situated at from one- third to three-fourths of an inch above the articular edge, and is transverse, but may be oblique in either direc- tion, and sometimes the lower frag- ment is comminuted. In the young it appears usually to folloAv the epi- physeal line. The common displace- ment is of the lower fragment back- ward (Figs. 91 and 92), Avith ascent of the styloid process by crushing, and of the posterior articular border by tilting or angular displacement, so that the articular surface looks down- ward and backward instead of doAvn- ward and forward. The periosteum on the back of the bone remains untorn, but is stripped up from the upper fragment so as to form a "peri- osteal bridge:" the consequent forma- tion of bone in the interval gives to specimens of old unreduced fractures the appearance of deep penetration of the lower by the upper fragment. Exceptionally the styloid process of the ulna may also be broken off, or even the shaft of the ulna broken close above its loAver end. The symptoms are a characteristic deformity, consisting in a prominence on the back of the forearm close above the wrist corresponding to the loAver fragment, producing Avhat is often called the "silver-fork" deformity (Fig. 93), and a fulness on the palmar surface at a somewhat higher level, corresponding Recently-united Fracture of the'Lower End of the Radius. Fracture of the Lower End of the Radius, displacement of bro- ken fragment back- ward. 308 AX AMERICAN TENT-BOOK OF SURGERY. to the end of the upper fragment; the ascent of the styloid process of the radius to or above the level of that of the ulna; pain on pressure along the line of the fracture posteriorly; and swelling of the front of the wrist, with deepening Fig. 93. " Silver-Fork " Deformity of Colles's Fracture, photographed half an hour after the accident. of the transverse lines between it and the hand. Crepitus and abnormal mobility are often absent. Treatment.—Reduction, Avhich at times is very difficult and even impos- sible, should be first attempted by traction upon the hand and direct pressure upon the fragments ; if that fails, the Avrist should be placed in forced extension and the fragment pressed downward by the surgeon's thumbs while his fingers grasp the forearm above the fracture. If this also fails, an anesthetic should be given, and the fragment mobilized by pressing it backAvard, and then forced forward into place. It is of great importance to the appearance of the limb that the posterior displacement should be fully corrected: that which is due to the crushing of the spongy tissue and shortening of the outer border of the bone cannot be corrected. If reduction is Avell made, there is but little tendency to recurrence. The limb is then placed between short anterior and posterior splints, the former padded lightly at the point corresponding to the end of the upper fragment, and the latter more thickly where it rests against the loAver fragment, and the splints fastened by a circular strip of adhesive plaster near each end and at the middle, or held in place by a roller bandage. The posterior splint should end at the wrist; the anterior one may end at the same level, or may be carried to the palm with a pad at its lower end, over which the fingers may partly close. Many surgeons prefer after reduction to place the hand in flexion on a Levis's metallic splint. In cases where there is little tendency to displacement of the loAver fragment a Bond's splint with the Avedge-shaped compresses as above will give excellent results. The dressing of Barton is that preferred by some surgeons, and varies a little from the one just described. Tavo wedge-shaped compresses and tAvo light, well-padded splints long enough to reach from the elbow to the tips of the fingers are employed. The compresses are placed over the region of the fracture, one on the dorsum of the wrist Avith its base upAvard and resting on the upper end of the lower fragment, the other on the front of the Avrist, its base downward and correspond- ing to the lower end of the upper fragment. They are held in place by a few turns of a roller; the anterior splint (the shorter of the two) is next put in position, and the roller is carried over it while extension is kept up by an assist- ant, and then the posterior splint is applied. The arm is kept midway between pronation and supination; the thumb is left free. Passive motion of the fingers FRACTURES. 309 should be constantly made. In the young, groAvth of the bone may be arrested by the traumatism, with a resultant deformity resembling that of a fracture with much crushing of the spongy tissue. Fracture of the anterior or posterior lip of the lower end of the radius is an occasional accompaniment of dislocation of the carpus forward or backward respectively ; the latter is known as Barton s fracture. Fracture of a metacarpal bone may be produced by direct or indirect violence; the diagnosis is made by localized pain increased by pressing the corresponding finger upward, and perhaps by abnormal mobility and crepitus. The tendency to displacement is slight, and no special treatment is required other than a palmar splint padded to preserve the concavity of the metacarpus. Fractures of the phalanges are usually the result of direct violence, and are often compound. In fracture of the proximal phalanx there is a marked tendency to angular displacement with the apex directed forward, which if left unreduced is the source of considerable disability. A convenient and efficient treatment is to close the fingers over a cylindrical roller bandage of suitable size, and bind them there with longitudinal strips of adhesive plaster or another roller bandage outside; or a padded palmar splint may be employed. FEACTUEES OF THE PELVIS. These fractures include complete fractures at one or more points of either or both innominate bones, and fractures of any of the three bones constituting the innominate. Fracture of the ring of the pelvis is caused by great external vio- lence, such as the passage of the wheel of a Avagon across the bone, the fall of a heavy object, the caving in of an embankment, the kick of a horse, or a fall from a height. It may be single, double, or multiple. The most frequent seat is in the pubic bone, the line of fracture passing through the upper ramus just internally to the ilio-pectineal eminence, and through the lower ramus near its junction with the ischium. With the anterior fracture may be associated a posterior one (double vertical fracture of the pelvis), either in the ilium behind the acetabulum or in the sacrum, or partly in either bone and partly along the sacro-iliac synchondrosis, or another anterior one through the opposite pubic bone. Separation of either symphysis is the practical equivalent of a fracture, but separation of the pubic symphysis alone may be occasioned by much slighter violence than that AArhich is required for a fracture; separation of both symphyses is caused only by great violence, and is usually described as disloca- tion of the os innominatum. The pubes is sometimes broken in two places or comminuted. An exceptional form of fracture of the lateral portion of the ring is that in which the violence is exerted through the femur and produces a radiating fracture of the acetabulum. Associated injuries are common and severe: the most frequent in the male is rupture of the membranous portion of the urethra (see Injuries of the Urethra), the laceration extending in severe cases through the perineum and around the rectum and anus ; rupture of the bladder is next in frequency, and then injuries of other abdominal viscera. The displacement is sometimes very marked, so that it is easily recognized by the finger and eye; in other cases the diagnosis must be made by localized pain caused by direct pressure or by pressure imvard or backward upon the wing of the ilium. The patient is unable to raise the leg from the bed. Rup- ture of the urethra is indicated by bleeding from the meatus. The treatment of the fracture consists in immobilization of the pelvis by a 310 AX AMERICAN TEXT-BOOK OF SURGERY. girdle, aided in double vertical fracture by traction upon the limb, as after fracture of the thigh. If the fracture is compound, ample drainage must be provided, and if the urethra is injured, perineal section must be made. Transverse fracture of the sacrum is very rare, and has always been caused by direct violence. It is frequently associated Avith paralysis of the bladder, rectum, and lower limbs. The displacement is angular, with the apex directed backAvard, and can be corrected by pressing the coccyx forward. Fracture of the coccyx, which is very rare, resembles in symptoms and treatment dislocation of the same bone. Fractures of the wing and processes of the ilium are compara- tively frequent. The crest of the ilium may be broken off by direct violence, the size of the fragment varying greatly in the different cases. The anterior superior spinous process has been broken off by direct violence and by muscular action; the posterior inferior and the anterior inferior, by direct violence. The diagnosis is made by recognition of a movable fragment with crepitus. No special treatment other than rest in bed is required. The ischium has been broken in a few cases by direct violence, as a fall upon the buttocks; the fragment in some cases has included almost the entire bone, in others only the tuberosity. Fracture of the pubes not extending across both rami is rare: we have seen one case in which the upper half of the body and the adjoining part of the horizontal ramus were broken off; the fracture Avas compound, and the fragment Avas removed. Fracture of the rim of the acetabulum is a complication of disloca- tion of the hip. FEACTUEES OF THE FEMUE. Fracture of the Neck of the Femur.—This is far more common in elderly people, especially in women, than in the young or middle-aged, and is Fig. 94. Fig. 95. Fracture at the Small Part of the a-^,Jir Neck of the Femur. Fracture at the Base of the Neck of the Femur, with splitting of the great trochanter. generally caused in them by comparatively slight violence, as a fall while walking, a misstep, or even the effort to avoid a fall. The old classification as intra- and extra-capsular fractures, which was ahvays unsatisfactory ERA CTURES. 311 and took no account of the large group of "mixed" fractures in which the line lay partly within and partly without the capsule, has now in great part given place to a division into fractures at the base of the neck and fractures at the small part of the neck. In fractures at the small part of the neck (Fig. 94) the line of frac- ture crosses the neck transversely or obliquely, and is rarely impacted: a portion of the periosteum, usually on the anterior and inferior surface, com- monly remains untorn and aids in supplying blood to the head. Bony union is possible, but unlikely. Separation of the epiphysis, which is constituted by the head alone, occasionally happens, and belongs in this group. In fracture at the base of the neck (Fig. 95), the more common variety, the line of fracture follows more or less closely the junction of the shaft and neck; the fragments are often impacted (PI. XII, Fig. 2), and the great trochanter split; the crushing or impaction appears commonly to Fig. 96. be greater at the back than at the ,„--------^ front, so that the neck is inclined ,-''' backAvard from its normal position / with reference to the shaft, or, in other words, the shaft is in outward rotation upon the neck (Fig. 96). Bony union is the rule, and often Avith excessive production of bone about the fracture and the trochanter. The symptoms of both varieties are inability, often complete, to use or move the limb; but occasion- ally the patient has been able to raise the limb from the bed or even to Avalk a short distance. As a rule, hoAvevTer, the limb lies straight and helpless on the bed, the foot is everted, the upper part of the thigh is fuller and rounder than usual. Complaint is made of pain at the hip, and often in the anterior and inner part of the middle of the thigh. Pain is caused by pressure in front of or behind the neck, against the trochanter, or upAvard at the knee or ankle; but sometimes the limb can be pressed quite forci- bly upAvard Avithout causing pain. If eversion of the foot is absent, it will nevertheless be found that passive inversion is less complete than normal. Occasionally the foot is fixed in inversion. Pressure over the front of the neck shoAvs that the tissues are less depressible than on the other side—a valuable sign in obscure cases. On gentle rotation of the limb the trochanter is found to share in the movement, and occasionally crepitus is felt. Measurement (in making Avhich care must be taken to place the limbs sym- metrically with reference to the pelvis, as mentioned on page 281) shoAvs the injured limb to be shorter than its fellow, the difference varying betAveen a small fraction of an inch and two inches. This is best done by marking the Impacted Fracture at the Base of the Cervix Femoris, with bending of the head backward. 312 AN AMERICAN TEXT-BOOK OF SURGERY. A C D, Bryant's ilio-femoral triangle; A B, Nelaton's line. site of the spines with an aniline pencil, and then measuring from the fixed malleolus to the mark over spine without touching the skin at the latter point. Similarly, the trochanter is found to occupy a higher posi- tion than its felloAv with refer- ence to a line draAvn across it from the anterior superior spinous process of the ilium to the tuberosity of the ischium (Ndlaton's line) (Fig. 97). If a line be draAvn through the two anterior superior spines, and the distance from the summits of the trochanters to this line be measured, it will be found shorter on the injured side (Bryant's line) (Fig. 97). The diagnosis between the two varieties cannot ahvays be made Avith certainty: a positive sign of fracture at the base of the neck is enlargement of the trochanter, due to its splitting; and it is thought that in fracture of the small part of the neck the shortening is more likely to be slight at first and to increase suddenly and rapidly during the first few days from separation of the interlocked fragments. It may even be impossible to say Avith certainty that a fracture is present, but in any case in Avhich an elderly person, especially a Avoman, has fallen and complains of pain at the hip, with inability to use the limb, a fracture is prob- able, and the case should be treated as such for at least three weeks and until all pain and soreness have ceased. It has happened, often enough to justify great caution in giving an opinion, that the positive signs of fracture have not appeared until after a number of days, perhaps after the patient has been assured that he has suffered no serious injury and has been encouraged to use the limb. In not a few cases the patient has remained disabled long after the surgeon has ceased his attendance, and has sued the latter for malpractice. The indications for treatment are, in the order of their importance, in the case of the old and feeble, to guard against the danger to the life of the patient arising from the traumatism and the necessary confinement, to secure firm union, and to have the minimum of deformity. The vital indication requires that the patient's strength should not be further taxed by dressings that cause pain or by prolonged confinement to bed if its ill effects become manifest and threaten to become serious. In the latter case, if necessary, union of the frac- ture must be sacrificed to the preservation of life. Special attention must be given to securing comfort and good nourishment and to the avoidance of bed- sores. Local treatment is limited to making only so much reduction of the shortening as can be effected by moderate traction, and to immobilization by traction and cushions or by a fixed dressing. Complete removal of the short- ening is liable to break up an impaction that Avould be valuable in securing union. Traction by Buck's extension (Fig. 76) Avith a weight of five, or at most ten, pounds prevents further shortening and promotes comfort, and small firm cushions or sand-bags placed behind the trochanter and along the outer side of the thigh aid the immobilization. Ilodgen's suspended splint (Fig. 80) is also highly recommended. For immobilization Avithout permanent traction either a long side splint, extending from the side of the chest to the foot, or a plaster- FRACTURES. 313 of-Paris dressing, including the entire limb and the pelvis, may be employed. Lateral pressure in non-impacted fractures is of great importance in securing bony union, and on this account Senn recommends Avith the latter dressing the use of direct pressure imvard against the trochanter, made through a fenestra by a pad at the end of a screAv that passes through an iron support imbedded in the plaster. A well-applied plaster dressing appears to meet the indication suffi- ciently well. The dressing should be Avorn for about two months if the patient's condition permits. It is to be expected that some shortening and outward rotation of the limb will persist; and the range of motion of the joint may be considerably restricted by the consequences of the arthritis or by an exuberant callus. Even if union fails or is fibrous, the patient may still be able to make fair use of the limb, the support being given by the Y-ligament, which secures a bearing against the ilium in the ascent of the shaft. In a feAv cases in Avhich union has failed and the disability has been great and the condition painful, operations have been done to obtain union by freshening the surfaces and suturing or pinning the fragments together, or to remove the detached head. Fracture of the great trochanter has been occasionally caused by direct external violence. The patients have usually been able to walk not- withstanding the injury. In the specimens obtained after death the fracture has always been found to be entirely outside the joint. The fragment may be large or small, and in the young may comprise the entire trochanteric epiphysis, separated along the conjugal cartilage. The diagnosis must be made on the independent mobility of the fragment and localized pain. The treatment is rest, aided perhaps by a bandage to oppose the retraction of the fragment upward and backward by muscular action. Fracture of the shaft may be caused by direct or indirect violence or by muscular action. All the varieties of fracture of the shafts of long bones are found here, but the commonest is oblique fracture, often with the splitting off of a lateral piece, and with either or both main fragments ending in a long sharp point: transverse fracture appears to be quite common in children. Symptoms.—Angular displacement and overriding are greatly favored by the contraction of the muscles, both those connecting the loAver fragment with the pelvis and those that flex and abduct the upper one. Outward rotation of the lower fragment may be produced by the unsupported weight of the foot, which turns to the outer side ; outward rotation of the upper fragment may be caused in like manner by the unsupported Aveight of the upper and outer por- tion of the thigh, the foot being meanwhile held upright. The latter displace- ment is equivalent to inward rotation of the loAver fragment, and Avhen the patient begins to walk he finds that the toes turn in. Compound fracture and associated injury to the large vessels are infrequent. Distention of the knee- joint by an effusion immediately after the injury is the rule, and is probably due to a concomitant sprain. The diagnosis is made by pain, loss of function, shortening, abnormal mobility, and crepitus. Measurement is made, as in fracture of the neck of the femur, from either the malleolus or the knee to the anterior superior spine of the ilium, and the same precautions are needed to ensure symmetry of posi- tion. The fact that the shortening has occurred in the shaft, and not in the neck, is shoAvn by the normal relation of the trochanter to Nelaton's line. Abnormal mobility can be recognized by passing the hand under the limb at the suspected point and gently raising it, or by grasping the upper part of the thigh firmly and moving the foot inward and outward, or by observing that the trochanter does not share in gentle rotatory movements communicated to the 314 AN AMERICAX TEXT-BOOK OF SURGERY. lower portion of the limb. Steady traction overcomes or diminishes the short- ening. The thickness of the overlying muscles usually prevents recognition of the details of the fracture and displacement. Sometimes the sharp end of one fragment perforates the muscles and the skin, commonly the upper frag- ment in front; the penetration can be relieved by flexing the thigh upon the pelvis and the leg upon the thigh, the movement drawing the muscle down past the fragment. Treatment is commonly by one of the methods of continuous traction, Buck's extension by weight and pulley (Fig. 76) or suspension by Hodgen's (Fig. 80) or N. R. Smith's anterior splint (Fig. 79) in adults, or vertical sus- pension in infants and young children. Hodgen's splint is especially useful in compound fractures, because of the facility with which it permits the dressings of the wound to be changed. The methods of applying Buck's extension and the suspended splints have been already described. The plaster-of-Paris dress- ing, including the pelvis, is still in use, but its results are not so satisfactory as those obtained by the other methods. Vertical suspension in young children is very useful, because of the ease with which the position can be maintained and the child kept clean. The suspension is made by two india-rubber cords attached to a cross-bar above the bed and one to each leg by adhesive plaster, as in Buck's extension; the limbs are kept parallel by attaching the feet to a short foot-piece. The traction should be just sufficient to raise the buttocks slightly from the bed. Union is complete in the adult in from six to eight weeks; in young children, in three or four. It is advisable to keep the patient in bed for a week after the dressings have been removed, and to insist upon the use of crutches for a Aveek or two thereafter. Usually some shortening persists. Fractures at the Lower End of the Femur.—In this group are included the supracondylar, intercondyloid, fracture of either condyle, and separation of the epiphysis. Supracondyloid fracture is commonly produced by indirect violence, as a fall upon the feet; the line of fracture is oblique or transverse; and the usual displacement is of the lower fragment backward. Flexion of the lower frag- ment upon the tibia by the action of the gastrocnemii, by Avhich its fractured surface is directed somewhat backward, occasionally occurs, but is by no means so frequent as has been alleged. A dangerous complication Fig. 98. i§ sometimes found in rupture or stretching of the popliteal vessels. The diagnosis is easily made by recognition of the common signs of fracture. Treatment is by the plaster-of- Paris dressing or by suspension in Hodgen's or Smith's an- terior splint. Separation of the epiphysis is commonly caused by torsion or hyperextension of the leg. The treatment is the same as in the preceding variety. In intercondyloid fracture (Fig. 98) the condyles are separated from the shaft and from each other. It is caused by great violence, as in a fall from a height, and is consequently often compound and accompanied with much intercondyloid Fracture displacement. It is always a serious injury, and if com- of Femur. pound, a grave one. Continuous traction by Buck's exten- sion or a suspended splint is advisable for the first two or three Aveeks, after Avhich, if all is going well, the limb can be put in plaster. If compound, it is, of course, to be treated antiseptically. Fracture of either condyle may be caused by direct violence, as in a FRACTURES. 315 fall upon the flexed knee, or by lateral flexion of the leg: the line of frac- ture runs from the intercondyloid notch more or less obliquely upAvard. The fragment remains attached to the tibia by its lateral ligament, and the dis- placement is therefore usually slight, although the fragment is sometimes carried forward or backward by rotation of the leg. The course is usually simple and the result good, but in a feAv cases suppuration of the joint or necrosis of the fragment has followed. The diagnosis is made by the recogni- tion of abnormal mobility and crepitus; sometimes the only sign is localized pain on pressure, or on lateral flexion of the leg toward the injured side. The treatment is reduction of the displacement, if any, by bringing the leg to its proper position in full extension, and immobilization, preferably in plaster. Fracture of the patella is an injury of frequent occurrence between the ages of tAventy and fifty years, especially in males. It is usually the result of muscular action, but sometimes of direct violence, and sometimes of forcible flexion of the partially stiff knee when the descent of the patella is prevented by adhesions; the latter is the common method of production of refracture. Dull pain is occasionally felt in the patella for some days before it breaks. Simultaneous fracture of both patellae has been reported a number of times. The line of fracture is almost ahvays transverse, and, while generally near the middle of the bone, may be close to either end; exceptionally it may be oblique. In fractures by direct violence it is more or less comminuted, and is likely to be compound, or to become so by the sloughing of the bruised skin. The upper fragment is draAvn upAvard by the quadriceps to a greater or lesser distance, but in some cases, and especially in fractures by direct violence, so much of the periosteum remains untorn that the separation is very slight. As a rule, the periosteum ruptures at a different level from that of the fracture, and thus is produced a narroAV fringe Avhich lies betAveen the fragments when they are approximated, and to Avhich much importance has been attributed as a cause of failure of bony union. The capsule is torn transversely on each side to a distance that varies with the separation, and the cavity of the joint promptly fills with blood and synovia, Avhich still further increase the separa- tion by distention. The symptoms are loss of the power of active extension of the leg, inde- pendent lateral mobility of the fragments, and usually a distinct transverse gap between them which can be closed by pressing them together. The treatment is immobilization of the extended knee for about tAvo months, usually combined with dressings arranged to keep the fragments in contact with each other. When the peri- osteal covering is not torn Fig. 99. and the separation is slight, ft a plaster-of-Paris dressing, extending from the ankle to the upper third of the thigh, is sufficient, but in other cases special dressings * are needed. Of these the variety is great. The sim- plest form consists of turns of a roller bandage, with a long posterior splint, applied obliquely above and beloAv the fragments, so as to press Hamilton's Dressing for Fracture of the Patella. The final turns of the roller in front of the knee are not shown in the cut. and hold them together (Fig. 99); the patient 316 AN AMERICAN TEXT-BOOK OF SURGERY. should be kept in bed with the foot raised. Agnew's splint (Fig. 100) consists of Fig. 100. Agnew's Splint for Fractured Patella. a piece of pine board thirty inches long, five inches wide at the top, and four at the lower end, with four lateral pegs. Fig. 101 shows the manner of its appli- Fig. 101. Fig. 102. Agnew's Splint Applied. cation, the fragments of the fractured patella being drawn together by the adhe- sive plaster strips. Another method is by elastic traction applied to the upper fragment: a piece of rubber tubing is made fast to each end of a strip of adhe- sive plaster about eight inches long and tAvo inches wide ; the adhesive plaster is then placed transversely close above the upper fragment, and the rubber cords are stretched down on each side of the leg and made fast to the posterior splint. Malgaigne's hooks (Fig. 102) are used by forcing one through the skin into the upper border of the upper fragment, the other into the loAver border of the lower fragment, and then bringing them together by means of the screAv. Treves employs them after a prelimi- nary exposure and freshening of the frag- ments, as in the operation of suturing, over Avhich he thinks this procedure has some advantages. In any of these methods the effusion in the joint may often be promptly removed by the use of a rub- ber bandage, or the joint may be primarily emptied by aspiration of its con- tents. Operative measures include various forms of suture. The first to be employed Avas an open arthrotomy Avith direct suturing of the fragments with silver Avire : it has given many brilliant successes, but also cases of suppuration of the joint, some Avith loss of the limb or loss of life—a risk which, in the opinion of some surgeons, the nature of the injury rarely justifies. The ope- Malgaignc's Hooks FRACTURES. 317 ration should only be done under strict antisepsis and in healthy subjects. In compound fractures it is not only permissible, but is often clearly indicated. The operation is done by exposing the fragments, freshening the fractured sur- faces if the fracture is an old one, or dissecting a\vay the fibrous tissue and fragments of periosteum or synovial membrane often found interposed, and drilling the bones in the median line, the drill-holes running obliquely from the anterior surface of the attached border of each fragment toward the posterior edges of the fractured surfaces. Silver wire is then introduced and the fragments are approximated, the wire being cut short and the ends ham- mered into the bone, or else left to protrude from the wound to be with- drawn later. The substitution of a silk ligature through the tendon of the quadriceps and the ligamentum patellae for the Avire suture through the bone is preferred by some. The joint must not be invaded by the ligature. Subcutaneous suture has been used in several Avays: that through the tendon of the quad- riceps and the ligamentum patellae is done as follows (Stimson): After thorough antiseptic preparation of the limb and instruments, four small incisions or punctures are made deeply through the skin at each corner of the patella, O 5 then a strong silk suture is passed by means of a long half-curved Hagedorn needle from one lower incision to the other through the ligamentum patellae, then in again at the point of exit and upAvard between the patella and the skin to the upper puncture on the same side, then transversely to the other upper puncture through the tendon of the quadriceps, and then back betAveen the bone and the skin to the point of beginning ; the fragments are drawn together with tenacula inserted above and beloAv, the suture drawn tight and tied, the ends cut short, and the small incisions closed, if necessary, with a catgut suture. It can be easily done under cocaine. An antiseptic dressing is applied, and the limb kept on a posterior splint for a Aveek. If all has then gone Avell, a plaster- of-Paris dressing is applied and worn for a month; after that, for another month it is Avorn only in the daytime and removed at night. The silk should be boiled and all antiseptic rules should be most rigidly followed ; if suppuration occurs, free exit should be promptly given to the pus, to diminish the risk of invasion of the joint. This method does not provide for the removal of the fringe of periosteum or the portions of capsule which are often found betAveen the frag- ments of a fractured patella, and Avhich, as has been said, are thought by many to be the chief cause of failure to obtain bony union. Union is almost invariably fibrous in cases treated without the suture, and the bond of union habitually lengthens somewhat under use, but this does not materially affect the usefulness of the limb. In cases treated by the suture the union is closer, and may occasionally be bony. Rupture of the bond or refracture of the bone at another point occasion- ally happens: the common cause is forcible flexion of the knee, in Avhich the upper fragment is prevented from moving by adhesions that unite it to the femur or by shortening of the capsule on each side, which does not allow it to pass below the condyles. The injury may become compound by rupture of the adherent skin along the line of fracture. In old cases, in Avhich the disability is great because of the Avide separation of the fragments, open arthrotomy Avith suture has been done many times. Since modern aseptic methods have come into use, the proportion of successful cases has been much larger than formerly. 318 AN AMERICAN TEXT-BOOK OF SURGERY. FKACTUEES OF THE LEG. Fractures at the Upper End.—The tibia may be broken at its upper end by direct or indirect violence, and the fibula may be simultaneously broken or its upper end dislocated, or it may be uninjured. The fracture may be transverse, oblique, or comminuted and impacted, or the line may run from the side of the head into the joint, separating only one condyle, or it may folloAv the epiphyseal line (separation of the epiphysis). In fractures by direct violence, usually by a heavy blow upon the front of the bone, there may be marked angu- lar displacement, the apex directed backward, or backward displacement of the loAver fragment, with the possibility of serious injury to the main vessels. In fracture by a fall upon the feet the lowrer fragment is driven into the upper one, splitting it and opening the joint. When the fibula is neither broken nor dis- located, displacement of the tibia is slight. The prognosis is serious because. of the probability of implication of the joint in the inflammatory reaction, and it has been noted that repair of the fracture takes an exceptionally long time. After separation of the epiphysis the growth of the bone may be arrested. The treatment consists in the reduction of the displacement, and in exten- sion by continuous traction, or by splints, according to circumstances. Fracture of the Upper End of the Fibula may be caused by muscular action (vigorous contraction of the biceps), by forced adduction of the leg, or by direct violence. The fragment may remain in place or may be draAvn upAvard by the biceps. In several cases the external popliteal nerve has been injured, either in the accident or in the process of repair, with consequent paralysis of the anterior and peroneal groups of muscles. The treatment is immobilization, Avith the knee flexed to relax the biceps. Fracture of the Shaft may be caused by direct or indirect violence, and in the latter case is more frequently situated at or near the junction of the middle and lower thirds. It may be transverse, oblique, V-shaped, or commi- nuted, and is frequently compound, either by the direct action of the violence upon the overlying soft parts or by perforation of the skin by the sharp end of one of the fragments, especially the upper one. When both bones are broken the fracture of the tibia is commonly at a lower level than that of the fibula. The common displacement is angular with overriding, the loAver end of the upper fragment being displaced forward. The injury can be readily recognized by palpation of the subcutaneous surface of the tibia; abnormal mobility, which is greater when both bones are broken; and crepitus. Fracture of the fibula alone is shown by localized pain, and sometimes by abnormal mobility. Treatment.—After reduction by traction and coaptation the limb may be secured by lateral splints or in a Volkmann splint or fracture-box for a few days until the SAvelling shall have subsided, and then in a plaster-of-Paris dressing, or it may be secured at once in moulded plaster-of-Paris splints, posterior and lateral. Care must be taken to prevent angular displacement by the sinking of the foot, and it is ahvays advisable to remove the dressings and inspect the fracture after the first fortnight, Avhen it is still possible to correct angular displacement. Compound fractures should be dressed in accordance with general prin- ciples, and the limb placed in a fracture-box or Volkmann splint; if the fracture has not become simple by the end of the first fortnight, interrupted plaster splints arranged for suspension Avill be found convenient. Delayed union and failure of union are not uncommon if there has been much loss of substance of the tibia by splintering; and if the fibula has maintained its FRACTURES. 319 length a piece should be cut from it in order that the fragments of the tibia may be brought together. Fig. 103. Fig. 104. Diagrams to Illustrate the Mechanism involved in Fracture of the Lower End of the Fibula: A, Parts in normal position: o, tibio-fibular ligament; 6, external lateral ligament; c, internal lateral ligament; B, fracture of fibula due to eversion of foot; C, fracture of fibula due to inversion of foot. Fractures at the Lower End.—Of these the most common and import- ant is the one known as Pott's fracture at the ankle, which is caused by forcible eversion and abduction of the foot; rarely by inversion and adduction of the foot. Fig. 103 sIioavs the mechanism of both varieties. In a typical case there are three separate lines of fracture (Fig. 104): one of the fibula about three inches above the tip of the malleolus; one of the internal malleolus ; and one of the outer lower edge of the tibia; but in the place of the last two there is often rupture of the internal lateral ligament of the ankle and of the ligaments of the lower tibio-fibular articulation respectively. The essential feature of the injury is the separation of the external malleolus from the tibia and its displacement outward in company with the foot. The symptoms are the characteristic deformity (Figs. 105, 106), consisting in outward displacement of the foot and prominence of the internal malleolus, the existence of three points of localized pain on pressure corresponding to the three lines of fracture or the equivalent injuries, and the possibility of moving the foot from side to side within the widened tibio-fibular mortice. Oc- casionally the (broken) internal malleolus is forced through the skin and the joint thus opened, or if the displacement remains unreduced the skin overlying the malleolus may slough in consequence of the pressure. The foot has a decided tendency to slip backward, sometimes so far that the body of the astragalus lies entirely behind the tibia; and this displacement is frequently overlooked. The essential point in treatment is to reduce the displacement completely and prevent its recurrence; the former is easy, and so too is the latter if suitable dressings are used, but each requires close attention and full appreciation of The Usual Three Lines of Fracture in Pott's Frac- ture at the Ankle. 320 AN AMERICAN TEXT-BOOK OF SURGERY. Pott's Fracture, showing Outward Displacement. the needs. Reduction is made by grasping the leg firmly with one hand and the foot with the other, and then, after lifting the latter fonvard, pressing it forcibly inward until, the Fig. 105. astragalus is felt to rest against the internal malleo- lus. An efficient dressing is made of moulded plaster- of-Paris splints, one of Avhich is placed posteriorly from just beloAv the knee, along the calf, the heel, and the sole, to and beyond the toes ; the other begins on the dorsum of the foot, crosses the outer border and the sole, and is carried up the inner side of the leg; circular turns are placed above the ankle and at the upper ends of the splints. It is advisable to invert the sole of the foot, in order to make sure that the lateral reduction is complete. While the splints are hardening the foot must be held in place by the sur- Fig. 106. geon or by an assistant who appreciates the necessity and the means of main- taining the reduction, both inward and forward. This dressing is to be preferred to "complete encasement in plaster, because it permits inspection of the region. Good results can also be obtained, though with less security, by the use of an internal lateral splint (Du- puytren's splint) project- ing below the foot. A Avedge-shaped pad is placed betAveen this splint and the leg, the base of the wedge being just above the internal malleolus. The foot is then secured to this internal splint in adduction. Great care must be taken to protect the skin from too great pressure. Fracture of the External Malleolus is caused by an imvard twist of the foot, by which the astragalus is so turned in its mortice as to force the malleolus outward and break it. The line of fracture is loAver than in Pott's fracture, and lies within the loAvest inch or inch and a half; sometimes separation of the fibula from the tibia at the loAver tibio-fibular articulation is produced instead of fracture, as shoAvn by pain on pressure over the front of the joint; and, much more rarely, the tip of the internal malleolus is sometimes broken off by the pressure of the astragalus against it in the same twist of the foot. The diagnosis of the fracture of the fibula is made by local tenderness on pressure at its seat and on twisting the foot inward, and possibly by abnormal mobility Pott's Fracture, showing also Backward Displacement. DISEASES AND INJURIES OF THE MUSCLES, ETC. 321 recognized by pressure imvard against the tip of the malleolus; it is supported by the history of the accident and the appearance by the second or third day of an ecchymosis below the malleolus. No treatment is needed except rest and the support of a dressing to prevent the occurrence of another twist of the foot. FRACTURES OF THE BOXES OF THE FOOT. The astragalus may be broken by a fall upon the foot, the line of fracture passing through the body or the neck, and the injury is frequently associated with dislocation of one of the fragments. An exact diagnosis may be difficult or impossible except Avhen dislocation is present. The choice of treatment lies between immobilization and removal of one or both fragments; the latter is obligatory Avhen the fracture is compound or Avhen the associated dislocation is such that the skin will slough or that the subsequent disability will be great. The functional results after removal of the astragalus are very good. The calcaneum may be broken by a fall upon the foot or by forcible contraction of the muscles attached to the tendo Achillis. In the latter case a larger or smaller posterior fragment is torn off and may be displaced upward ; the treatment is immobilization with the knee and ankle so flexed as to relax the calf-muscles. Fractures due to a fall are usually comminuted, Avith depression of the central part of the bone; the diagnosis must be made upon the flattening and broadening of the sole and heel (which can be best seen by making the patient kneel and then comparing the soles of the two feet), and by the relaxation of the tendo Achillis. The treatment is by massage and immobilization, but the patient should be encouraged to use the limb as soon as possible. Fracture of the Metatarsal Bones is commonly caused by direct violence, and is frequently compound ; the first and fifth are the most frequently broken. The diagnosis is made by pain on pressure at the seat of fracture or on pressing the corresponding toe directly backAvard, and by abnormal mobility in the case of the first and fifth or when several toes are broken. In simple cases no treatment is required except rest, Avith the foot elevated, and massage. CHAPTER IV. DISEASES AXD IXJURIES OF THE MUSCLES, TEXDOXS, AND BURS^E. SECTION I.—DISEASES AND INJUEIES OF THE MUSCLES. The muscles, with very few exceptions, are situated beneath the external layer of the deep fascia. By virtue of their contractility they bind together and move the parts of the skeleton, contract and compress organs to which they are attached, and aid in the protection of vessels and nerves, and of the viscera in the great cavities. Their essential sarcous elements are held in place and maintained in proper relation by connective-tissue investments; their power is transmitted through inelastic fibrous bands—the tendons—in part inserted into the bones, in part blending Avith the periosteum or the great fascial planes. Like other structures, they are at times the seat of disease and injury, though much less frequently than might be thought probable from their number, size, and location. 21 322 AX AMERICAN TEXT-BOOK OF SURGERY. Myalgia.—Pain located in a muscle, and to a greater or less extent pre- venting its use, is of very frequent occurrence, and depends upon the action of many causes, such as strain, twist, or slight laceration of the fibres, acute infectious disease, poisoning, as by lead or syphilis, etc. Muscle-pain is the one common symptom. In the majority of cases it is neuralgic, but may at times be inflammatory. It is easily diagnosticated, and usually quickly sub- sides, either spontaneously or in consequence of the employment of heat, elec- tricity, anodynes, or anesthetics; or it disappears with the removal of the exciting cause. Rupture.—Blows from without or undue and sudden unopposed contrac- tion may cause laceration, varying in degree from a tear so slight as not to be distinguishable from simple stretching to a complete purification; and in result from speedy and perfect recovery to destruction of the part or even to loss of life. Spontaneous rupture of healthy muscle can occur only Avhen the contraction is sudden, unexpected, or of unusual character, as in the " lawn- tennis leg" or "arm" of those unaccustomed to that form of exercise. But when, in consequence of disease, especially typhoid fever, and, much less frequently, scarlet fever, yellow fever, or other acute grave pyrexia, the fibers have undergone granular or vitreous degeneration, their extreme brittleness makes it possible for rupture to follow voluntary movement of slight extent. The rectus abdominis, the rectus femoris, the adductors of the thigh, the calf muscles, the psoas, and the flexors of the forearm are those most frequently affected, and in the order given. Except in cases of laceration occurring in the progress of general diseases, the occurrence of rupture is generally indi- cated by a sudden sharp pain, accompanied Avith the sensation of snapping or of the "giving way" of something in the injured region, by a well-marked depression or a wide gap at the seat of injury, and by extravasation of blood, with the subsequent color-changes in the skin. The ability to use the muscle is either Avholly or in great measure lost. Complete recovery may be expected when the laceration is but slight, and even when quite extensive the ultimate damage may not be great. When the abdominal muscles are the ones injured, intestinal obstruction, simulating strangulated hernia or peritonitis, may be developed. In the treatment of these injuries the chief reliance must generally be placed upon rest and the approximation of the edges of the laceration by posi- tion and due compression. In rupture of healthy muscle sutures may advanta- geously be employed, but are of little or no value when the muscle has under- gone degenerative changes, since the stitches will ordinarily quickly tear out. Hernia of Muscle.—Occasionally, in consequence of the imperfect heal- ing of a wound of the overlying deep fascia, limited protrusion of the muscle is observed to take place, Avith resulting impairment of muscular power. Such a hernia is readily recognized by the marked fulness in the region at the time of muscular contraction, disappearing when relaxation occurs, and by the detection of an opening in the aponeurosis, the rounded edges of which may readily be felt through the skin. In recent cases rest and methodical pressure will generally effect a cure. When the hernia has long existed the edges of the opening should be freshened and united by stitches. If, as is often the case, the inconvenience resulting from the presence of the hernia is but slight, the wearing of a bandage may be all that will be required. Myositis.—Muscle inflammation is almost always due to traumatism, to contiguous inflammation, to diathetic states, or to the presence of parasites. If consequent upon injury, it is usually a matter of but little importance in comparison with the other conditions dependent upon the traumatism. Sup- DISEASES AND INJURIES OF THE MUSCLES, ETC. 323 puration rarely takes place unless the injury be of the psoas muscle, and when it does occur is usually followed by recovery. Occasionally, and especially in badly-nourished individuals, there occurs a diffused inflammation of great severity, almost ahvays of septic origin, in which the affected muscle quickly breaks down, the patient generally dying speedily of septicemia. Only rarely can it be cut short by early free incision. So-called rheumatic myositis {myositis a frigore, muscular rheumatism) often affects the muscles of the back, the chest, or the neck, and is generally attributed to sudden chilling of an exposed part. It is probably, in the great majority of cases, not an inflammation at all, but the result of a sprain or a twist of the muscle, the symptoms and treatment being those of myalgia. During the course of a gonorrhea myositis has occasionally been observed, generally in the muscles in relation with an inflamed elbow or knee, such inflammation differing from the ordinary one only in its cause, Avhich is proba- bly a mild sapremia. Unless associated with joint or bone disease, a slowly-developed chronic myositis is almost always syphilitic in origin. Generally in these cases the affected part is so much indurated that the hardness has been characterized as "woody." An exceedingly annoying myositis of the sphincter ani has been observed in syphilitics, in women more often than in men. Contractures. (See also Orthopedic Surgery.)—Persistent shortening of a muscle—that is, the fixed approximation, more or less, of its points of origin and insertion, Avith resulting change in the position of the parts to which it is attached—may be due to the action of very many causes. Among these may be mentioned loss of substance, intra- or extra-muscular, followed by cicatricial contraction; inflammation, either traumatic, infective, specific, or toxic; con- tiguous bone or joint disease, with associated deviation from pathological causes or from gravity; Aveakened ac- tion of its proper antagonist; Fig. 107. paralysis, Avith resulting con- nective-tissue sclerosis, due to a central lesion, either cerebral or spinal; reflex irritation from local injury, with or without retention of a foreign body ; or it may be but a symptom of a general nervous affection, hys- teria, chorea, etc. As ordinarily met with in non-traumatic cases, it is asso- ciated with disease of the cord or brain, with infantile paral- ysis in children, or, much more rarely, with cerebral paralysis and intracranial hemorrhage in Anderson's Method of Lengthening a Tendon. adults. In the former it is of late appearance, and is observed most commonly in the legs, chiefly because of diminished resistance by opposing groups of muscles. In adults it is either early, transitory, variable, increased upon voluntary motion, absent or greatly lessened in sleep, and irritative in character; or late, degenerative, increasing, permanent, and especially affecting the upper extremity. The face and neck, occasionally also the lower extremities, may be contractured, but never so alone. It produces, as a rule, abnormal flexions in the upper extremity, but extension L v 324 AN AMERICAN TENT-BOOK OF SURGERY. at the knee and ankle ; Avhen, however, the contractions occur in connection with chronic spinal inflammation there is strong flexion t.t the hip and knee. When it is due to or indicative of an inflammation of a neighboring joint and is developed early, it is protective in character, producing such fixation of the articulation as is likely to lessen the disease in it by affording rest. Not seldom when unassociated Avith joint disease or paralysis a contracture will be found to be of syphilitic origin; and this is especially true of that affecting the biceps cubiti. Lately Anderson and several other surgeons have simultaneously proposed to lengthen tendons by a definite amount in cases of contracture. Fig. 107 sIioaws very Avell how this is accomplished by splitting the tendon, sliding one end up or down, and then suturing the ends, thus securing a definite amount of length- ening of the tendon. Hypertrophy.—The enlargement of a muscle may be real, the sarcous elements being increased in number or in size; or apparent, due to change in the amount of fat or connective tissue or to an overgrowth of the lymphatics and blood-vessels. It may be physiological and consequent upon increased action of the affected muscle, as in certain classes of workmen, or associated Avith pathological states, when, as in the enlarged heart or the thickened blad- der, it may be compensatory, and therefore to some extent salutary. Lessened use of the part, or rest, aided by compression, may effect a reduction in size. In adults there has occasionally been observed a progressive muscular hypertrophy affecting chiefly the upper extremity, as a rule on one side only, which is usually attended with lessened rather than increased functional strength. Atrophy.—Diminished size of muscles is of frequent occurrence, and may be due to disuse, to diseases of joints, to nerve-injury, to disease of the spine or the brain (rarely observed except Avhen the pons is affected), or to a general depraved or poisoned state of the blood. As met Avith in connection with lesions of bones or joints, it is in great measure, if not wholly, due to reflex disturbance of the trophic nerves, and not to the enforced quietude of the affected part. Very often it is associated with degeneration, granular, pigment- ary, fatty, or waxy, the latter two being the more common and the more im- portant. In the fatty degeneration there may be a substitution of fat for the true muscular elements, or. still oftener, for the connective tissue, occurring sloAvly and of limited extent, or, as in cases of phosphorus-poisoning, rapidly developed and largely generalized; or, as is much oftener the case, the fat may be present as an infiltration or accumulation in relation with the connective-tissue framewrork of the muscle. In the former, though the deposit may be absorbed and muscular redevelopment folloAv, there is generally permanent destruction of the affected fibers ; Avhile in the second either no effect is produced upon the contractile substance or it is affected only through pressure. In certain of the acute infectious fevers, especially yelloAv fever and typhoid, in not a few cases of tetanus, and occasionally, though rarely, after nerve-inju- ries, the muscular elements appear as a transparent, waxy, very brittle mass which breaks up into cuboidal blocks, the connective tissue at the same time taking on increased groAvth. Pain, Aveakness, impaired function, and liability to rupture are the effects of this vitreous degeneration. It is always destruc- tive to the affected fibers,—Avhich may be feAv in number or may constitute the greater part or the whole of the muscle. In three diseases (progressive muscular DISEASES AND INJURIES OF THE MUSCLES, ETC. 325 atrophy, pseudo-hypertrophic paralysis, and infantile paralysis) muscle atrophy is a strongly-marked symptom, of medical rather than surgical interest, except so far as resulting weakness and deformity, especially in infantile paralysis, necessitate the use of supporting and correcting mechanical appliances with or Avithout operative interference. Ossification.—Inflammation following long-continued irritation may result in the formation of bone in the belly of a muscle, or, as is more often the case, in its tendon, such, for example, as the bone-plates in muscles close to exuberant callus after a fracture, or as the so-called exercise or rider's bone, the latter being of not infrequent occurrence in the upper or lower tendon of the adductor magnus femoris. At times the ossification is of syphilitic origin. If it is in one of the superficial muscles, the bone-plate can readily be felt when near the attached end of the tendon, the only question being Avhether it is tendon, bone, or a true exostosis; but if deeply placed its existence remains undetected during life. To whatever cause it is due, the bony growth is permanent unless removed by operation. This may occasionally be rendered necessary by exist- ing pain or impairment of function, which at times is consequent upon the size or location of the osseous mass. A few cases have been observed of an early-commencing, slowly-advancing, general muscle inflammation, starting usually in the neck and back, in Avhich after a time the atrophied parts become the seat of bone-formation, myositis ossificans, the cause of which is as yet undetermined. Generally very pro- tracted in its course, it resists all treatment, death resulting from involvement of the respiratory muscles or from simple exhaustion. Tumors.—These may be either benign or malignant, located in the belly of the muscle or in its tendon. The majority of those Avhich are not sarco- matous or carcinomatous are of syphilitic origin, the specific disease affecting any muscle, but particularly the sterno-cleido-mastoid and the biceps cubiti. The malignant tumors are very rarely primary. In an interesting, though fortunately seldom observed, class the developing cause is parasitic—i. e. the presence in the muscle of the echinococcus, the cysticercus, or the trichina. The diagnosis will be based upon the history of the case and the recognition of a more or less Avell-defined SAvelling intimately connected Avith the muscle or the tendon; in the parasitic form the microscopic examination of an excised portion of the tumor will establish the diagnosis. The treatment will depend upon the nature of the growth, which Avill either be left untouched or taken out of the muscle, or removed with the part in Avhich it has grown. Wounds.—These may be either subcutaneous or open wounds. The former are sometimes accidental, but usually operative; the latter are most frequently incised or lacerated. Hemorrhage and separation of the edges are the chief symptoms, the latter, of course, being much more marked in complete than in partial transverse section. If protected from septic infection, their gravity is very slight, and unless there has been extensive loss of substance the repair functionally is very good, union taking place ordinarily through the medium of a connective-tissue scar, though Avhen the Avound is small and its edges have been early and closely approximated true muscular regeneration may occur. The treatment consists in securing close apposition and in the mainte- nance of rest. Incised Avounds and lacerated and contused ones in Avhich the parts can be brought together, after trimming of the torn edges if necessary, should be united Avith catgut or silk buried sutures rather than treated simply by strapping and bandaging, since, Avhen sepsis is prevented, the stitches do not readily tear out, and a quicker, closer repair is secured. 326 AN AMERICAN TEXT-BOOK OF SURGERY. SECTION II.— DISEASES AND INJURIES OF TENDONS. Tenosynovitis, or Thecitis, and Palmar Abscess.—Inflammation of a tendon sheath may be either acute or chronic. The acute form is due to traumatism, and is suppurative or non-suppurative according to the presence or the absence of pyogenic microbes; the chronic form is of tubercular origin. The acute form may follow a wound or a slight but frequently repeated contusion, as in certain classes of workmen, or it may result from a strain or be connected with rheumatism, syphilis, or gonorrhea. In the nonsuppurative variety there are present pain and swelling along the course of the tendon, with early-developed crepitation, due to the rubbing of the exudation-lined surfaces. Such crackling disappears as the sheath becomes distended with fluid, to reappear again for a while as absorption takes place. The associated constitu- tional symptoms are ordinarily slight, except in cases of the special diseases mentioned, when they are those of such diseases. The duration of the affection varies, according to its severity and to the treatment, from a few days to three or four weeks, terminating commonly in complete recovery7, though at times some dry crackling remains for a Avhile. Rest and pressure by splint and bandage are usually all that is required in the way of treatment, though hot- or cold-water applications are often of service at first, and the use of the tincture of iodine is thought highly of by many. Opiates may be needed to relieve pain. When the thecitis is suppurative the severity of the inflammation is great: unless free incision is promptly made, destruction of the sheath and its contained tendon will take place, often with wide extension of the disease along the ten- don and in the neighboring connective tissue, followed, it may be, by general infection. The pain is intense and throbbing, the tenderness excessive, the swelling marked and rapidly developed, the overlying skin red, the constitu- tional symptoms of high grade. Elevation and rest of the part, as complete as possible, must be secured, and hot applications made; but the first and most imperative demand is for free opening of the sheath, curetting, and thorough antiseptic drainage and dressing. If, notAvithstanding these measures, the sup- puration extends, other and more free incis- ions must be made, and thus destruction be limited as far as possible. The disease often affects the flexor sheath of a finger, and, unless promptly arrested, palmar abscess is very likely to follow. This danger is much greater if the disease attacks the thumb or the little finger rather than the other three fingers, since, while the proximal closed end of the sheath in the index, middle, and ring fingers (Fig. 108 b) is separated from the cavity of the general synovial sheath of all the tendons in the palm (a) about half an inch, the sheaths of the thumb and the little finger communicate directly with it. Whether secondary to teno- synovitis of the finger, or primary and due to direct infection and inflammation of the palmar fascia and the connective tissue under it, it is a serious matter. Fig. 108. Synovial Sheaths of Flexor Tendons of Fingers: a, general sheath common to the tendons in the palm and those of the thumb and little finger; 6, separate sheaths of the fore, middle, and ring fingers. DISEASES AND INJURIES OF THE MUSCLES, ETC. 327 It may be limited or general, according to the intensity of the infection, and is indicated by the presence of symptoms similar to those already mentioned as characteristic of thecitis—pain, swelling, restrained at first by the firm fascia, high fever, etc. Frequently a small superficial serous or purulent effusion early shows itself in the palm, which has often been mistaken for the real affection, to the serious injury of the patient because of the resulting delay in freely lay- ing open the parts. If untreated, or it may be in spite of treatment, the pus may pass between the bones to the dorsum of the hand or under the anterior annular ligament, upward beyond the palmar pouch into the connective tissue of the forearm, along the planes of Avhich it may be carried to or even beyond.the elboAv. Here, again, free incision must be made in the line of a metacarpal bone and disinfection and drainage secured. The incision may be made fearlessly up to a line transverse to the Aveb of the thumb, as the palmar arches both lie above this line. Beyond that the vessels should be avoided, or if divided both ends must be tied. At the best, some stiffness of the fingers and impairment of the functional value of the part not seldom results, and the hand is often " griffed " (claAv-hand). Necrosis of the carpus may occur, necessitating, at times, ampu- tation ; there may be troublesome, even dangerous, hemorrhage from the vessels of the hand or forearm; and in a small proportion of cases death takes place because of exhaustion or septic infection. Chronic teno-synovitis, as has been stated, is a tubercular disease, pre- senting itself either as a firm SAvelling (Fig. 109) consequent upon the presence of a thick mass of granulation-tissue in and upon the sheath; a more or less dis- tinctly fluctuating SAvelling in Avhich there is less deposit upon the Avails, but fluid in considerable quantity in the cavity of the sac ; or a similar swelling con- taining in addition small firm bodies resembling rice-kernel, riziform, or melon- Fig. 109. Fig. 110. Chronic (Tubercular) Teno-synovitis or Thecitis of the Sheaths of the Extensor Tendons. seed bodies attached to the walls or floating free (Fig. 110). Tubercle bacilli in greater or less number are almost invariably present in each form of the affection. It is observed most frequently, indeed in nearly four-fifths of the cases, in the forearm. It may be developed in con- nection with any of the tendons, but especially those of the fingers and those in the vicinity of the knee and ankle. Though very slow in its course, particularly in the cystic varieties, its tendency is to extend upward and dowrmvard along the affected tendon (Avhich in the fungous variety is invaded and in part or wholly destroyed), to attack other ten- dons in close proximity, and to pass into underlying joints. Rice-kernel or Melon- Frequently it is secondary to joint tuberculosis. As it is same c^Fig™^).1*16 attended by little or no pain, for a long time it may cause 328 AX AMERICAX TEXT-BOOK OF SURGERY. no material functional impairment. Very rarely it spontaneously disappears. The contents having broken doAvn the sheath and escaped externally (and this is very much more common in the fungous variety), an ordinary tubercular abscess generally follows, the spontaneous or non-aseptic opening of Avhich permits of infection by pyogenic organisms Avith resulting extensive suppuration, The locality of the swelling, its more or less spindle shape, its sIoav course, and the little attendant inconvenience are the diagnostic signs of the dis- ease in general; the degree of resistance to touch and the absence or presence of fluctuation, those of the variety, fungous or cystic; a peculiar crepitation elicited by pressure or upon movement indicates the presence of the riziform bodies. When located in the palm of the hand, affecting the several flexor tendons and extending up to the Avrist, the swelling of this so-called " compound ganglion " is more or less hour-glass in shape because of the constriction made by the anterior annular ligament. The treatment to be effective must be operative, by tapping and injec- tion, by evacuation and scraping, or by excision. When there is but little thickening of the sheath and the contents of the sac are simply fluid, aspira- tion or limited incision, Avith injection of iodoform, will generally bring about a cure; Avhen the melon-seed bodies are present the sheath must be laid open to such extent as to permit a complete evacuation and thorough scraping of the walls (in the palmar ganglion the annular ligament, if necessary, being divided and later reunited); Avhen the case is fungous, relief can be afforded only by complete removal of all the infected tissue outside the sheath, in the sheath itself, and in the tendon. The parts should be rendered bloodless by the Esmarch bandage, so as to permit of the recognition and careful dissection of what must be taken away, and great care should be exercised to do as little damage as possible to contiguous healthy structures. If it becomes necessary to remove any considerable part of the tendon, much benefit will follow sutur- ing to the upper end of the loAver fragment a piece secured by splitting from the upper fragment and turned down. Relapses very often occur, and not seldom the patient ultimately dies of one form or other of visceral tuberculosis, In all operations for teno-synovitis and in the after-treatment it is of extreme importance to prevent sepsis, since pyogenic infection is very dangerous to the part and to life. Paronychia, Whitlow, or Felon is an inflammation of a finger, rarely of a toe, consequent upon traumatism, usually of slight character; it may be but a scratch or prick or little abrasion, permitting of the entrance of septic germs. It may be of moderate or great severity according to the virulence of the organism and the general state and resisting power of the individual affected. It is more common upon the right than the left hand, and usually commences upon the last phalanx. It may be superficial or deep, in the latter case begin- ning as such or becoming so by extension from the under surface of the derm, favored in the pulp of the finger by the fibrous threads that tie it doAvn to the bone. The superficial variety is the more common and the least troublesome, affect- ing one finger or several in succession or at the same time, as is often the case in debilitated subjects, especially children, and located generally around and under the nail. The inflammation may be slight and subside quickly; or some- what more severe, causing subepidermal serous or purulent effusions. The former is absorbed in a feAv hours or days; the latter is associated Avith ulceration, but soon heals, though often leaving a scar Avhich is red and tender for some time. In much-enfeebled individuals the inflammation may be of a high grade, the pain intense, the swelling decided, the suppuration abundant, and may cause loss of DISEASES AXD IXJURIES OF THE MUSCLES, ETC 329 part or the Avhole of the nail and the development of fungous granulations, the disease often in neglected cases lasting for Aveeks or months until the necrosed nail is throAvn off. The treatment varies with the severity of the inflammation. Rest and elevation of the part and cold applications are all that is required in the milder cases. The use of hot fomentations, simple or medicated, together with prompt and complete evacuation of the pus, is indicated Avhen suppuration occurs. In the graver cases early incision and the administration of tonics and anodynes are necessary. Change of residence, if it can be effected, is use- ful. The nail must be removed as soon as it is evident that it must be lost, and iodoform, corrosive sublimate, carbolic acid, nitrate of lead, or other similar agent may be applied to the ulcerated surface. The deep whitlow usually commences on the palmar aspect of the last phalanx, though it may originate in an injury of the second or first phalanx, or, more rarely, upon the dorsum. In a ftnv hours it may be, or more commonly within a day or tAvo, after the receipt of the injury, the finger becomes painful, tense, hot, and throbbing, with accompanying elevation of temperature and acceleration of pulse. These symptoms rapidly increase in severity, especially the pain and tension, and are both aggravated by the dependent position. Resolution rarely occurs, suppuration usually taking place. Associated with the deep collection of pus there is often a superficial abscess that may be mistaken for the real disease. Though at times the application of cold, of the tincture of iodine, of car- bolic acid, or of a blister has afforded relief, in the great majority of cases such treatment is of no value. Carbolic acid has been knoAvn to produce gan- grene of the finger. So strong is the probability of the formation of pus, that it is better to employ hot antiseptic solutions or fomentations from the begin- ning, and if within tAvo or at most three days decided improvement does not take place, free incision should be made—to the bone Avhen it is the last pha- lanx that is affected, to the tendon Avhen the first or second, since in the former locality the disease is almost certain to have gone down to the periosteum, while in the latter it very probably is as yet only a teno-synovitis, and the integrity of the tendon may be preserved by opening the sheath. The after-treat- ment should be thoroughly antiseptic. Often in spite of early incision and proper dressing necrosis of the last phalanx occurs. When it does, it is likely to stop at the epiphyseal line, and the dead bone can be removed later without opening the articulation. Necrosis of the second or first phalanx will gene- rally necessitate amputation, though a tolerably useful finger may at times be secured by simple removal of the necrosed bone. Ganglion.—Closely connected with a tendon, especially upon the back of the hand, there is often found a small round SAvelling, firm to the touch, at times almost as hard as bone, sloAvly developed as a rule, and causing little inconve- nience except when in consequence of the occupation of the patient the tendon has been largely exercised. The contents of this SAvelling are a viscid honey- like fluid. At any period of its development the little SAvelling may disappear or cease to groAV. Formerly regarded as a dropsy of the tendon sheath (hence a common name, " Aveeping sineAv "), it is probably an outgroAvth of the synovial follicles of these sheaths, more rarely of the synovial pouches or the subsynovial bodies of Henle, or perhaps it is a iicav groAvth, a colloid cyst, having nothing to do with the tendon sheath except that it lies in close apposition with it. It is diagnosticated by its shape, location, and feel, and is to be treated by subcutaneous evacuation or by excision. Generally the former method is adopted, though refilling of the sac often occurs. By pressure of the thumb a thin-Availed ganglion may be readily burst, and even a somewhat thick-walled 330 AX AMERICAN TEXT-BOOK OF SURGERY. one, by a smart blow. Preferably, however, the sac should be subcutaneously divided by a small knife or spear-pointed needle, and the contents pressed out alongside the instrument or into the surrounding tissue, Avhen rapid absorption ordinarily takes place. When the tumor is very hard or very large, or there have been several recurrences, excision should be done, the sac being freely exposed and carefully dissected off the tendon. Under proper antiseptic dress- ing primary union may be expected. Rupture of a Tendon.—Sudden violent efforts are at times followed by rupture of a tendon, indicated by a snap which may be both felt and heard, by pain, by cessation of the action of the associated muscle, and often by a fall when the tendon is in the lower extremity. A gap at the seat of injury, increased upon extension, may frequently be recognized on palpation, and a depression may be seen. At the knee there wdll soon be marked effusion into the joint, and if the ligamentum patellae is ruptured the patella may be more or less displaced upward. The rupture may be complete or partial, generally the former. The tendon of the rectus femoris above or beloAv the patella, or the tendo Achillis in the lower extremity, and those of the triceps or biceps in the arm, are the ones usually torn. The treatment consists sometimes of approximation by position of the separated ends as much as possible, and maintenance of the same by splints, bandages, or apparatus until reunion takes place, which commonly occurs in from four to eight Aveeks. Generally, however, the better method is by suture, especially when the existing gap is a wide one or the tendon is that of a muscle in wdiich contraction can be controlled only imperfectly or with great difficulty. In the leg especially operation is indicated unless great age or other contraindication exists. The old-time objections to exposing and operating upon a tendon no longer hold good, since septic infection can very generally be prevented. This is especially important at the knee, as the joint may be opened at the operation. Wounds of Tendons.—These are either punctured, subcutaneous, or open. The former are of no importance unless accompanied by the entrance of pyo- genic organisms, when they may be very destructive from the inflammation of the tendon, its sheath, and the surrounding parts. Subcutaneous Avounds, Avhen complete, as in the operation of tenotomy, are attended with a snap and separa- tion of the ends, causing the formation of a depression both seen and felt; they are accompanied ordinarily with but slight hemorrhage and little pain. Repair takes place readily without any decided local or general disturbance, the connective-tissue callus being shorter or longer according to the amount of approximation secured. When formal tenotomy is done apposition of the ends is not wanted, and by position considerable separation is maintained, the func- tional value of the part ultimately becoming nearly or quite perfect. Open wounds are dangerous or not according as they do or do not become infected. If aseptic, they are quickly recovered from, and modern experience has so clearly demonstrated this that to-day, by preference, most such operations are performed openly in cases in which until recently the greatest care wras exer- cised to prevent any extensive division of the overlying soft parts. After operative tenotomy the treatment is by position and pressure. After acci- dental division, however, the treatment should invariably be by suture, the stitch being of buried catgut or silk. At the Avrist, Avhere several tendons may be simultaneously divided, care must be taken that the two ends of the same tendon are united. Tendon-suture may be done also in old cases of rupture or wound, even Avhen extensive dissection is required to find and free the widely-separated ends buried it may be in a mass of scar tissue. If the freshened fragments DISEASES AXD INJURIES OF THE MUSCLES, ETC. 331 Czerny's Method of Tendon-suture when the Ends cannot be Approximated. can be applied to each other, either end to end or overlapping, they should be stitched together, the sutures being drawn only sufficiently tight to maintain the apposition Avithout making undue constriction of the included parts. If there has been too great loss of substance to permit such direct attachment, but the sheath ends can be united, this should be done, as redevelopment of the tendon will occur in the canal thus formed ; or long catgut stitches may be used which Avill serve as a frameAvork upon Avhich the neAv formation can take place; or one of the pieces of the tendon may be longitudinally split for the necessary distance nearly to the end, and the detached half turned down FlG- 111< and united to the other part of the tendon, the ultimate result being the formation of a tendon sufficiently strong fully to per- form its physiological function (Fig. 111). Where this can- not be done, transplantation may be effected, either of an- other tendon from the same individual Avhen there has been extensive injury of the part, or of one taken from a lower animal: in the latter case usually, if not always, the graft is absorbed and its place taken by a new formation. When only one end can be found and separated from the surrounding cicatricial tissue, it may with advantage be united to an adjoining uninjured tendon having the same general anatomical course; as, for example, the flexors or extensors of the hand and fingers of the foot and toes. In all cases of tendon-suture much advantage will be derived from the use of the Esmarch bandage during the operation, by preventing the blood from obscuring the field of operation. Displacement of Tendons.—Unassociated with fracture or dislocation, displacements of tendons are of rare occurrence. Consequent upon sudden muscular action or extreme violence the tendon is forced from its normal posi- tion, is quickly and spontaneously replaced, or remains luxated until returned by manipulation. The tendons of the peroneal muscles are those most usually affected, especially that of the brevis, which is not very seldom found thrown out of its bed behind the external malleolus and carried forward so as to be readily felt and easily moved upon the malleolus. Slight pressure Avill return it to its proper place, but it is held there with much difficulty and only imper- fectly as a rule. The parts should be immobilized and a retentive dressing kept on until repair of the torn sheath or lateral ligament has taken place, if this can be secured. An aseptic suture or two may assist in retaining it in place. The late Dr. James R. Wood devised and carried into effect an opera- tion for the relief of dislocation of the tendon of the peroneus, viz., tenotomy followed by fixation wTith plaster of Paris. A similar muscular displacement is at times observed in the latissimus dorsi as it crosses the lower angle of the scapula, and there is here the same ease of replacement and difficulty of after- holding in position. Dislocation of the tendon of the long head of the biceps flexor cubiti is said to occur occasionally. White has reported and figured a case. SECTION III.—AFFECTIONS OF BUES.E. In connection with some tendons and in close relation with most joints there are to be found bursas, which are either normally present or acquired. The 332 AN AMERICAN TEXT-BOOK OF SURGERY. former are present at the time of birth or soon after; the latter are developed later in life in consequence of muscular action and friction. They may be superficial or deep-seated ; many of the latter communicate directly with neigh- boring articulations, especially in adults. As the result of injury and of diathetic affections these bursas are frequently the seat of disease, giving rise to simple excess of fluid; to suppurations; to deposits, tubercular, syphilitic, or malignant; to thickenings; and to fibrous and calcareous degenerations. Bursitis.—The inflammations are acute, subacute, and chronic, the last at times succeeding to the second, but generally such from the beginning. When it is one of the superficial pouches that is affected, the prognosis is ordinarily good, though at times, because of neglect of proper treatment, extensive and destructive cellulitis results: when a deep-seated bursa is affected the prognosis is much more grave, since there is danger of the exten- sion of the inflammation to the joint as the result of the affection itself or of the measures adopted for its relief. Acute bursitis, due ordinarily to injury, at times to over-use, when super- ficially located, is indicated by pain or at least tenderness, skin-redness of vary- ing intensity, and, particularly, by SAvelling, coming on rapidly and consequent upon excess of secretion, and, oftentimes, blood in considerable quantity. The peculiar location in relation to a tendon and the limited extent and globular form of the swelling serve to distinguish the disease from an ordinary cellulitis. The associated general symptoms may be of high grade. If suppurative, unless promptly arrested there is strong probability of extension to the connective tissue outside the bursa, with resulting increase in the severity of symptoms local and general. The deep-seated inflammations will often be mistaken for those of the joints near by ; and, indeed, in a considerable proportion of cases they actually become articular after a little time, the bursa and the synovial sac either directly communicating or being separated by a thin Avail that soon breaks down. Many of the extra-articular inflammations also doubt- less originate in bursal disease. The local treatment is at first by rest, elevation, pressure, and cold appli- cations ; later, if the effusion does not rapidly diminish and the inflammatory symptoms do not subside, the sac should be aspirated, or, if pus is present, freely laid open, disinfected by pure carbolic acid, and dressed antiseptically until oblit- eration of the cavity has been secured. If the patient is rheumatic, gouty, or syphilitic, the ordinary general treatment of the particular diathetic state should be employed. Chronic bursitis, of much more frequent occurrence than the acute variety, generally gives rise to little or no distress, and is characterized chiefly by sAvell- ing. due to sac distention, or to this combined Avith much thickening of the Avail. At times the swelling is solid and of fibrous character, it may be, though rarely, bony. A very common locality is on the front of the knee, the prepa- tellar bursa being the one usually affected (Fig. 112). It is due to long-con- tinued pressure and irritation, as in those Avho kneel much, and is knoAvn as housemaid's knee, as a similar affection of the olecranon bursa is spoken of as miners elbow. The enlargement of the prepatellar bursa is median in position, is globular, usually fluctuates, and, unless it has become acutely inflamed, is painless or nearly so, though some Aveakness of the knee is often complained of. The subligamentous bursa is sometimes diseased, when the SAvelling shoAvs itself on the sides of the ligament, the tension of which causes a central depression. The treatment of the prepatellar enlargement is by aspiration or free incision; the latter, when aseptically done and Avhen the resulting wound is DISEASES AND INJURIES OF THE MUSCLES, ETC. 333 Fig. 112. aseptically treated, gives the best result. Instead of a median cut, small open- ings may be made on the sides and a drainage-tube carried through. When suppuration has occurred lateral incisions Ioav doAvn are to be preferred to a central one, as they much more certainly secure drainage of the pockets on the sides Avhere the bursa overlaps the inner and outer edges of the pa- tella. If the sac has very thick walls or the mass is solid, it should be dissected out, care being taken in the removal to keep as close as possible to the outer surface of the SAvelling. The deeper subligamentous bursal swelling Avill ordinarily be treated by rest, together Avith pres- sure or the application of small blisters, and relief may be ex- pected only after considerable time. The likelihood of existing communication Avith the knee- joint makes aspiration the pref- erable form of operative treat- ment. Occasionally the bursa beneath the semimembranosus tendon is diseased, and Avhen it has enlarged so much as to cause marked swelling, not only, as at first, near the inner border of the knee, but Avell out to or beyond the median line, the affection may easily be mistaken for an intra-articular one or for an aneurysm. The very general connection of this pouch Avith the synovial cavity, at least in adults, as a gen- eral rule contraindicates any operation other than aspiration. As the result of abnormal pressure combined Avith malposition of the articu- lating surfaces there is frequently observed a bursal tumor over the metatarso- phalangeal articulation of the great toe, much less frequently over that of the little toe or over one of the other toe-joints. This is knoAvn as a " bunion " (Fig. 128). It may cause but little inconvenience, but almost always there is some tenderness in the part, and it is quite likely to become acutely inflamed. Then the pain is decided—and it may be excessively severe—the skin is red- dened, the fluid in the sac much increased, and Avalking becomes difficult, and, it may be, impossible. When suppuration occurs the pus may break through the Avail and cellulitis be developed, or a joint inflammation be excited and cause more or less destruction of the articulating surfaces. The treatment is that of acute bursitis in general—rest, cold, discutient lotions, tapping, or incision and prompt evacuation of pus. If either the surrounding connective tissue or the underlying joint has become infected, free incision should be made and the wound dressed antiseptically. Should the bone have become diseased, it must be removed by the sharp spoon or the gouge forceps, and the previous malposition of the toe corrected during the period of healing. Double Housemaid's Knee. 334 AN AMERICAN TEXT-BOOK OF SURGERY. CHAPTER V. ORTHOPEDIC SURGEKY. Orthopedic surgery has to do, properly, with the treatment of deformities and contractions, especially by some form or other of mechanical appliance, though of late its field has been somewhat extended so as to include the con- sideration of many deformity-producing joint affections. Torticollis, or wry-neck, is a contracted state of one or more of the mus- cles of the neck, producing an abnormal position of the head. As ordinarily observed it affects, either Avholly or chiefly, the sterno-cleido-mastoid muscle (Fig. 113), though the deep muscles are at times at fault, and in long-standing cases they are apt to be in greater or less measure involved. It is occasionally acute, and is then commonly due Fig. 113. to either cold or trauma. But it is more commonly chronic, and is then spastic in character and dependent upon nerve-irri- tation. It has been produced by an habitual malposition of the head, assumed because of existing ocular defect. It is noticed commonly in young children: though rarely, it may be congenital and due to ver- tebral deformity or to injuries received at time of birth. If it first appears in adult life, as it does occasionally, though for- tunately not often, instead of being spastic it is intermittent, Torticollis. spasmodic, and generally affects one or more of the muscles in- nervated by the spinal accessory nerve. When acute it generally passes aAvay under the influence of rest, heat, and time, or it may become chronic and per- manent. The spasmodic variety may disappear without treatment or after the employment of baths, friction, and massage, electricity, tonics, quinine (for it may be of malarial origin), change of locality, etc., or it may remain until stretching, section, or removal of a portion of the spinal accessory nerve be done ; and even these operations may leave the patient little or no better than before. The diagnosis of the commonly observed spastic contraction of the sterno- cleido-mastoid muscle is easy: the head is turned to the opposite side, the chin is extended, the ear of the affected side is drawn downward toward the shoulder, and the muscle is in strong relief and abnormally firm. At times only one of the divisions of the muscle, and that more commonly the sternal, is markedly contracted. When the disease has been of long duration there is often decided atrophy of the corresponding side of the face. The posterior rotator muscles of the neck are probably involved, together with the sterno-mastoid. Pain is not usually present. Rectification of the malposition can often be effected, at ORTHOPEDIC SURGERY. 335 least to a considerable extent, voluntarily or by manual pressure, but at once recurs when the pressure is removed. When the deeper muscles are diseased there may be a question as to the existence of caries of the cervical spine, but the history of the case, the absence of bilateral rigidity, and the character of the deformity will generally suffice to indicate the nature of the trouble. Having no tendency to get Avell of itself, the spastic form should always be treated either mechanically or by operation, followed by the application of proper retentive apparatus. Collars and braces of various kinds have been devised Avith the intention of holding the head in the improved position secured by forcible manipulation, and the plaster-of-Paris bandage over head, neck, and shoulders has been used for the same purpose. Often in the milder cases relief of the deformity may, in time, be secured by such appliances, but when- ever the muscular contraction is well marked the tendon and the adjacent fascial bands should be cut, either subcutaneously or through an open wound. Until recently the former method was almost uniformly employed, being much safer and leaving but a very slight scar; but, aseptically made, the open wound is attended with little or no risk, and has the advantage of permitting a more complete division of the contracted tissues. The subcutaneous method will, however, often be preferred. The head being so held as to render the tendon tense, a small incision is made low doAvn over its internal border; through this a blunt-pointed tenotome is carried to and along the under surface of the sternal portion, its cutting edge turned forward, and section made, after which, in the same manner, the clavicular portion may be divided if necessary. At times the sternal tendon can be cut upon the bone, thus avoiding the danger of wounding the anterior jugular vein as it passes behind the muscle a short distance above the sterno-clavicular articulation—an accident, how- ever, of little moment, as the hemorrhage can be easily controlled by pressure and the clot will soon be absorbed. The internal jugular vein has been wounded, the knife having been carried too far back in the first stage of the operation. As has been stated, for the relief of spasmodic wry-neck, affecting the sterno-cleido-mastoid muscle, the spinal accessory nerve may be stretched, cut, or in part removed, the latter being much the most promising procedure. To expose the nerve an incision may be made along the posterior edge of the sterno-cleido-mastoid muscle at its middle or along the anterior edge, begin- ning at the mastoid process and carried downward for about three inches: the muscle being drawn aside, the nerve can be readily lifted and a piece of it cut aAvay. Exsection of one or more of the upper cervical nerves when the posterior muscles are affected necessitates careful dissection and somewhat exten- sive division of the trapezius and complexus muscles, and will not often be per- formed. Contractures.—As has already been stated, there are at times observed in adults, as late phenomena of hemiplegic paralysis, contractures of the muscles of the arm, forearm, and hand, especially of the flexors: such contractures increase in intensity in proportion as the parts to which the muscles are sup- plied are farther removed from the trunk. As commonly seen, the arm is adducted, firmly held against the side (though occasionally it is abducted), the forearm is flexed upon the arm, the hand upon the forearm, and the fingers upon the palm; these flexions cannot be entirely overcome by either passive or active movements in extension. The deformity produced is proportionate to the degree of contracture, and ordinarily is not relieved by any treatment. Traumatic contractures due to wounds, not seldom to burns, and those conse- quent upon extensive cellulitis with loss of tissue and the formation of strong 336 AX AMERICAX TEXT-BOOK OF SURGERY. cicatricial adhesions, are so variable in locality, extent, and force that each case must be treated according to its special indications, mechanically or opera- tively, by the use of apparatus or by stretching, rupturing, dividing, or by the plastic insertion of healthy tissue taken from a near or a remote part of the body or from a loAver animal. At times the disability consequent upon the irremediable deformity is so great that amputation is done. For the treatment of contractures by lengthening of the tendon, see p. 323 (Fig. 107). Contraction of the Palmar Fascia {Dupuytren s contraction) (Figs. 114 and 115), producing permanent flexion of a finger or fingers, is at times Fig. 114. Fig. 115. Dupuytren's Contraction of the Palmar Fascia. The Same Hand after Operation. met Avith, generally in individuals beyond the middle period of life, much more frequently in men than in Avomen. It affects indifferently either hand, some- times both. The ring or the little finger or both are most frequently flexed; next the middle finger; the thumb and the index more rarely. The degree of flexion varies with the case and the length of time that the disease has existed. It is not the flexor tendons that are contracted, as Avas formerly believed to be the case, but the palmar fascia and its digital prolongations, together "with the fibrous bundles uniting the fascia and the overlying skin, which latter is involved only late and secondarily if at all. Beginning usually as a small hard nodule at or near the line of the metacarpophalangeal articulation, the disease extends more or less sIoavIv both doAvmvard and upward, Avith corresponding draAving doAvn of the affected finger or fingers, until in very severe cases the finger-tip is strongly and steadily held against the palm. Its occurrence has ORTHOPEDIC SURGERY. 337 been attributed to the action of various causes,—slight traumatisms frequently repeated, the rheumatic or gouty diathesis, reflex nervous irritation, etc.; but which of these is its real cause, or whether it depends upon any single cause, has not been determined. It certainly seems to be most frequent in those who are rheumatic or gouty. A recently-reported cure by hypnotic suggestion, as far as it goes, gives support to the nervous theory. The diagnosis is easily made: the thickened elevated band in the palm extending to the sides of the finger, the marked flexion resisting strong efforts at extension, the absence of pain, the sIoav development of the condition, the age of the individual, the non-existence of cerebral or spinal disease, or of injury of the extremity folloAved by loss of substance and resulting scar-con- traction,—all taken together render it impossible to mistake the nature of the affection. Treatment.—Left to itself, the palmar contraction ahvays gets worse, and it can be relieved only by operation. Such operation may be either subcu- taneous or open. If the former, the contracted bands are divided by a tenotome at a sufficient number of points, and the attachments to the skin separated until full extension of the fingers can be secured, after which a retaining splint and bandage are applied and worn until healing has taken place, and for a con- siderable time longer during at least a part of each twenty-four hours. The fingers for a few days should be slightly flexed, and later completely extended. In the open operation the skin may be divided by a linear wound or reflected in a V-shaped flap, base downward, and the contracted tissue dissected out, or the bands divided sufficiently freely by cross cuts at different levels—an opera- tion Avhich of late years has been frequently done with entire success. Club-Hand (Fig. 116) may occur congenitally as the result of defective osseous development, or later because of wounds attended Avith much loss of substance in the soft parts or the bones of the forearm or carpus, or Fig. 116. of paralytic contractions. There is a deviation, lateral, anterior, or posterior (very rarely the latter), similar to that in the lower extrem- ity constituting club-foot, and hence known as club-hand. Gene- rally the hand is drawn over in Double ciub-Hand. flexion and toward the radial side. It is often present at birth, or has followed extensive resection of the loAver part of the radius or ulna or of the carpus. Little or no relief can usually be afforded, though early and persistent manipulation, with the use of a retentive dressing, plaster or instrumental, has occasionally been folloAved by decided improvement in the position and usefulness of the hand. Always after bone-removal, espe- cially of the lower end of the radius, care must be taken for many months to prevent the deflection of the hand, otherwise likely to occur, by passive and active movements, and, if necessary, by the employment of a suitable apparatus. Tenotomy ordinarily has done little good, and at times has done harm. Webbed Fingers (Syndactylism) is a congenital affection. It may affect two or more fingers on one or both hands, the union extending to any point, even to the tips. There may be a Avide Aveb of skin with but little connective tissue Avithin, or a narrow and thick one, or the phalanges of the two fingers may be in close apposition. Frequently the deformity is a family peculiarity, running back through three, four, or more generations. If only two fingers are united, they are usually the ring and middle ones. The strength and use- 22 338 AN AMERICAN TENT-BOOK OF SURGERY. Fig. 117. Agnew's Operation for Webbed Fingers. fulness of the hand are often but little impaired. Simple division of the web rarely gives other than temporary relief, the Aveb re-forming from the bottom as the wound heals. To prevent such re-formation a flap of skin may be fixed in the angle between the sepa- rated fingers (see Fig. 117), or a small hole may at first be made at the level of the edge of the normal web, in which a thread or a button may be placed and retained until the edges of the cut have healed, after Avhich the remainder of the Aveb may be cut through. The most satisfactory op- eration is that in which a flap the length of the finger and half its width, Avith the added width of the web, is taken from the dorsal surface of one finger and the palmar surface of the other (thus splitting the web and separating the fingers), and each carefully applied over the denuded portion of the finger to which it is attached, securing a normal skin covering of the surfaces that are to be in apposition (Figs. 118, 119). Supernumerary Digits (Polydactylism) are also congenital, are not infrequent, and, like webbed fingers, in many cases are hereditary. They are generally symmet- rical, and often pres- ent on both hands and feet. Usually there is but a single digit in ex- cess, commonly on the side of the little finger or little toe; though not rarely the thumb, much less often the great toe, is double. The development may be complete, even to an extra supporting meta- carpal or metatarsal bone, or it may be more or less imperfect, so that the supernumerary digit is scarcely more than a rudimentary nodule connected Avith the side of a phalanx. When perfect it is most often attached at a greater or less angle to the broad- ened end of the metacarpal or metatarsal bone of the normal finger or toe, though at times the normal and extra digit are very closely7 apposed, or even fused, and held in a common envelope of skin. At times the connection with the hand or foot is by a fibrous band of varying length and firmness. It may be amputated at any time, but if not closely fused with the adjoining digit it is best to remove it very soon after birth; and "even if so fused, it should be taken aAvay while the child is still quite young, to lessen the resulting deformity. If there is a completely formed hand or foot, Avith an extra metacarpal or meta- tarsal bone and corresponding digit, no operation need, or indeed should, be done. Fig. 118. Fig. 119. Diday's Operation for Webbed Fingers. Transverse Section, showing flaps before and after suture. ORTHOPEDIC SURGERY. 339 Genu Valgum, or Knock-Knee (Fig. 120).—This is the result of over- growth of the internal condyle and curving inward of the shaft of the femur in its loAver part, with associated relaxation and elongation of the internal lateral liga- Fig. 120. raents of the knee-joint. These changes pro- duce an abnormal inclination of the interar- ticular line, more or less close approximation of the knees, and more or less Avide separation of the feet, the individual in standing being unable to bring the heels together. It usually manifests itself in early childhood, soon after the child begins to walk, but may not do so until about the period of puberty, or even, though rarely, much later in life. In the former case it is a rhachitic manifesta- tion ; in the latter, it is consequent upon an occupation requiring long-continued standing by a person of feeble muscular and ligament- ous development. Often there is associated flat-foot, which, indeed, at times may be the Genu valgum, or Knock-Knee. primary and causative lesion. It may affect one or both knees, may be so slight as to escape detection except upon very careful examination, or so severe as to cross the knees, separate the feet very widely, and render locomotion difficult and the gait wobbling. In children other evidence of the existence of rickets will commonly be found. The diagnosis is made on sight, except in the mildest cases. Left to itself, Avhen not severe it often spontaneously improves as the rhachitic state passes away and the general strength increases. This favorable termination is common in the static knock-knee of adolescents. The earlier, hoAvever, that treatment, general and local, is begun, the speedier will be the recovery and the less the resulting deformity. The ordinary medicinal and hygienic treatment of Aveak and rhachitic subjects is the appropriate one for young children. The local treatment is mechanical, supplemented by baths, frictions, massage, electricity, and preceded, in the severer cases, by osteotomy. If the rickets is still active and the bones are soft and yielding, standing and Avalking should be forbidden, the limb should be straightened as much as possible by manipulation, and maintenance of the correct position should be secured by an outside splint and bandage. Later, Avhen the bones have become firmer, great benefit often folloAvs the use of such a splint with a counter-press- ing pad on the inside, the resulting change in the relative positions of the articular surfaces of the femur and tibia permitting the increased growth of the external femoral condyle Avith restriction of that of the internal. Plaster of Paris is an excellent material for this splint, or the limb may be completely enveloped in it. Immobilization with the leg flexed at a right angle with the thigh is, by many, preferred to that in the straight position, as the deformity is much less- ened by the flexion. Forcible rectification folloAved by immobilization has often been folloAved by great improvement, there being produced in the rapid straight- ening an epiphyseal separation of greater or less extent or a laceration of the external lateral ligament. But if sufficient force to produce such condition is required, it is better instrumentally to break the thigh at a determined level or to divide the bone with saw or chisel, especially as severe injury to the soft 340 AX AMERICAX TEXT-BOOK OF SURGERY. parts and the joint structures has at times been produced by the former method. Braces of various kinds have been devised, all intended to correct the deformity and allow the patient to go about, and many of them are of much service in very young children. If the knock-knee is great and the bones are firm, no material change for the better can be effected without operation, either fracture (osteoclasis) or section (osteotomy), of which the latter is to be preferred, fracture requiring the use of a special apparatus, and not always being produced at the desired place. Section may be so done as to separate the internal condyle or divide the loAver portion of the femur, which latter is the operation ordinarily performed. A small longitudinal incision being made down to the bone, half an inch or a little more above the adductor tubercle, the chisel is introduced, turned at right angles, and by successive blows of the hammer driven toward the outer side, being so moved upward and doAvnward as to secure division of the entire thick- ness of the bone for three-quarters or four-fifths of its transverse diameter, the uncut portion being readily broken by moderate force. The limb is then to be straightened, an antiseptic pad applied, a layer of cotton put on, and immo- bilization made by plaster of Paris. Little or no reaction ordinarily follows: in about a month the dressing may be taken off, and after two or three weeks' additional rest the patient is allowTed to walk. Though the operation is not altogether devoid of danger, since there may be serious hemorrhage from a divided popliteal or anastomotica magna artery, or from the bone itself, or a resulting aneurysm or gangrene, causing death or necessitating amputation, or damage inflicted upon the external popliteal nerve, yet the likelihood of these accidents is very slight, and may be practically disregarded in deciding upon the advisability of making the section. Genu Varum, or Bow-Legs (Fig. 121), the opposite of genu valgum, is a deformity usually affecting both limbs, in which the knees are more or less widely separated, the joint surfaces are in such relation to each other that the angle betAveen them points outward, and the chief pressure is between the internal con- dyles. Except in a very feAv cases there is outward curvature of the femur and tibia, or of the tibia alone, with at times an anterior bend of the latter bone. The curves of the two legs together may form an almost complete circle. A line drawn from the center of the femoral head to the ankle is internal to the knee. The disease begins in early childhood and is of rhachitic origin, and the deformity is the direct result of the Aveight of the body and muscular action. Inspection at once reveals its existence, which is further indicated by the turning in of the feet and the rolling walk. In elderly persons suffer- ing from osteitis deformans there may be a bow- Genu varum, or Bow-Legs. legged condition Avhich is a part of the general bone disease, and is irremediable. Treatment.—Spontaneous correction sometimes occurs, much more fre- quently than in genu valgum; but if the case is at all severe and the child so young that the bones have not become firmly set in the abnormal curves, mechanical treatment should be employed to bring the limbs in toward the median line. This may be by plaster or braces, according to circumstances. In older patients the bones are too strong to yield to any such pressure, and correction of the deformity can be made only after fracture or section. Though ORTHOPEDIC SURGERY. 341 osteoclasis by the aid of one or other of the instruments now employed gives better results than in cases of genu valgum, yet osteotomy is the operation that is generally done, linear division being effected at such levels as the con- dition of the individual case may indicate. The method of operating and the after-treatment are the same as in knock-knee. Turning in or turning out of the knee consequent upon paralysis or vicious union after fracture requires no special consideration. Each case must be treated according to its character, medically, mechanically, or operatively. Antero-posterior Curvature of the Legs is another of the deformities due to rickets Avhich in its aggravated form can be relieved only by operation. When slight and detected early, it may be expected to disappear, either with- out treatment or more probably under rest and appropriate fixation dressing; but in neglected cases, in some of which there is excessive bowing, linear or often cuneiform osteotomy must be done on one or both bones according to circumstances. In the performance of the latter the summit of the curve in the tibia is freely exposed by a longitudinal incision of sufficient length. By a saAV or chisel a wedge, with its base anterior, is cut out of the tibia, after which, if necessary to the straightening of the leg, the fibula is broken or instrumentally divided. Proper adjustment having been made, the limb is immobilized and quietude maintained until repair and consolidation are com- pleted. The operation and dressing must be done aseptically, that suppuration may not take place, Avhich Avill ahvays materially lengthen the period of treat- ment. There is a risk, but not a great one, of wounding the anterior tibial vessels or nerve. Club-Foot, or Talipes, is a non-traumatic deviation of the foot in the direction of one or other of the four lines of movement—extension {T. equinus, Fig. 122), flexion {T. calcaneus, Fig. 123), adduction {T. varus), and abduc- Fig. 122. Talipes Equinus. tion {T. valgus),—or of two of these combined, as in equino-varus (Fig. 124). It is due either to under- or over-action of muscles or to abnormal position, 342 AX AMERICAN TEXT-BOOK OF SURGERY. shape, or relations of one or more parts of the skeleton of the foot. It may be either congenital or acquired, in the latter case being generally devel- oped in early childhood and the result of infantile paralysis (acute anterior poliomyelitis). In the congenital variety the displacement is almost ahvays one of adduc- tion, with commonly some elevation of the heel (Talipes Eqiixo-varus, Fig. 124). Generally affectin» Fig. 124. both feet, it may be confined to Ig^ §|j ..v:v~7.. one5 tne right oftener than the left. The inner border is raised, the sole turned toward the median line of the body, the heel more or less lifted, the distal part of the foot flexed upon the proximal part at the mid-tarsal articulation. The degree of deformity varies from that Avhich is but little in excess of the natural inclination Double Equino-vams. of the foot of the new-born infant up to so great rotation that the weight in the erect posture is borne upon the upper and outer part of the dorsum. At the time of birth and for some months afterward the deformity can usually be easily corrected by manipulation, but later, if left to itself, it becomes in greater or less measure fixed, in consequence of muscular contraction and developmental changes in the shape of the bones. As to its cause, there has been much question. It has been attributed to uterine pressure, to intra-uterine disease of the cerebro-spinal axis with result- ing paralysis and arrests of development (it is not seldom associated with malformations of the head, the face, the spine, the abdominal wall, or the pelvis), and to persistence of the earlier fcetal position of the foot, the later normal rotation of the leg and foot, or at least of the latter, not having taken place—an explanation that seems, at present, the most likely to be correct. In a considerable number of cases it is a family peculiarity, either in the ascending line or affecting several children of the same parents. The diagnosis is easy, and the prognosis good if proper treatment is promptly adopted and steadily maintained for a sufficient length of time, though even under the most favorable circumstances the ultimate development of the foot is not what it would have been had the deformity not existed. The treatment must be either manipulative or mechanical, or both. In those cases—and they are the majority^—in which at birth and soon afterward the foot can readily be brought into proper position by hand-pressure, such pressure, could it be steadily maintained, Avould in time relieve the deformity. As this cannot be done, some substitute for it must be found, and that is best Avhich most nearly approaches it in evenness and gentleness of pressure. Simple bandaging or the application of adhesive straps has been used, and, at times, Avith success, but immobilization of the foot and leg by plaster of Paris or gutta-percha is venT much better, the parts being protected by cotton and the dressing carried sufficiently high up to prevent its ready displacement. Frequent removals and reapplications of the plaster will be required. Very rarely in these young subjects is there such tendon contrac- tion as to necessitate section. The earlier the deformity is corrected and the foot held in right position the better. If the case has been neglected and nothing done until the child has begun to stand and walk, the malposition may ORTHOPEDIC SURGERY. 343 still be corrected by manipulation and overcome by immobilization, but with much more difficulty. Decided retraction of the heel may often in this way be relieved, but considerable time will be required—time which may be saved by tenotomy. The tenotome is introduced by the side of the tendo Achillis (rendered as tense as possible by flexion of the foot), carried underneath it, its cutting edge turned against it, and division made by pressure and a slight saw- ing motion. There are but two dangers in this operation, that of Avounding the posterior tibial artery, and that of freely dividing the skin, neither of Avhich is likely to occur if care is taken. If either accident does happen, it is usually a matter of no great importance. Pressure will stop the flow of blood, and under antiseptic treatment the open wound will quickly close without inflammation. Elastic traction has been employed with much benefit. Upon far the larger number of these patients club-foot shoes are applied. They should be either solid or jointed opposite the middle tarsal articulation to permit of any required lateral movement of the parts in front. The side-pieces should be carried nearly up to the knee. If properly made, adj usted, and watched, if it overcomes the deformity and maintains the correction, such mechanical appliance is of great service. But as very often used it is of little or no bene- fit, frequently a positive injury, since it is put on by an instrument-maker or dealer uninformed in anatomy or pathology, and makes uneven pressure, produces callosities and ulceration, fails to hold the foot in proper position, frequently breaks and gets out of order, thus necessitating expense that can be ill afforded, and is often Avorn long after it should have been thrown away and a new one applied. Much better results will be secured by the average practitioner, and especially among the poor, by plaster-of-Paris immobilization than by the use of a club-foot apparatus. Before a proper mechanical appliance can be put on, forcible correction under anesthesia may have to be made, together Avith tenotomy of the tendo Achillis, of the tibial tendons, anterior or posterior or both, and of the plantar fascia. In the aggravated long-standing cases in which there has taken place marked Oo ACC. If the muscle have its motor nerve destroyed, the ACC quickly increases until KCC = ACC, and finally KCC