m & Nl" 0Q5S51&7 3 SURGEON GENERAL'S OFFICE LIBRARY. Section, Mo. NLM005551873 A TEXT-BOOK ON SURGERY GENERAL, OPERATiyE, AND MECHANICAL BY JOHN A. WYETH, M. D. Professor of Surgery in and President of the Faculty of the New York Polyclinic Medical School and Hospital; late Surgeon to Mount Sinai Hospital and Consulting Surgeon to St. Elizabeth's Hospital; Member of the New York Pathological Society; of the New York Surgical Society; of the Academy of Medicine; of the New York State Medical Association ; of the New York County Medical Association ; Honorary Member of the Texas State Medical Association; of the College of Physicians and Surgeons of Little Rock, Arkansas THIRD EDITION, REVISED AND ENLARGED LIBRARY SURGEON GENERALS OFFICE SEP.-21M899 ^gz&B^a^' r W' \\" Fig. 7.—Two connective-tissue corpuscles from the subcuta- neous connective tissue, highly magnified. The dark streak below I, in the right-hand corpuscle, is a lamella which happens to be projecting toward the observer, and is seen in optical section. (After Sharpey and Quain.) INFLAMMATION AND REPAIR IN THE TISSUES. 5 it rapidly divides in two, the thin capsular membrane closing in and sur- rounding each new, as it did the parent nucleus (Fig. 8). The main body of the cell may now divide and form two new cells, each with a single nucleus, or the protoplasm may simply enlarge without division, the nuclei dividing indefinitely within the cell. In this way the polynucle- ated or "giant cells" are formed (Fig. 20). It is now held that all cell proliferation takes place by this process of Tcaryokinesis, or primary division in the nucleus. The dilatation of the blood vessels, with the increased supply in the part, the escape of leuco- cytes, plasma, and lymph, and the enormous cell proliferation, cause the heat, redness, swelling, and pain of inflammation, together with the loss of function in the part, as well as a partial or complete stoppage (stasis) of the circulation in the inflamed area. Stasis is always more pronounced at the center of the disturbed zone, and here the discolora- tion is deeper, gradually diminishing toward the periphery. The sud- den contraction and immediate dilatation of the vessels is due to a Fig. 8.—Karyokinesis in the cells of salamander larva, a, cell in rest, showing parts of the nuclear network colored black ; the remaining portion of the nucleus is the nuclear matrix ; c, nucleus transformed into closely contorted filaments ; /, filaments converging toward the center with commencing separation into an upper and a lower portion ; h, separation more advanced ; m, a further step in the process in which the perinuclear protoplasm is taking part; q, two cells, the product of karyokinesis, the nuclear network again assuming the cell in repose. (After Flemming and Quain.) momentary irritation of the vaso-motor nerves and the paralysis which follows their injury. It is difficult to explain just why the leucocytes appear in such large numbers at the seat of inflammation. It is claimed that they are attracted there by some chemical change in the parts involved, and this is termed chemiotaxis* It was formerly taught that the leucocytes not only stimulated proliferation in the cells of a part, but that they themselves underwent proliferation and aided in the form- ation of the common embryonic tissue ; but this is now disclaimed, and more recent observers assert that they have no function beyond the stimulation of the fixed cells, and that they are taken up as food by the proliferating embryonic tissue, while some of them re-enter the vessels and again take their place in the circulation. When infection occurs they are found in large numbers, forming pus corpuscles and floating in the pus serum. In non-infective inflammation the process of repair begins within a few hours after the injury. The phenomena of regeneration are prac- tically identical in all vascular soft tissues. In bone, by reason of the * The property living cells exhibit, with reference to non-living organic material, by virtue of which they approach or recede from certain substances. In positive chemiotaxis the cell ap- proaches, in negative it is repelled (Sternberg). 6 A TEXT-BOOK ON SURGERY. dense structure which surrounds the vessels and medulla, and in the two non-vascular structures, the cornea and cartilage, the process differs somewhat and will be spe- cially studied. In infective inflammation the destruc- tion of tissue is much great- er, the process of repair is slower, and regeneration is always imperfect. Chemi- cal and mechanical destruc- tion of the tissues is always followed by the formation of a fibrillated connective tissue, producing a scar or cicatrix. The most important step in the regeneration of in- jured tissue is the distribu- tion of blood and nutrition by the new formation of vessels. From the stumps of the divided or occluded capillaries, buds (Fig. 9) of protoplasm, springing from the new cells of the proliferat- ing endothelia, are pro- jected into the mass of embryonic cells. Some of these meet and fuse with similar buds pro- jecting from opposing surfaces of the inflamed area, or at times two Fig. 9.—(After Paget.) Fig. 10.—(After Paget.) Fig. 11.—Development of blood vessels by buddiuar; different forms of buds a b c first <*t simple and branching solid buds ■ e vascular bud which is being made hollow and whchSdv tains blood-corpuscles. (After Tillmann.) "U1 aire»*ay coh- buds from the same surface unite to form a capillary loop (Fig 10) Some of these embryonic vascular buds begin as tubules, communicating with the vessels (e Fig. 11), while others are more solid prolongations of INFLAMMATION AND REPAIR IN THE TISSUES. 7 protoplasm not yet canalized (d Fig. 11). According to Ranvier, the centers of these undergo liquefaction, and thus becoming cannulated, they ultimately communicate at their extremities and become continuous with the vessels from which they spring. The cells of the embryonic tissue immediately in contact with the new canals aid in forming the walls of the newly made vessels. When haemorrhage has occurred, the coagu- lum is rapidly infiltrated with the new cells and disappears after a vari- Fig. 12.—Steps in the fibrillation of connective-tissue cells. (After Paget.) able time, either undergoing granular metamorphosis or is taken up as nourishment by the proliferating cells. Even in aseptic inflammation many of the capillaries and vessels disappear as the result of the con- traction which takes place in the final stage of inflammation. This formation of connective tissue (Fig. 12) in septic inflammation is so much more extensive that occlusion of the newly formed capillaries is often complete, giving the pe- culiar bleached appearance to cicatrical tissue. In the skin the repair in the deeper layers of the cuticle is carried on by the proliferating prickle cells and the elongated and granular cells of Langer- hans, while in the corium the embryonic tissue springing from the fixed connective-tis- sue cells develops into a new connective tissue. In adipose tissue the fat vesicles, when ruptured, allow the escape of their contents, which disappears by granular metamorphosis. The nucleus of the capsule enters into the general cell proliferation, the capsule itself being originally a connective-tissue cell. As the inflammatory process subsides, fat droplets again appear in cer- tain of the new embryonic cells which are gradually distended and form new fat vesicles (Fig. 13). In the regeneration of muscle the process is somewhat analogous to Fig. 13.—Deposition of fat in connective-tissue cells (adi- pose tissue). /, a cell with a few isolated fat droplets in its protoplasm ; /', a cell with a single large and several minute drops;,/'", fusion of two large drops; g, granu- lar cell, not yet exhibiting any fat deposition; ct, fat connective-tissue corpuscle; c, c, network of capillaries. (After Sharpey and Quain.) A TEXT-BOOK ON SURGERY. Fig. 15.—Portions of two nerve fibers stained with osmic acid (from a young rabbit). 425 diameters. K,R, nodes of Ranvier, with axis cylinder passing through ; a, primitive sheath of the nerve; c, opposite the middle of the segment indi- cates the nucleus and protoplasm lying be- tween the primitive sheath and the medul- lary sheath. In A the nodes are wider, and the intersegmental substance more ap- parent than in B. (From a drawing by Mr. J. E. Neale, after Sharpey and Quain.) the budding in new forming capillaries. From the ends of the muscular fibers, which are infiltrated with embryonic cells (to the formation of which the muscle cells or sarcoblasts and the connective-tissue cells of the perimysium contribute), protoplasmic swellings or buds, which are rich in nuclei, are pro- jected. By division of the nuclei (practically analo- gous to the formation of muscle plates from the mesoderm in the embryo) the new fiber is constructed, meeting and becoming continuous with the buds from the opposing surface. These formative cells arrange themselves in elongated or fusiform shape, in which, later on, fine longitudinal striae are seen. The transverse striae appear about the twenty-first day. Muscle has not the reproductive power of other tissue, and when the injury is extensive, or when infection or suppuration occurs, the lost sub- stance is replaced by fibrillated, connective, or cica- Fig. 14- -Tendon of mouse's tail, showing chains of cells between the tendon bundles; 175 diameters.' (After Sharpey and Quain.) tricial tissue. Even when new fibers are produced, their arrangement is not so symmetrical as in the normal muscle. In the regeneration of tendon, the tendon cells and the connective-tissue cells of the sheaths are the agents of proliferation and repair in inflammation as well as after surgical or accidental division. A ten- don cell is a fusiform body of protoplasm containing a singlo nucleus in which are several nucleoli. They are arranged in rows between the layers of fibers. From these rows tendon buds are projected, which, growing longer, become fibrillated and arrange them- selves in parallel layers, interlocking with the grow- ing fibers or buds from the opposite side. The process of repair in inflammation or injury of the ligaments is practically identical with that of tendons and need not be separately considered. In nerves, in exceptional cases, the repair or re- union takes place soon after extensive injury, with the resumption of function. As a rule, howjr-,7^ sient, since the parent bacteria '7"S7^Si7^.:{7j:\:7.^-' "-•"-'-••'"C^. "^ is essential to maintain pro- .^^^^Q^r.f^''--77i7' "7^.J:- longed septic infection. (dif'^'-r7^^ ^ S?ks Certain sterilized chemical '"' 77^77^^^ ^7:%7:^''' ^'v^S substances, as well as sterilized Fig. 33. Fig. 34. hnrfpria will whpn im'ppfprl FlG- 33l—Pus from an acute abscess> showing pus cells, uaoiciid, v\in, vvucu iujcuucu shreds of broken-down connective tissue and micro- intO the tissues, Cause inflam- v cocci (After Landerer.) ' Iig. 34.—Bacilli of blue pus. (After Landerer.) mation and a liquefaction of the exuded plasma and connective and embryonic tissues with which they come in contact, and produce a creamy liquid which very closely resembles true surgical pus. The inflammatory process, however, is mild, and systemic infection does not occur. Surgical writers have termed this "laboratory pus." Treatment.—In the treatment of inflammation the first great essential is rest, and this should be as complete as possible. If necessary to assure this, some form of fixation apparatus should be applied. In non-infeotive inflammation, as a rule, nothing further than this will be required to bring about absorption of the excess of embryonic tissue and coagu- lated exudates, and the repair or regeneration of the tissues which have been injured. As far as local applications are concerned, as a rule, patients prefer cold to heat. The neatest way to apply cold is by the rubber ice bag, which can be laid directly upon the inflamed part, with a piece of lint or thin layer of cotton batting between the skin and the ice bag. The cold-water coil (Fig. 35) is also very useful. In the absence of these preferable methods, benefit may be derived by applying towels dipped in cold water, partially squeezed out, and laid directly upon the inflamed surface. When one of the extremities is the seat of lesion, the painful throbbing, which is often a part of inflam- mation, may in good part be relieved by elevation of the limb. For the upper extremity the Fluhrer swing (Fig. 36) is useful for this pur- pose, and adds to the patient's comfort. A very important feature in the treatment of all surgical lesions is a careful attention to the con- dition of the alimentary canal. It is of great importance that before an operation the alimentary canal be carefully emptied by the administra- tion of from one to two grains of calomel triturates—preferably one grain repeated in four hours. If after twelve hours no movement of the bowels has taken place, this should be followed by one or two tea- spoonfuls of Epsom salts, or half a tumblerful of Hunyadi water, or some other effective saline laxative. Whenever any inflammatory pro- cess is under treatment, it is just as important to keep the bowels open every day or every other day after, as it is before the operation. There is 24 A TEXT-BOOK ON SURGERY. no more important precept in surgery than this, and the surgeon fails in his duty who does not fully appreciate the dangers of intestinal toxaemia. In suppurative inflammation more urgent measures are demanded. It is difficult to deal with any form of infective inflammation without the use of the knife, even in its early stages, and the sooner the knife is used in these cases, as a rule, the better. It is a surgical axiom that Fig. 35.—(Modified from Fischer.) er wounds should be strictly antiseptic from the moment a wound comes under consideration. If the laity were thoroughly trained in the sim- plicity and safety of the sterilization of wounds, not one in a hundred of the serious accidents of infection would occur. Patients should be instructed to keep on hand tablets of bichloride of mercury with direc- tions for making a simple and safe solution in which any parr of the body may be immersed or bathed; and, this being done, to dry the SUPPURATION. 25 wound off with a clean towel that has been boiled, press the edges of the abrasion together, and cover the exposed surface with a layer or two of ordinary collodion, applied with a brush or poured on. When, however, a wound has been neglected and sepsis is established in the earlier stages, the next best thing is to cocainize the part by the injection of from one to ten minims of a two-per-cent solution into the integument about the wound, taking pains to follow the directions given in the use of cocaine in the chapter on local anaesthesia; then incise in the safest direction the focus of infection, and inject from thirty to sixty minims of a l-to-3,000 bichloride solution into the tissues, making a complete circle of the area of infection. When lymphangitis is established and septic inflammation has taken place along the lymphatic channels toward Fig. 36.—Fluhrer's swinging cradle (Mt. Sinai Hospital). the center of the body, at the first indication of suppuration in the glands they should in like manner be incised so that the current of septic matter coming into them from below may be poured out into a wound where sterilization is secured by antiseptic moist dressing and infection beyond the lymphatic glands prevented. In a condition of general cellulitis resulting from infection it is im- perative to make multiple incisions, not only to relieve tension and pre- vent gangrene, but to give free escape to septic matter and to permit sterilization of the deeper portion of the infected tissues and secure as thorough drainage as may be possible. On general surgical principles, all incisions should be made parallel with the axis of the body. Any variation from this practice should be made for the purpose of keeping away from any nerves or vessels which might run in another direction. 26 A TEXT-BOOK ON SURGERY. The recognition of an acute abscess will depend upon certain symp- toms of a local as well as a constitutional character. The sudden rise of temperature, preceded by a chill or series of rigors, are symptoms of puru- lent infection. The local signs are those of inflammation—heat, pain, redness, and swelling. Fluctuation is also present in well-advanced cases. The integument and subcutaneous tissues about an abscess are often oedematous and doughy. The positive test is, however, by aspiration. A hypodermic syringe (used only for this purpose) with a large-sized Fig. 37.—Exploring-needle and syringe. needle (Fig. 37) is invaluable. The needle should be held over a flame or boiled just before using. It is best to employ strict antiseptic pre- cautions in aspiration as in other surgical procedures. A preliminary injection of one or two minims of two-per-cent cocaine solution with the finest needle will prevent pain. If incision is determined upon, the same anaesthetic may be employed. In the neck or in any vascular region it is best to dissect carefully down to or near the abscess wall. In some cases it is safer to push a dressing forceps tightly closed through the tissues into the abscess, then separating the blades and stretching the opening, through which, after irrigating with l-to-3,000 bichloride solution, a drainage tube is inserted. The constitutional symptoms of septic infection should be combated by careful attention to the condition of the alimentary canal, as hereto- fore described, and the prompt and persistent effort by careful nourish- ment (and stimulation, if necessary), and by a bountiful supply of as pure air as can be obtained, to hold the tissues of the patient as nearly as possible in a condition of normal resistance. The survival of the patient depends upon the power of the tissues to resist destruction from the invading micro-organisms until, failing to find a suitable pabulum for their rapid proliferation, they perish. In suppurative cases, after incision a warm, moist dressing of weak bichloride or of plain sterilized gauze covered in with protective or oil silk to prevent evaporation, is often advisable. In exceptional instances an aseptic poultice, made by wetting flaxseed meal or any other substance in warm bichloride solution (1 to 5,000), may be employed with benefit. Septicemia.—Septicemia (o-^ttt^?, putrid, alp,a, blood), or blood poisoning (with or without metastases), results from the entrance into the blood channels of either an infectious organism or the ptomaine or toxic product of such organism, or of gaseous emanations from the de- composition of diseased tissues of the body or of ingested material. The term pycemia was formerly used to imply the entrance into the blood of the semi-solid products of suppuration, while septico-pyemia is now proposed by some writers to express a mixed condition of septicaemia and pyaemia. It seems to me, however, that an effort should be made to simplify the terms used in pathology, and that septicemia would express SEPTICAEMIA. 27 a condition of blood poisoning in which metastases do not occur, while septicemia with metastases would express all that is contained in the term "pyaemia." The term septico-pyaemia is entirely unnecessary. Septicaemia, or blood poisoning, may be caused not only by the pres- ence of bacteria in the tissues, but can also be produced by -ptomaines* or toxic products derived from these organisms entirely separated from the bacteria which produced them. When septic bacteria are present, the septicaemia is sudden, and may continue indefinitely, while the sep- ticaemia resulting from the toxic products alone is temporary. Septic infection takes place in the vast majority of cases from an abrasion or wound of the skin or mucous membrane ; bacteria, entering here, travel into the tissues, lymph spaces, and blood vessels, and in severe cases are rapidly disseminated by the blood. They attack by preference the white blood-corpuscles until these seem to be mere aggregations of bacteria. The red blood-corpuscles later become disintegrated, and after death the blood is dark in color and decomposes rapidly. Haemorrhages occur in the gastro-intestinal tract and various organs; the spleen and liver are enlarged and softer than normal; the kidneys are seriously affected and seem, from the shoals of micro-organisms found in them, to be chiefly depended upon for the elimination of the bacteria. Septicaemia in severe cases is introduced by high and continuous fever, with, however, varying tem- perature, rapid pulse, great discomfort, and a feeling of prostration. In milder cases fever may be wanting. In some instances there are repeated chills, followed invariably by a rapid rise of temperature. From the point of infection the progress of invasion is marked by lymphangitis and at times by phlebitis, a condition favorable for the development of pyaemia and inflammation of the skin and subcutaneous connective tissue. The lymph glands between the wound of infection and the central or- gans become enlarged and break down in suppuration. When the cellu- litis or phlegmon is extensive, gangrene may ensue on account of the tension of the parts involved and the interference with the circulation. The parts are swollen, and often extremely painful. In the treatment of septicaemia it is of vital importance to regard all wounds as capable of conveying infection to the tissues ; and if the principles of prophylaxis just given in the treatment of infective inflam- mation were carefully carried out, there would be no such thing as septic infection. When infection has taken place, and free incision been made, it is advisable, after making the incisions, to keep the hand or part in- * Various basic substances containing nitrogen and in chemical constitution resembling the vegetable alkaloids have been isolated by chemists from putrefying material and from cultures of bacteria concerned in putrefaction, as well as from certain pathogenic organisms. These products are called ptomaines (wrw/jta, a corpse). In contradistinction to the ptomaines are the leucomaines (Aeu/ccD/xa. white of egg), which differ from the foregoing in that they are derived from tissue changes in the body independent of the presence of bacteria. Among the ptomaines are neuridin, cadaverin, putrescin, saprin, methylamine, dimethylamine, and trimethylamine. Also neurin, de- rived from decomposition of brain matter and putrefying muscular tissue ; cholin, found in hogs' bile, in the yolk of eggs, etc.; musearin, found in poisonous mushrooms and putrefying fish ; pep- totoxin, tyrotoxicon, typhotoxin, from cultures of typhoid bacillus; tetanin, from tetanus-bacil- lus cultures. 28 A TEXT-BOOK ON SURGERY. volved submerged in a warm solution of bichloride of mercury (1 to 2,000 to 3,000) for at least half an hour after the incisions are made. Beyond this local treatment not much can be done except to support the pa- tient in every way by careful nourishment and proper stimulation. When the lymphatic glands become engorged and are about to sup- purate, they should be incised and treated as the original point of infection. Septicemia with Metastases.—hi septicemia with metastases (pyae- mia) the symptoms just given as characteristic of simple septicaemia are exaggerated ; the resistance of the tissues in the inflamed area seems lessened ; the blood vessels are invaded by the bacteria (Fig. 38), and, as a result, clots or thrombi form upon the vessel walls, which, under the Fig. 38.—Bacilli of septicaemia in a vein of the diaphragm, taken from a septicemic mouse. White blood- corpuscles, some containing bacilli and some changed into masses of bacilli, x 700. (After Koch.) disintegrating action of the micrococcus of inflammation, break down, and thus purulent fragments are swept along the blood channels to the heart, from whence they are distributed through the lungs to the various organs of the body. They form emboli, or arrested clots, chiefly in the capillaries of the lungs, and each embolus may form a metastatic abscess. From here other thrombi are developed, and these are swept into the circulation and distributed by the left ventricle to the entire system. If the point of infection is in the area of the portal system the liver is apt to be the seat of metastatic abscesses. In Mr. Thomas Bryant's analysis of two hundred and three cases at Guy's Hospital the lungs were involved in one hundred and eighty-seven, and in seventy-eight of these, infarc- tions occurred in no other organ. The fever in pyaemia is usually pre- ceded by a chill, and this is apt to recur with more or less frequency during the disease. The febrile movement does not follow a regular course, but is generally intermittent. After a high temperature there is a sudden fall, often coincident with profuse and exhausting sweats. The thermometer not infrequently within a period of twelve hours will vaiy from 96° to 104° F. The condition of these patients is deplorable and the prognosis very grave. Recovery is extremely rare. I have, how- ever, seen one or two cases in which recovery ensued after metastatic abscesses had formed. SEPTICAEMIA. 29 The treatment of pyaemia does not differ from that given for septi- caemia, except that it is essential to open any metastatic abscesses that can be reached within the limit of safety to the patient.* * In 1890 a young lad of sixteen years came to me suffering from pyaemia as a result of ure- thral infection due to the use of a sound for old organic stricture. There was no specific urethritis. Metastatic abscesses had developed in the sterno-clavicular articulation of the right side, in the right elbow, right hip joint, left knee joint, and there were four or five metastatic abscesses of the soft parts in various portions of the body. The septic temperatures were high and continuous. Every symptom of most pronounced pyaemia was present. The joints were opened and drained, discharging considerable pus, and drainage was kept up for from three weeks to four months. By great care and careful feeding the patient recovered, and is to-day, five years after, in perfect health in every particular. CHAPTER III. SPECIFIC AND NON-SPECIFIC URETHRITIS. Urethritis.—The general inflammatory lesions of the urethra should be considered under two headings, specific and non-specific. Specific urethritis (misnamed gonorrhea, from 701/09, semen, pelv, to flow) is a violently contagious disease affecting by preference the ure- thra in the male and the urethra and vagina in the female, occasionally invading the rectum. In many instances, chiefly in neglected cases, the virus of specific urethritis, either alone or by mixed infection with one or more other forms of pyogenic bacteria, invades the glandular appa- ratus of the vulva, the uterus, and Fallopian tubes in the female, while in the male it may involve the glandular apparatus connected with the urethra and the entire seminiferous tract, leading from the floor of the prostatic urethra to the substance of the testicles. It may also involve the follicular apparatus of the prostate, the membranous and prostatic urethra, and the bladder, and, in exceptional cases, the march of the in- flammation is along the ureters to the pelvis and calyces of the kidney. Upon the conjunctiva it readily establishes a violent and destructive inflammation, and in rare instances spreads along the lachrymal canal into the nose and mouth. 'The germs of specific urethritis have also been found in peri-urethral abscesses, in the pus of suppurating buboes, and by metastasis in certain lesions of the joints which are at times met with in the progress of this disease, the so-called "gonorrhoeal rheu- matism." The specific germ of urethritis was discovered by Neisser in 1879, and was termed by him gonococcus. In size it varies from 0*8 to T6/* in length and 0-6 to 0'8 p. in width.* A single germ is kidney- or bean-shaped, but it appears almost always as a diplococcns, two of the bean-shaped bodies adhering with their concave surfaces toward each other. Gonococci are found not only free in gonorrhoeal pus, and in large numbers within the substance of the pus corpuscles, but never within the nucleus of the cell. In Hke manner they penetrate the epithelial cells which come away with the urethral discharge. C. W. Allen, in 1887, demonstrated the gonococcus in gonorrhoeal pus which had dried for several weeks upon the clothing by scraping the stains, macerating, and staining (Lustgarten). * A micromillimetre equals jtuvv of an inch- 30 SPECIFIC AND NOX-SPECIFIC URETHRITIS. 31 The specific action of the gonococcus of Neisser was demonstrated by Bumm, who from even the twentieth generation of a pure culture produced typical gonorrhoea in a healthy urethra. In order to appreciate the importance of the gonococcus in the ure- thral discharge, it is well to study the micro-organisms of the normal *-.- 7'7:;^*!^>7^>'- $■ *~i\-f *v "'i:>j£ d •'•^{."•'' Fig. 39.—a, b, d, Smegma bacilli, which maybe -"'• ' VV j • mistaken for tubercle bacilli; c, f, diplococci " -'~r in small hyaline cell—pseudo-gonococcus; e, Fig. 40.—Streptococcus pvogenes in large hyaline staphylococcus pyogenes aureus. epithelium of urethra. urethra. According to Lustgarten, the principal organisms of the normal urethra are : 1, The smegma bacillus, closely resembling the tubercle bacillus, which requires careful study in diagnosis to exclude tuber- culosis of the urinary tract; 2, the pseudo-gonoccoccus, found at times in the cast-off epithelia within the pus corpuscles, and therefore prac- tically not to be differentiated from the gonococcus ; 3, the staphy- lococcus pyogenes aureus ; and 4, the streptococcus pyogenes. While it has been claimed that the diagnosis of specific urethritis (gonorrhoea) can be made positive by the presence of the gonococci in the pus corpuscles, it is considered by competent investigators to be extremely difficult unless the presence of this organism is taken into consideration, along with the grosser symptoms of gonorrhoeal infection. According to Lustgarten, who has made careful investigations in this department, " several species of diplococci resemble completely Neisser's gonococcus in shape and staining qualities, especially in being decolor- ized by Gram's method." It is essential, therefore, in diagnosis, to recognize the shoals of diplococci crowding the pus corpuscles, epithe- lial cells, and floating free in the discharge, and associate these with the general and grosser symptoms of specific urethritis. A simple and rapid method of demonstrating the gonococcus of Neisser is as follows : Place a small drop of the discharge upon a cover glass and smear by rubbing two cover glasses together ; dry it by passing one of the cover glasses with pus side upward through a spirit flame two or three times ; immerse this at once in a solution of 32 A TEXT-BOOK ON SURGERY. methyl blue ; wash ♦ off the excess of coloring matter by holding it under clear running water or by dipping the glass several times into clear water ; dry the stained pus well by pressing with blotting paper; then cover it with a small drop of cedar oil; put on a thin cover glass and examine with a lens magnifying from 700 to 1,000 diameters. The peculiar double bean-shaped arrangement of the diplococci will be seen within the protoplasm of the pus corpuscle and epithelium.* When the discharge is scanty it may be obtained on a film of cotton wrapped about a probe and introduced into the urethra. When the microscope is not employed the diagnosis will be emphasized by the history of exposure, the time elapsing between contact and the appear- ance of the discharge, the peculiar, irritating character of the discharge, and the progressive increase of the same during the first five or six days. Symptoms.—When the virus is brought in contact with the mucous surface of the urethra, the period of time which elapses before local 07$?:. pICr. 41.—Pure gonococci free and within lym- Fig. 42.— Pseudo-gonococcus in an epithelial cell and pnoid and epithelial cells. free r symptoms of inflammation appear varies greatly in different individ- uals, and even in the same individual in different inoculations. It is very probable that the condition of the mucous membrane at the time of contact, as well as the variations in the normal resistance of the patient's tissues, have a great deal to do with the rapid progress of the inflam- * Gram's method, which may be used in doubtful cases, is more complicated. To fresh aniline water (aniline oil shaken well with water and filtered through moistened filter paper) a concen- trated alcoholic solution of gentian violet is added, drop by drop, up to the point of saturation -i. e., until the liquid loses its transparency. The cover glass prepared as above is allowed to float on this solution for ten minutes. It is then washed with water, and placed for five minutes in a solution of iodine (one part), iodide of potassium (two parts), distilled water (three hundred parts), and from there put in absolute alcohol, where it remains until no more color is extracted After a renewed washing, the preparation is subjected for half a minute to a second process of staining in a weak (light-brown) watery solution of Bismarck brown or vesuvin washed wi„ with water, and examined as before in water or Canada balsam. If a preparation'treated inthh manner shows blue diplococci, it is sure that they are not gonococci; but in case of brown dinln cocci, no absolute certainty is reached. For the bacterioscopic examination of gonorrheal urethral discharges a good microscope with Abbe's condenser and highly magnifying 1 . needed. Dry objective lenses are not to be recommended except Zeiss's new apochromatic sv T ** while a one-twelfth-inch homogeneous immersion lens and an ocular No. 2 and No. 3 will ^ the purpose very well. (Lustgarten.) M^er SPECIFIC AND NON-SPECIFIC URETHRITIS. 33 mation, and it may be that the virus in some instances is more intensely infective than in others. Thus the period of incubation varies from a few hours to several days, and in very rare instances as much as two weeks have elapsed between the contact and the recognition of the in- flammatory process. The limit, however, between twenty-four hours and three days will include the large majority of cases of specific urethritis. Usually the earliest symptom is a burning sensation at the meatus, which is more severe as the urine is escaping. The lips of the meatus soon become swollen, usually everted, prominent, and red. When carefully separated, a thin film of muco-pus will be seen coat- ing the mucous membrane. The first stage of the disease may be con- sidered as beginning at the moment of contact, and ending with the first appearance of suppuration. The average duration is from two to ten days. From this period, in neglected cases, the inflammatory symp- toms increase for from four days to as much as two weeks. The quantity of pus discharged varies from a few drops to several drachms in the twenty-four hours. It is increased by exercise, by unnecessary exposure to cold and wet, the use of alcoholic stimulants, any form of dissipation, and improper diet. The color of the discharge varies from the bluish- white hue of the first few drops to the yellow and yellowish-green tinge of that discharged during the height of the inflammatory process. In some instances it becomes stained with blood as a result of rupture of the capillaries in the engorged mucous membrane. The second stage, that of increasing inflammation and suppuration (in cases not treated), lasts about twelve days. It is followed by the third stage, that of decreasing inflammation, the duration of which is from three to six weeks. In addition to the purulent discharge and the pain which characterizes the second stage of the disease, there is a dim- inution in the size of the stream of urine, due to the swollen and puffy condition of the mucous membrane of the urethra. In the milder forms of gonorrhoea there are no other symptoms present in the second stage. In many neglected cases, however, the inflammatoiy process extends into the membranous and prostatic urethra, theDce along the seminal ducts, oftentimes into the bladder, epididymis, and testicle, producing serious consequences. In the female it may produce endometritis and salpin- gitis, resulting either from infection of the specific germ or from a mixed infection with other pyogenic organisms, which find their way into the Fallopian tubes, causing abscesses, producing sterility in the vast major- ity of cases, and ultimately leading to the necessity of surgical interfer- ence. In males, infiltration of the vascular erectile tissue of the corpus spongiosum occurs in a varied degree, and occasionally the exudation extends into the corpora cavernosa. A more frequent complication of gonorrhoea is inflammation of the glans penis (balanitis) and of the prepuce (posthitis), due not only to mechanical irritation of the part, but to direct infection. As a result of such extensive inflammation, the penis is liable to various deformities, painful in an extreme degree, and not without danger to its integrity. Chordee, or bowing of the organ, is a common symptom. It becomes in part or wholly erect, and, on account of the 3 34 A TEXT-BOOK ON SURGERY. infiltration of the vascular spaces of the spongiosum with the embryonic inflammatory tissue, it fails to expand with the corpora cavernosa. Pathology.—Strictly speaking, the morbid process is an inflammation of the mucous membrane of the urethra and the submucous connective tissue with or without extension to other organs. It commences at the meatus and travels backward. The epithelium is swollen, there is marked hyperaemia of the submucous tissue, with the escape of leucocytes, the production of pus, and the formation of the common embryonic tissue of inflammation. In milder cases the products of inflammation undergo retrogressive changes and are absorbed, while in other instances con- nective-tissue development is precipitated, ending in cicatrization and the formation of stricture. The organic elements of gonorrhoeal pus are leucocytes, embryonic cells, epithelia, and blood-corpuscles. In a certain proportion of cases the virus of gonorrhoea becomes absorbed and metastasis occurs in the joints, producing also endocar- ditis at times, the gonococcus being found in these secondary lesions as in other metastatic abscesses. Treatment.—From the foregoing, the importance of beginning the treatment of gonorrhoea at the earliest possible moment is evident. At the first recognition of the disease the urethra in both sexes and the vagina in the female should be irrigated at once, preferably twice, in the twenty-four hours, with a solution of 1 to 3,000 permanganate of potash, two quarts of this solution being used at a sitting. A convenient for- mula to have on hand for a ready solution is: Permanganate of potash, 3j; water, §vj. A tablespoonful of this solution to one quart of hot water gives a l-to-3,000 solution. A fountain syringe should be em- ployed (preferably one with a thermometer attached, so that the exact degree of heat may be ascertained), holding two quarts of the solution, at an elevation sufficient to give the proper degree of pressure, generally three feet above the level of the urethra. In male patients the standing posture is preferable, while female patients should lie down, as in using the ordinary douche. Since the gonococcus is killed by a temperature of 140° F. (Sternberg), the nearer this can be approximated in the appli- cation of the permanganate-of-potash solution the better. Usually, however, a temperature of 100° F. to 115° F. is as high as can be borne. Above 120° F. there is some danger of coagulating the albumin of the tis- sues. When patients are exceedingly sensitive, an injection of from one drachm to as much as three drachms of a two-per-cent solution of cocaine may be thrown into the urethra. For males, a glass catheter of the smallest diameter, five or six inches long, with lateral perforations (two or three in number) near the point, is preferable, for the reason that it can be easily introduced and thoroughly disinfected after each introduc- tion by boiling. The ordinary glass female catheter is perfectly satisfac- tory for this work. It should be lubricated with glycerin, and not with oil or vaseline, since the presence of these last two agents prevents the contact of the solution. Care should be taken not to push the instru- ment to or beyond the cut-off muscle, for fear of inoculating the deep urethra. A similar precaution should be taken in the shallow female SPECIFIC AND NON-SPECIFIC URETHRITIS. 35 urethra, and in douching the vagina the opening of the vulva should be closed at times so that this cavity may be thoroughly distended in order to bring the solution in contact with the entire surface. If a glass catheter can not be obtained, an ordinary rubber instrument may be em- ployed, but a second lateral perforation should be made opposite the one which is found in the ordinary male catheter. The opening should not be directly in the end of the instrument, for fear the solution may be thrown back through the cut-off muscle, nor, for the same reason, should the meatus or urethra be compressed. It is important that the instru- ment be of small size, to permit the free return and escape of the injected liquid. In addition to the local treatment, the following formula should be prescribed per os: $ Salol..................................... 3 j ; 01. gaultheria............................. 5 ij. The dose of this solution is twenty drops four times a day. It may be given in water, on sugar, or, preferably, in capsules. The effect of this is to sterilize the urine, which, as it is passed, aids in the antisepsis of the urethra. In the notes of one hundred and eight acute primary cases of gonor- rhoea treated in my genito-urinary clinic at the New York Polyclinic Medical School and Hospital by Prof. J. A. Bodine and the author, in which the diagnosis was made by the microscope, the average date at which the coccus disappeared from the discharge was the thirteenth day ; in some cases as early as the sixth, and in others as late as the twenty- fifth day of the disease. In some of these cases there was a slight glairy discharge which continued for a few days, but in none of these was the gonococcus present. In no single case did epididymitis or any remote complications ensue. In addition to local treatment, it is always important to carry out the strictest asepsis, in order to prevent the inoculation of the conjunctiva of the patient or physician with this virus. Thorough disinfection of the hands in a l-to-500 solution of bichloride is of great importance, and of this the patient should be cautioned at the first visit. An important adjuvant in treatment is rest, regulation of diet, and manner of living. The diet should be simple and nutritious ; stimulating beverages, such as alcohol, coffee, and tea, should be avoided. The bowels should be kept open daily, and, if necessary, by the use of calomel triturates or saline laxatives. In the first week of the disease citrate of potash (twenty grains, four or five times a day) decreases the irritating effect of the urine upon the urethra. The hip bath in warm water every night and morn- ing not only insures a degree of cleanliness which is desirable, but is also of value as an antiphlogistic. The free discharge of pus from the urethra, vagina, and prepuce is essential. The discharge should drop into a dressing or bag of oil silk, or rubber tissue, or thick cloth, made to fit without pressure, and held in place by strings fastened to a belt worn around the waist. Absorbent cotton is useful in taking up the discharge. 30 A TEXT-BOOK ON SURGERY. Several pieces of ordinary water-closet paper loosely wrapped about the penis and twisted in front of the glans affords a ready and satisfactory receptacle with drainage. Balanitis and posthitis (inflammations of the glans and prepuce) are conditions existing in a varying degree in almost all cases of specific urethritis, the acrid discharge readily affecting the epithelial covering of these organs. When the foreskin becomes swollen, tense, and painful, the annoying condition of phimosis results, and in some cases para- phimosis ensues, and may require operative interference to prevent sloughing. In phimosis it is often necessary to irrigate the glans be- neath a tight foreskin with the permanganate solution, either with a specially constructed syringe with a delicate nozzle or with a common fountain syringe. If these milder measures do not suffice, an incision through the prepuce along the middle line of the dorsum should be made to expose the excoriated surfaces or to relieve tension. The introduction of escharotics, as nitrate of silver, solid or in solu- tion, into the urethra, is rarely justifiable in view of the successful results obtained with permanganate of potash. In a few instances I have employed the method of Dr. F. A. Lyons,* of New York, successfully, and it may be used with propriety under conditions where it is urgent to arrest the discharge in four or five days, even at the risk of producing a deeper inflammation of the peri-urethral tissues than is ordinarily justi- fiable. The method is as follows : After the patient has urinated for the purpose of cleansing the canal, and is in the recumbent posture, the operator injects into the meatus with an ordinary funnel-pointed rubber syringe one drachm of a four- per-ceut solution of nitrate of silver. This is held in the urethra for from two to three minutes by the watch. There is little pain at the time and not a severe smarting on urination during the next twenty-four hours, at which time the treatment is repeated, provided that on careful examina- tion of the discharge gonococci are found ; if not, no further treatment is necessary. A two-per-cent solution should be used for the second injec- tion, and for a third if gonococci are still present. Non-Specifio Urethritis.—-This form of urethritis is due to infection of the mucous membrane of this canal by pyogenic organisms independ- ent of the gonococci. Traumatism due to external violence or excessive sexual indulgence, the introduction of unclean instruments' foreign sub- stances, calculi, etc., produce conditions favorable for the lodgment and proliferation of pus-making organisms and the development of a puru- lent discharge. It is usually of short duration, mild in character, and involves only a limited portion of the canal. The diagnosis may be made from the absence of the gonococci in large numbers and within the pus cells and epithelia, as given in specific urethritis, and from the absence of the symptoms of a violent infection. The treatment is rest the removal of any course of irritation, the dilution and sterilization of the urine, and irrigation, as in gonorrhoea. * " New York Medical Record," vol. xlvii, p. 549. CHAPTER IV. EEYSIPELAS, HOSPITAL GANGRENE, ACTINOMYCOSIS, GLANDERS, TETANUS, MALIGNANT (EDEMA, FOOT AND MOUTH DISEASE, HYDROPHOBIA, AND TUBERCULOSIS. Erysipelas.—Erysipelas (ipvaos, red, 7re\a?, skin) is an infectious inflammation of the skin and connective tissue immediately subjacent, or of the mucous membrane and the submucous tissues, and particularly of the lymphatic channels which permeate these structures (Fig. 43). The inflammation and disease may confine itself to the cutaneous surface alone, or it may be limited to a mucous surface, or, com- mencing in one of these structures, it may pass the muco-cutaneous border and in- vade the other. It is caused by a specific micro-organism, the streptococcus erysipe- latis (of Fehleisen).* An abrasion of the skin or mucous membrane is essential to the lodgment and development of this germ and the consequent disease. Though usu- ally existing as a chain coccus composed of twTo or many links, it is frequently met with in the tissues as a single germ. Ef- fecting a lodgment, this streptococcus (al- though classed as a non-motile germ) rap- idly proliferates, finds its way into the lymphatic canals, and spreads with rapidity, not only following the cur- rent of the lymph toward the center of the body, but with almost equal rapidity spreading toward the extremities. As the lymphatic channels become engorged with the rapidly proliferating elements, they break through the walls of these vessels, invade the intervascular spaces, and are found attached to and infiltrating the embryonic tissue and exudate of the inflammatory process, which they excite. They have been found also within the protoplasm of the leucocytes, and this is cited as an evi- dence of phagocytosis ((jxiyeiv, to eat, kvtos, a cell)—that is, the property which the leucocytes possess of destroying and appropriating as food invading micro-organisms (Fig. 44). Most of these cocci, however, are only attached to the leucocytes and lymph corpuscles and are not within the protoplasm. As the inflammation subsides, the shoals of * This organism as determined by Sternberg is destroyed in streaming steam at 54° C. 37 Fio. 43.—Streptococci of erysipelas, x TOO. Section through a lymph ves- sel of the skin (Fliigge). 38 A TEXT-BOOK ON SURGERY. Fig. 44.—Phagocytes (Metschnikoff). a, an anthrax bacillus about to enter a white blood-corpuscle; J. the anthrax bacillus within the white blood-corpuscle; c, white blood- corpuscle with anthrax bacilli which have become broken into pieces. germs disappear from the center or oldest areas of inflammation and are found more numerously near the periphery, which, in all proba- bility, is due to the fact that they rapidly exhaust the material upon which they depend for existence, the older or first developing organ- isms perishing near the cen- ter of infection. In excep- tional instances, due proba- bly to a subnormal resistance of the tissues attacked, the streptococcus makes its way through the walls of the ven- ules and thus produces rapid general and usually fatal sep- ticaemia, with or without me- tastases. Doyen seems to have established a close relationship between ery- sipelas and puerperal fever. In both mild and severe cases of this fever, he found a streptococcus which, under the microscope, could not be dif- ferentiated from the micro-organism of Fehleisen. By inoculations (according to Senn) he found that the streptococcus obtained from the inflamed tissue of puerperal fever caused erysipelas, and, vice versa, the streptococcus found in erysipelas developed puerperal fever. Clinically, we must then conclude that the micro-organism of puerperal sepsis is identical with that of erysipelas. The coccus of erysipelas very closely resembles the streptococcus pyo- genes, as heretofore mentioned, but there seems little doubt that they are separate specific germs, for aseptic injections of erysipelas cultures do not produce pus; therefore when pus is found complicating the inflamma- tion of erysipelas it is due to a mixed infection with pyogenic bacteria, Hajeck demonstrated in fifty-one inoculations of animals that the ery- sipelas microbe causes a migrating dermatitis which perfectly resembles erysipelas in man, while similar injections of the streptococcus pyogenes produces a deep-seated inflammation which in almost everv instance was accompanied by suppuration. Studying these tissues with the micro- scope, confirmation was emphasized in the fact that the erysipelatous cocci were found in shoals in the lumen of the lymph vessels, while the pus streptococci, in common with all pyogenic bacteria, infiltrated all the tissues, even passing through the vessels into the circulation, as given by Senn. Erysipelas occurs more frequently upon the face than any other part of the body, and particularly about the nose, for the reason that the face is most exposed to contagion and the germs rapidly find lodgment in the abrasions, however small, which are common about the junction of the mucous membrane of the nose with the skin It beo-irw a* or, acute dermatitis; the skin becomes red, swollen, and painful, due to the tension which the rapid infiltration causes in the canals and between the lymphatic spaces. The epidermis has a glazed, shiny, bright appear- ance ; the color is deeper in the center of infection, tending to a dark ERYSIPELAS. 39 mottled hue, while the bright red spreads to the periphery of the inflamed area, gradually fading into the normal color of the integument. The redness at first may not always diffuse itself, but may occur in several foci or centers of inflammation, radiating along the lymphatic channels. By fusion these rapidly form a solid surface bright red in color. The inflammation and discoloration spread in all directions, travelling toward the center of the body, however, with little more rapidity than against the lymphatic current. Cases are recorded in which two or more sur- faces of the body have been attacked simultaneously or successively. In one of my cases, in which I inoculated pure sterile cultures of erysipelas for the cure of sarcoma, the dermatitis and discoloration traveled from the point of inoculation, on the anterior aspect of the left thigh, and within five days spread over the abdominal wall as high as the nipple of the same side. In this case there was no suppuration. In portions of the body where the integument is loosely attached the exudate is usually extensive and the swelling considerable. Large vesi- cles or blebs develop in the part involved, which contain clear or straw- colored serum. Suppuration does not take place unless mixed infection has occurred. As the disease develops, rigors occur and cold and hot sensations alternate, while a general feeling of discomfort and uneasiness pervades the patient ; the temperature rises to a high degree, with rapid pulse and the ordinary symptoms of high febrile movement. In severer cases, when the organism invades the venules, the internal organs be- come affected. Albumin is present in the urine, which is dark in color, and occasionally there is hsematuria, with the presence of the pathogenic streptococci in the urine. These cases almost invariably end fatally. In ordinary cases (simple cutaneous erysipelas) the tendency of the disease is to recovery in from four to six days with limited tissue destruction. In others it may last for one, two, or three weeks, and in some cases there seems to be a chronic form of the disease, which entirely disap- pears for months, and then recurs without marked constitutional dis- turbance. When suppuration or sloughing occurs (the cellulo-cutaneous or phlegmonous variety) of course the prognosis is more grave. Under such conditions the symptoms of septic infection are exaggerated and general septicaemia, with or without metastases, ensues. Attacking the mucous membrane, the course and prognosis of the disease do not differ materially from that just described. Diagnosis.— Erysipelas, within the first twenty-four or forty-eight hours of its appearance, may be taken for dermatitis, or simple erythema, phlebitis, lymphangitis, or cellulo-dermatitis. Dermatitis occurs, as a rule, from local irritation, and is not accom- panied by any of the constitutional disturbances which accompany erysipelas. In simple inflammation of the skin the color is red, but it never has the glazed appearance which is always present in a typical erysipelas. Erythema, a mild form of dermatitis, may also be mistaken for erysipelas. In erythemapapulatum the expo.sed and extensor sur- faces, as the dorsum of the hand and the posterior aspect of the forearm, are apt to be involved. There is no wound of inoculation ; very slight, if 40 A TEXT-BOOK ON SURGERY. any, infiltration of the skin proper. Children and younger adults suffer most frequently. It lasts for only a few days, then fades away, leaving a dry scale to indicate the location of the papule. Owing to the various shapes and the different shades of color assumed by the papules, and efflorescence of the erythema, it has been divided into erythema annu- lare, erythema gyratum, and erythema iris* In erythema intertrigo there is a general redness of the skin in parts subjected to friction or irritation from perspiration. Erythema nodo- sum is almost peculiar to chlorotic females. The color, at first bright red, soon changes to a dark hue. The patches are oval, elevated, and nodular. Phlebitis and lymphangitis are more severe forms of inflammation than those just given, and are accompanied with constitutional symptoms not unlike those present in a typical erysipelas. The chief point of diag- nostic value relates to the anatomical arrangement of the vessels, for in phlebitis and lymphangitis the lines of inflammation and discoloration travel along the course of the vessels without the general and wide- spread efflorescence of erysipelas. Diffuse cellulitis occurring from a poisoned wound, as with a dissect- ing knife, or after the bite of a serpent, will offer no difficulty in diagnosis. It may, however, occur without a recognized cause. The subcutaneous tissues are first attacked, and the skin may or may not be involved in the process of inflammation. There is swelling and painful tension of the part affected, and, if the process be uninterrupted, transudation of serum occurs, causing oedema, and giving a doughy feeling on pressure. Pus may be found in quantity, and infiltration become extensive. This result is more apt to occur in diffuse non-specific cellulitis than in phlegmonous erysipelas. This condition, especially when the skin becomes involved, offers considerable difficulty to a positive diagnosis. If, however, the peculiar symptoms heretofore given be carefully considered, and a com- parison instituted between them and the phenomena of the various dis- eases which may simulate or complicate erysipelas, it will be found that, in the great majority of cases, a correct diagnosis may be made. Treatment—-The streptococcus of erysipelas is destroyed in a l-to-1,000 bichloride solution within fifteen seconds, and the inference is natural that the injection with a hypodermic syringe immediately around the periphery of the beginning focus of erysipelatous inflam- mation would arrest the spread of the disease. Of course this treat- ment could only be justified where the circle of injection would not require enough of the mercuric chloride to endanger systemic poisoning from this substance. I have used a l-to-500 solution under such con- ditions in an area one inch in diameter without any symptoms of poison- ing and with arrest of infection. It should be employed when the first limited blush of the disease is observed. As the injection is painful a weak cocaine solution, either Schleich's normal or a one- or two-per-ce'nt solution, should be employed to produce local anesthesia. * Neumann, " Handbook of Skin Diseases." Bulkley. D. Appleton & Co. 1872 ERYSIPELAS. 41 fo.a r-j(\x 4ff 0 -rys7/etatous rednis* St. Klein reports three cases of erysipelas treated with excellent results with a preparation of equal parts of ichthyol and vaseline applied over the affected parts two or three times. The skin should be thor- oughly cleansed with warm water and soap before the application. The ointment should be gently rubbed into the surface and the parts covered with a compress wet with a solution of salicylic acid, and over this a thick layer of cotton wadding (Senn). Kraske and Euhnast recommend scarification or limited incisions entirely around the area just outside the border of inflammation, fol- lowed by irrigation with a five-per-cent solution of carbolic acid and the application to the erysipelatous area of compresses wet with a 2-5-per- cent solution of carbolic acid, the compresses to be changed once or twice a day (Tillmanns). A l-to-1,000 bichloride solution, however, should be preferred to the carbolic-acid compresses. In making these incisions general anaesthesia is to be employed; they should be made in latticework fashion, as ad- vised by Dr. W. Meyer.* The incisions should not extend through the skin, but well through the epithelial layers down to the corium. The point of these incisions should not be nearer than half an inch to the margin of redness (Fig. 45). The lines should be about one inch long and about half an inch apart and parallel with each other, forming a zigzag fence or latticework entirely encircling the inflamed area, In these cases the disease has frequently been arrested, the discoloration extending into the angles of the latticework incision, but not crossing the incised lines. When the arm or leg is involved in its entire circumference, two complete circles of the latticework incision should be made, one above and one below the erysipelatous area. When a mixed infection occurs, and when the swelling is great and gangrene threatened as a result of the extensive exudate, parallel and sufficiently deep incisions directly through the swollen parts should be made to lessen tension, and these wTounds treated by a moist bichloride dressing (l-to-3,000), covered over wuth cotton batting. Certain constitutional measures aid in the success of the local treat- ment. The bowels should be kept open and the most careful nourish- ment should be ordered. The patient should be isolated at the earliest suspicion of the disease and placed by preference in a large, warm, well- ventilated room. All dressings should be strictly antiseptic, the attend ants should bathe their hands in l-to-500 bichloride solution, all instru- ments should be boiled as soon as used, and every precaution exercised to prevent spreading of the disease. The surgeon, while visiting a Fig. 45.—Zigzag incisions, actual length. (After Meyer.) " New York Medical Record," March 15,1890. 42 A TEXT-BOOK ON SURGERY. patient with erysipelas, should wear a gown moistened in l-to-2,000 bichloride solution, and should bathe the hands, face, beard, and hair in the same before visiting other surgical cases. All furniture in the room should be well washed in l-to-500 bichloride solution, the bedclothes boiled, and mattress and pillows burned to prevent further infection. The prognosis in erysipelas is favorable in the vast majority of cases, and this should encourage us in advising artificial inoculation of this disease in certain cases of malignant neoplasm, as in sarcoma, in which, without any doubt, cures have been effected by the institution of acute septic infection. A disease milder in type and somewhat similar to erysipelas, which in all probability is an infectious, non-suppurative dermatitis, is met with at times in the persons of those who are brought in contact with the skins and meat of animals. Pain is slight, and usually confined to the point of infection. It has been called erysipeloid, but is so rare that it does not call for special mention. Hospital Gangrene.—Hospital gangrene, formerly one of the most terrible of all the infectious diseases connected with the treatment of wounds, has practically disappeared since the introduction of aseptic and antiseptic surgery. During the civil war it caused the destruction of several thousand wounded soldiers. The epidemics that occurred then seem to have been fatal by reason of improper nourishment and lack of cleanliness. It occurred more frequently in the fall and winter than in the summer months. Cases are so rarely met with now that no experimental investigations have been made to determine the peculiar micro-organism of this disease. In some experiments upon animals Koch discovered an organism, a streptococcus, which had a diameter of about 0-5 p., which produced gangrene and was always present in his experi- ments upon mice. It is likely that this organism is closely related to the streptococcus of erysipelas, but it is more destructive. The tissues be- come swollen and discharge an enormous quantity of yellowish serum. During the civil war almost fifty per cent of the cases proved fatal; the cause of death was a severe form of septicemia, due to the absorption of the products of decomposition in the tissues involved. The treatment then was to destroy the infected area with the actual cautery, or, as Hamilton recommended, writh pure bromine. Actinomycosis.— The germ of actinomycosis (actinomyces), a disease quite common in animals, is rarely met with in man. It is classed with the fungi. It was described by Bollinger in 1877, and seen by James Israel in man a year later (Warren). To the naked eye the organism appears to be about the size and shape of a millet seed, yellowish^brown or green in color, soft in consistence ; under the microscope it consists of clusters of wavy, bushy shreds, or club-shaped projections (Fio-. 46). The most common seat of infection in man is the mouth, or it may be ingrafted upon any abrasion of the skin. It is characterized by inflam- mation and swelling, of a slow chronic type, with indurated margins to the sinuses formed by the discharge of serum and pus, which is usual in this disease. The fungus is not a pyogenic organism, hence the pus is ACTINOMYCOSIS. 43 due to a mixed infection. When the gum is infected the bone also be- comes involved and breaks down. The disease progresses slowly as a rule. The diagnosis rests upon the recognition of the peculiar millet-seed particles discharged from the swelling which can be seen under the microscope if not by the naked eye. The disease may attack the lungs through the respiratory tract, or make its way through the mediastinum and attack the deeper organs ; or pass into the alimentary ca- nal and produce fatal results. Iodide of potassium in large doses has destroyed the organism in a number of cases and should be faithfully tried before resort- ing to operation. Every effort should be made to remove all the tissues involved in the early stages of the disease, and careful disinfection should be made with a strong solution of bichloride of mer- cury. Local use of nitrate of silver has succeeded in destroying the fungus and producing a cure when applied early in the history of infection. Anthrax. — Anthrax ('' milzbrand," "splenic fever," "charbon," "malignant pustule "), a disease frequent in animals in certain portions of Europe, less fre- quent in the United States, attacking by preference cows, sheep, and horses, is rarely met with in man. The specific germ, the bacillus of anthrax (Figs. 47 and 48), was dis- covered in 1850 by Davaine and Rayer. Under the microscope they ap- pear as bright, transparent rods, with slightly rounded or swollen ends, giving a dumb-bell appearance, are from 3 to 6 p in length and 1 to 1*5 p. in width, do not possess spontaneous movement, are aerobic, and perish in moist heat at 54° C. In chains of three or more links, they are com- pared to the articulation of the phalangeal bones or joints of bamboo rods (Warren). In sporulation, according to this author, the first indi- cation is a thickening in the middle of the rod, which soon becomes a bright spot of irregular outline. In fresh bouillon at a temperature of 37° C, where a generous supply of oxygen can be obtained, the spore soon loses its glistening appearance and increases in length. The envel- oping membrane gives way and the young bacillus projects from the opening; the shell finally disappears and the completely developed bacil- lus is hatched out. Spores do not develop in the living body or in the cadavers of animals dead from this disease. Before sporulation the bacil- lus is readily destroyed by a temperature of 54° C, but it is exceedingly difficult to destroy the spores. While the action of the gastric juice is usually fatal to this organism, the spores are unaffected and pass into the small intestine, where they develop. Infection in man is most frequently Fig. 46.—Actinomyces (ray fungus) with one branching filament separated from the others. (Ponfick.) 44 A TEXT-BOOK ON SURGERY x7 Fig. 47.—Blood from a mouse with anthrax, dried on the cover glass and stained with methyl violet. Eed blood- corpuscles and anthrax ba- cilli, x TOO. (Koch.) through a slight wound in the skin, and occasionally through the respira- tory tract. Those engaged in handling hides and caring for animals are most frequently affected ; the bite of flies has also been known to con- vey this organism into the body. The period of incubation is from one or two hours up to as many days. In the ~ >^ rill few cases that I have seen infection has been lliJli 7^ rapid. In one instance the patient was inocu- lated on the side of the nose by a fly. Within an hour the infected point became painful and within six hours this area was deeply injected and swollen. The tension was relieved by a cru- cial incision under cocaine anaesthesia, and the immediate injection of bichloride solution (1 to 1,000) into the wound and the tissues surround- ing it arrested the spread of the bacilli. In neglected cases the tissues at the seat of inoculation may become gangrenous, and as infection pro- gresses there is high fever, nausea, vomiting, headache, disturbance of circulation and respiration, in severer cases, ending in convulsions. In these cases the bacillus enters the circulation and is distributed through the blood to all the organs. The treatment of malignant pustule de- mands the thorough saturation of the tissues about the wound by the subcutaneous injection of a l-to-1,000 solu- tion of corrosive sublimate. Immediate ex- cision of the point of inoculation or thorough destruction with the cautery will suffice when the injection is not possible. After free incision in neglected cases, hot aseptic poultices should be applied. According to Warren, the bacillus pyocyaneus has been found to exert an inhibitory action upon the development of the anthrax poison, and it is yet possible that this organism may be employed as a therapeutic agent. Glanders.—Glanders (farcy) is a disease met with chiefly in horses, but it can be transmitted, with the exception of cattle, to other domestic animals, and also to man. It is caused by the introduction of a specific ba- cillus which was first positively demonstrated by Loeffler and Schultz. They are delicate rodlike bodies, growing in the presence of oxyo-en at a temperature ranging from 25° C. to 40° C, and are without mo- tion. They enter the body usually through an abrasion of the skin or mucous membrane, or may be carried into the system by the re- spiratory apparatus. It has been shown that in all probability they can pass through the unbroken skin and through the hair follicles This organism is killed at a temperature of 55° C. It occurs most frequently in persons who work among horses, from which animal the disease is usually contracted. It has been known to attack the con- junctiva and the mucous membrane of the nose, but is more frequentl Fig. 48.—Anthrax bacilli joined together in the form of thread's from a three hours' old culture of the blood of a guinea-pig in humor aqueus. x 650. (Koch.) GLANDERS. 45 met with in the integument. In the mucous membrane of the respira- tory tract and in the skin it is characterized by the presence of peculiar nodules, varying in size, and metastatic nodules are found in the deeper vessels (Tillmanns). In the acute form, destruction of the tissue involved is exceedingly rapid, with all the symptoms of severe general sepsis : pain in the back, joints, and limbs, high fever, and marked destruction of tissue at the seat of infection ; lymphangitis, with widespread inflam- mation of the skin overlying the lymphatics, with suppuration, are also symptoms of this disease. In the subacute or chronic form, the local symptoms are less manifest, but me- tastases in the spleen, liver, kidneys, and other viscera occur. When found in the tissues, the glanders bacilli are in parallel groups or collections. The diagnosis of the disease must depend ^v 'WJ^^^' npon the peculiar appearance of the i)% v . ,s ^*Qh*v nodes and the association of the person '-. «^N- — attacked with animals known to have Fig. 49.—Bacillus of glanders. Pure cultures t-u„ Hiqpoop Tillmq-nn<5 C~ which he believed to be the specific infective •>7-"iSvi-^5)?^::^-e-i": agent. He described it as a straight or curved '>^k7^:-.'*^:*7''C ^' bacillus, resembling the tubercle bacillus, but • C^.-C'? >/^ /''"'.' differing somewhat in reaction from staining. $&Vi7~7Bv •'■"J'.y.^-.'>' It is usually curved, or at times " S "-shaped, -■I-'-^^cH^ cvlv 7^-7 with knoblike swellings on the ends, 3*5 to Fig. 55. - Wandering cells with 4'5/i in length and 0'25 to 0'3 fi in diameter. garthen!)bacillL x 1,05°' (Lust" Lustgarten also described the presence of spores in this organism. They are not found free in the tissues, but inclosed in cells about twice as large as blood- corpuscles, one or two in a single cell, occasionally more. Eve and Lingard, in 1886, obtained in cultures from the blood of syphilitic patients who had not undergone mercurial treatment bacilli which in form and dimensions resembled the tubercle bacillus and which stained readily by Gram's method, but not by Lustgarten's (Sternberg). © /~\ M^ Other investigators claim to have found ~ ^ k^j /? Lustgarten's bacillus in preputial smegma. V> \J In practice, two distinct forms are met (^L ^ f^Q with—namely, the acquired and the inher- (J) ~~ ®P)-QQ© ited. ' ©^S^OCf Acquired syphilis ensues when the specific ^ ^ '^':'' ? ;rr># virus is carried into the lymph or blood chan- ¥l\!L~flTZ a^phS boISS nels of a human being not syphilitic at the with syphilis bacilli, x 1,050. ° ^ r (Lustgarten.) time of inoculation. While it is generally believed that an abrasion of the skin or mucous surface is essential to the absorption of the virus, it is extremely proba- ble that, if it is brought and kept in contact with the thin unbroken skin or mucous membranes, absorption may occur. A disease, the germs of which are transported within the spermatic elements, and with such po- 54 SYPHILIS. 55 tency that the impregnated ovum is affected, can, under favorable condi- tions, in all probability be transmitted by unbroken cutaneous or mucous surfaces through which it is demonstrable that the absorption of other elements occurs. The chief source of the contagion is in the fluid which transudes from the surface of the initial lesion or ulcer (chancre), and, next in order, that from mucous patches. The blood of a syphilitic patient also carries the poison and produces the disease if injected into or inoculated upon the tissues of another. The same is true of the matter or fluid from the cutaneous lesion of the secondary stage of syphilis. It is doubt- ful if the lesions of tertiary syphilis are capable of reproducing the dis- ease. Saliva from a syphilitic subject, unmixed with the discharge from mucous patches, fails to produce syphilis. Seminal fluid from a syphi- litic man, in any stage of the disease, is held to be not directly contagious. However, the mother may acquire the disease from a child in utero, the child being syphilitic from the spermatozoa. Milk from a woman in any stage of syphilis will not produce the disease if injected into the tissues or ingested as food. The transudation from a fissure in the nipple of a syphilitic nurse will, if lodged in an abrasion upon the lips, tongue, or buccal wall of the child, produce the specific disease in a non-syphilitic subject. On the other hand, a syphilitic child may inoculate a healthy nurse. The urine, tears, and sweat of syphilitic patients do not convey the specific virus. Pus from a vaccine pustule on a syphilitic subject does not convey the virus of this disease even when the vaccination is successful. If, how- ever, blood or the fluid from any early syphilitic lesion is mingled with the pus, syphilis results. While the most frequent seat of inoculation is upon the genital organs, or in their immediate vicinity, it may occur at any part of the body. Physicians are frequently inoculated on the finger in examining patients and in like manner they may transfer the virus to others. Dentists and barbers may also transfer the virus from a syphilitic to a non-syphilitic subject. The contagion may be direct or indirect. In the former, the virus of a specific ulcer is brought directly in contact with an abrasion upon a non-syphilitic subject. In the latter, the poison adheres to some intermediate agent, and thence is conveyed to the abrasion.* The clinical history of a typical case of acquired syphilis left without treatment, and in a certain proportion of cases in which treatment is in- stituted, is divided by usage into three stages—primary, secondary, and tertiary. In a majority of cases, when properly managed, the later mani- festations may be eliminated, and the secondary stage made shorter and less severe. * In one of my cases the inoculation occurred in a fissure of the lip in the person of a mer- chant who was using a glass in common with a customer in sampling wines. In 1883 a patient presented himself at the clinic who had had a specific ulcer and syphilis resulting from being tat- tooed upon the arm. The operator moistened the point of the needle with saliva in which the virus from mucous patches was mingled, and thus conveyed it into the integument. 56 A TEXT-BOOK ON SURGERY. The primary stage includes: 1, absorption of the virus ; 2, the ulcer ; 3, local lymphangitis and adenitis. The symptoms which belong to the second stage are the cutaneous eruptions, mucous patches, fever, arteritis, condylomata, alopecia, iritis, and general adenitis. In the tertiary stage the pathological changes are chiefly confined to the arteries, viscera, bones, the integument, and the subcutaneous and submucous connective tissues. This is the period of gummy tumors, connective-tissue formations, arterial occlusion, and deep ulcers of the skin and mucous membranes. The usual duration of the first stage is from six to nine weeks. Sec- ondary symptoms may, however, appear at the fifth or sixth wTeek from the date of inoculation. On the other hand, in rare instances, they may be delayed to between the third and sixth month. The limitation of the stages of this disease is in great part arbitrary. The duration of the second stage varies from the fifth or sixth week (or in delayed cases the sixth month after contact) to about the end of the first year after the inoculation. The tertiary stage begins at the end of the preceding stage, and may last indefinitely. First Stage.—When the specific virus is brought in contact with a broken cutaneous or mucous surface, absorption may begin at once or be delayed for a considerable period. The abrasion may be so insignifi- cant that the patient's attention is not attracted to it, and, although the virus is lodged in it, it may heal over within a few days. If subjected to irritation by friction, or the simultaneous inoculation with the virus of phagedenic ulcer or other virus, inflammation supervenes, and an ulcer more or less phagedenic in character appears. Absorption takes place chiefly through the lymphatics. It may occur through the blood vessels, and it is possible that in those cases in which constitutional symptoms appear with great rapidity and severity, the dissemination of the virus takes place in this latter wTay. The rabidity of lymphatic absorption varies. There is usually a period of about three weeks from the time of lodgment of the virus until the local inflammatory process is recognized. That the specific virus has passed into the neighboring lymph channels before the appearance of the ulcer (chancre) seems satisfactorily proved in the repeated experi- ment of freely excising the initial lesion at its earliest appearance, in which cases constitutional infection was not retarded or prevented. The ulcer of syphilis always appears at the point where absorption of the virus took place. From the inoculation to its appearance, the lapse of time is usually about three weeks—not less than ten days ? occa- sionally delayed as many weeks. Its duration varies from two 'to ten weeks, occasionally longer. It often begins as a small papule, from the covering of which a clear serum escapes, or from the beginning it may exist as an erosion. There may be one or many, owing to the^number of points simultaneously inoculated. An uncomplicated initial lesion, not subjected to irritation, does not tend to ulcerate. It is usually circular or oval in outline, is shallow in- SYPHILIS. 57 creasing gradually in depth from the periphery toward the center, and its surface is covered with a yellow serous transudation. Grasped between the thumb and finger, it is found to be indurated, but not painful. The induration is closely limited to the sore, and termi- nates rather abruptly, not fading off gradually in a wide infiltration of the skin or neighboring tissues. When the specific ulcer of syphilis is inoculated with pyogenic bac- teria or a virus which induces phagedena, its peculiar character is lost, and it becomes in appearance and behavior a non-specific sore. If from friction, or the application of corrosive substances, or the cautery, an acute inflammation is precipitated, the specific character of the lesion also disappears. Local lymphangitis and adenitis always occur in syphilis during the formation and existence of the initial ulcer. Commencing in the lymph channels immediately around the lesion, the process travels in the direc- tion of the nearest glands. If the sore is well on one side, the glands of that side are usually first affected. When situated in the median line, or if ulcers exist on both sides, the adenitis is apt to be bilateral. In very exceptional cases, ulcer of one side is followed by unilateral ade- nitis on the opposite side of the body. Dating from the appearance of the sore, from eight to fourteen days usually elapse before enlargement of the inguinal glands is noticed. Less frequently, three or four weeks intervene. From one to seven distinct glandular nodules may be felt. They are hard, yet slightly elastic to the touch, not painful under ordinary pres- sure, and freely movable beneath the skin. The size varies from those which are so small as scarcely to be recognized up to a half inch or more in diameter. There is no periadenitis, and, unless an acute or phage- denic inflammatory process is superadded, the glands do not become matted together in one hard, painful lump, nor does the integument be- come red and painful, as in the adenitis of phagedenic ulcer or gonor- rhoea. The primary adenitis continues into the second stage, in which indu- ration of the glands is general. When the ulcer is situated upon the lips, tongue, or mouth, the sub- maxillary plexus becomes enlarged. Adenitis of the epitrochlear and axillary glands follows inoculation upon the fingers, hand, or forearm. Second Stage.—Cutaneous and mucous lesions, alopecia, fever, head- ache, arteritis, lymphangitis, adenitis, iritis, and osteitis. The cutaneous lesions of syphilis (syphilides) may be macular, papular, vesicular, pustular, and tubercular. Of these forms of erup- tion, some are peculiar to the secondary period, others to the tertiary, while, as will be seen, some are met wdth in both the second and third stages. The macular syphilide is usually first seen occurring as indistinct spots or stains, not elevated, and varying from a light red to a slate or copper color. They appear very frequently at the limit of the first stage of syphilis, about the sixth or seventh week after the ulcer occurs, but 58 A TEXT-BOOK OX SURGERY. often later than this period. The portion of the body where the maculae are usually first seen is upon the abdomen, whence they may extend over the entire cutaneous surface. In size they vary from a pin-head to round or oval spots a- half inch or more in diameter. The papular syphilide occurs in several forms which may be present in the secondary or tertiary period. The mucous surfaces, as well as the integument proper, are affected. Not infrequently the papulae are preceded or accompanied by maculae. The papulae assume various shapes, some being small and pointed, others broader at the base and flat on top, in shape like a truncated cone. Upon mucous surfaces the papular character of the eruption may be observed if seen early in its appearance ; but, on account of the moisture present, the papules soon disappear, leaving patches which may be elevated or depressed. Mucous patches, when recent, are red in color, but later become covered with a grayish film. The papular syphilide, which occurs near the junction of the skin and mucous surfaces, or in the deep folds, as those below the mammary glands in women, and between the thighs and gluteal regions in fleshy individuals of either sex, not infrequently, as a result of uncleanliness and irritation, be- comes developed into papillary or warty growths known as con- dylomata (Fig. 57). The eruption comes out in some cases over the entire body ; in others the face is exempt. Fl°-57--VegetaEufnsTeadyand juiil? vulva" (After The palms of the hands and the soles of the feet are not infre- quently invaded. At times the trunk is chiefly occupied, the face, hands, and feet escaping. The margins of the papulae are well de- fined, varying in size as did the maculae, and also in color. In the main they are darker, and the pigmentation is more marked. The eruption disappears by absorption of the cells which have infiltrated the papillae and corium, and this may occur with or without desiccation or scaling. The scaling syphilide, or so-called psoriasis syphilitica, is at times with difficulty differentiated from true psoriasis, especially when the venereal inoculation is denied. • The vesicular syphilide is peculiar to the second stage, and is seldom observed. The vesicles, like the papules, may be small, pointed, and gathered in clusters, as in herpes ; or larger, like the vesicles of chicken- pox, and scattered at varying intervals over the entire body. Commenc- ing as vesicles, they may become pustules, which, as evaporation occurs, are covered with small crusts or scabs. The pustular syphilide maybe met with on all parts of the body and may originate as a pustule, or, as stated above, become pustular from a vesicular or papular origin. This variety of cutaneous lesion SYPHILIS. 59 while most common in secondary, is not infrequently seen in tertiary syphilis. The smaller-sized, more superficial pustules, belong naturally to the earlier period ; those with wide bases and more extensive tissue destruction, to the later manifestations. The pustular syphilide originates around and in the hair follicles. In mild cases, and when of small size, the limit of infiltration and pus- tulation is immediately around the follicle. In other cases the infiltra- tion is wider, and the destructive process more extensive. Scabbing, with underlying ulceration varying in extent, is the com- mon history of all pustular syphilides, although extensive molecular death of tissue is less apt to occur in the secondary than in the tertiary stage. The color of the crusts varies from black to a brownish-copper color. If the scab is removed, the walls of the ulcer will be seen to be precipitate and curvilinear in outline, while the floor is covered with a varying amount of fluid and detritus. The tubercular syphilide is so rarely a lesion of secondary syphilis that it will be described with the symptoms of the third stage of this disease. It is exceedingly rare to observe all of the foregoing syphilides in any single individual. The macular and papular eruptions are fre- quently met with together, while the pustular syphilide usually exists alone. Alopecia occurs in a varying degree in most cases of syphilis. Though noticed chiefly in the scalp and beard, all the hairy portions of the body are involved. Except in the case of the pustular syphilide, the follicles are rarely destroyed, so that, as the violence of the attack is diminished, the hairs are reproduced. Alopecia, from general sebor- rhcea, is one of the later manifestations of syphilis. Fever.— Elevations of temperature occur in the second stage of syphi- lis in a large proportion of cases. In mild attacks it may not be ob- served, but in many instances the thermometer will register from one to two or three degrees above the normal. The febrile movement usually begins when the virus has passed through the first network of lymphat- ics and is being disseminated throughout the tissues. It may precede the eruption or occur with it, and, as a rule, continues after the eruption fades away. Headache, usually referred to the frontal region, at times to the ver- tex or base, occurs during the period of fever, and is generally propor- tionate to the intensity of the febrile movement. Arteritis, lymphangitis, and general adenitis occur in the second stage, and, in neglected cases, continue until the third stage. Iritis is not uncommon in secondary syphilis. It is usually unilateral, and may be recognized by immobility of the iris, photophobia, and by the red injection of the membrane. Pathological changes .in the bones do not occur, as a rule, in the ear- lier stages of syphilis. Pain, usually mild in character, is present in some cases in the second stage, but lesions of the osseous structures be- long especially to the last stage of this disease. 60 A TEXT-BOOK OX" SURGERY. Third Stage.—The lesions of tertiary syphilis rarely manifest them- selves earlier than the second year of the disease. Once present they may continue for a while, and disappear, to return at varying intervals during the life of the individual. No tissue or organ is exempt from the grave pathological changes induced by the syphilitic virus in this stage. Skin .—Externally, the changes in the skin are chiefly those of ulcera- tion. Nodules, resulting from cell-proliferation and accumulation in the deeper layers of the skin, and at times in the subcutaneous tissues (gum- mata), appear, and after existing for a variable period of time may, by interference with the nutrition of the part, lead to molecular death of the adjacent tissues, or, failing in this, undergo fatty metamorphosis and absorption. If an ulcer exists, it has the usual shape of the syphilitic sore—round, oval, or curvilinear, with regular edges, not ragged or in- dented. When granular degeneration of the new tissue occurs, the skin immediately over the tubercle has a stretched or glazed appearance, and is slightly discolored. A not infrequent pustular cutaneous lesion of the third stage of syphilis is known as rupia syphilitica. In very rare instances a pus- tular syphilide, similar in appearance and with difficulty differentiated from rupia, occurs as a secondary lesion. I presented one such case, with an unmistakable history of acute syphilis, to the New York Patho- logical Society in 1884. The pustules in rupia syphilitica are usually circular or oval in shape, appear as slight elevations or blebs, which soon break open. The sero-purulent contents ooze out; evaporation and scab- bing occur; the crusts, by reason of the new deposit underneath, are gradually lifted, and give to the scab a laminated, rough appearance, not unlike that of an oyster-shell. The crusts have a dark-brown or slightly greenish hue. When the late cutaneous lesions of syphilis attack the fingers, the nail or matrix is affected (paronychia), causing a roughened condition of the nail and a swollen matrix, leading frequently to temporary, and occa- sionally to permanent, loss of the organ. In like manner, permanent alopecia may occur from destruction of the hair follicles. Nervous System—Brain.—Paralysis is one of the most frequent le- sions of tertiary syphilis, and may result from one of several causes, namely—pressure of a gumma developed within the brain-substance, proper or upon the investments ; pressure from syphilitic exostosis of the skull; destruction of brain-cells by connective-tissue hyperplasia in the neuroglia, with consequent cicatrization and contraction ; more or less complete occlusion of the arteries (endarteritis obliterans). Hemiplegia, partial or complete, is the rule. Occasionally the center of language is alone affected. Dementia may ensue as a result of soft- ening or pressure, and epilepsy may be classed among the late manifesta- tions of this disease. Chronic meningitis is an occasional symptom of late syphilis. It is accompanied by headache, dull and persisting in character, impairment of intellect, interference with the functions of one or more of the cranial SYPHILIS. 61 nerves by extension of the morbid process, resulting at times in ptosis, strabismus, or impairment of vision, hearing, taste, smell, etc. The more serious cases progress gradually to coma and death. There is in all an elevation of temperature, loss or impairment of appetite, and derange- ment of the entire digestive apparatus. The spinal cord and its membranes, though less frequently attacked than the brain, may be involved as a result of similar pathological con- ditions. Paraplegia, more or less complete, ensues, involving at times the bladder and rectum. In milder cases co-ordination is disturbed, with little or no loss of muscular power. Pain may be present, referred to the back at or near the seat of the lesion, or along the distribution of the sensory nerves, or anaesthesia may occur. One or more of the nerves, sensory or motor, may in like manner be affected as a result of the development of gummata, or connective-tissue changes in the neurilemma, or the pressure of exostoses or other neo- plasms. Bones.—Periostitis and ostitis, especially in those portions of the skeleton most exposed to sudden changes in temperature and to direct violence, are among the more frequent lesions of tertiary syphilis. The bones of the skull, the spine of the tibia, and the clavicle, are more often involved. The swelling caused by the inflammatory exudation may be readily appreciated by palpation, and pain or tenderness is present on direct pressure. The tumefaction results from the formation of new bone (exostosis), which in some instances persists indefinitely. Gummata are developed upon or beneath the periosteum, forming soft, semi-fluctuating swellings, usually circular in shape, and from a half inch to an inch or two in diameter. These tumors, or nodes, while not very painful under ordinary pressure, are the seat of exacerba- tions of pain which are usually experienced at night. They frequent- ly break down in a process of ulceration which involves the underly- ing bone. When the inflammatory process is violent, extensive necrosis may occur. A peculiar type of ostitis in the later manifestations of syphilis is that known as osteitis rarefaciens, in which there is no suppuration or exfoliation, a portion of the bone-substance undergoing absorption, giving to the part involved a porous or worm-eaten appearance. Hypertrophy of the bones, even to a remarkable degree, is not un- common, and may be due to the development of compact substance beneath the periosteum, or the entire cancellous portion may be replaced by this eburnated tissue. On the other hand, the hypertrophy is in some cases entirely cancellous in character, the bone taking on two or three times its natural thickness. Joints.—The pathological changes in bone may also be accompanied by like changes ,in the articulations. Synovitis, with thickening of the membrane and surrounding cap- sule, is present, accompanied by impairment of motion and pain of a dull character. In severer cases, the cartilages and bones become involved, leading to osteo-arthritis and destruction of the joint. 62 A TEXT-BOOK OX SURGERY. Heart and Vessels.—Fatty degeneration of the heart-muscle, follow- ing syphilitic myocarditis, and the formation of gummata upon the peri- cardium or within the muscular walls, are the chief lesions of this organ in the tertiary period. The pericardium may also be affected, and in like manner the endocardium, which may undergo atheromatous degen- eration or give rise to vegetations. Of the vessels, the capillaries always affected in the first and second stages, are not so seriously involved in the last stages as the arteries. The veins are rarely affected. Arteritis, especially the variety known as endarteritis obliterans, is one of the most common and grave lesions of chronic syphilis. While the larger trunks are involved, the more characteristic changes occur in the terminal arteries and arterioles. The cerebral vessels are especially susceptible. Lymphatics.—Gummatous deposits occasionally take place in the lymphatic glands in tertiary syphilis. The superficial set may break down and discharge their contents. The deep glands undergo granular degeneration with absorption, or the gummatous material undergoes caseous or calcareous degeneration. Respiratory System—Nose.—The mucous membrane may be thick- ened, or may be more or less destroyed by ulceration. The cartilage and bony framework of this organ are very often destroyed. Larynx.—The mucous membrane of the larynx may also be thick- ened, or the seat of ulcers or vegetations. Chondritis and perichondritis are not infrequent; and, as a result of the chronic inflammation, stricture and stenosis, more or less complete, may occur from cicatricial contrac- tion. It may also be the seat of gummata. The trachea and bronchi are subject to similar lesions, inducing stricture. In the lungs the principal lesions are—(1) chronic interstitial or fibrous pneumonia ; (2) more or less widely disseminated gummatous deposits, usually in the lower portions of these organs. Digestive System—Mouth.—Superficial ulcers of the walls of the buccal cavity are not infrequent; deep, destructive ulcers are rare. This can not, however, be said with truth, concerning the palate, where, as a result of gummatous deposits or general infiltration, the most rapid and irreparable destruction of tissue may occur. The curtain of the soft palate is frequently destroyed, the bony septum between the mouth and nose is perforated, while in extreme cases the pillars of the fauces and the pharynx are involved. Other lesions of the pharynx do not differ from those of the buccal cavity. Tongue.—Gummatous deposits may occur in any portion of this organ, causing local or general tumefaction. Whether superficial or deep, they tend to break down, giving rise to ulcers varying in size and depth. The other principal lesion of the tongue in the tertiary period is more or less widely diffused connective-tissue hyperplasia, giving rise to a varying degree of enlargement, As the new-formed tissue contracts it gives to the organ a lobulated appearance, the boundaries of the lobules being well-marked fissures in the line of the contracting bands. Oesophagus.— Partial or complete occlusion of the oesophagus may occur from—(1) connective-tissue hyperplasia in its walls, or the contrac- SYPHILIS. 63 tion following ulcer (organic stricture); (2) the mechanical obstruction from gummatous deposits in the walls or in the immediate neighborhood of the oesophagus; (3) pressure from exostoses, aneurisms, enlarged glands, etc. Syphilitic ulcers of the stomach and alimentary canal have been observed, though rarely. Gummata form here, however, with a certain degree of frequency, and stricture of the pylorus, and of the in- testinal canal above the rectum, is known to occur in a certain propor- tion of cases. The rectum is especially liable to become seriously in- volved in the late manifestations of syphilis. Here, as elsewrhere, stric- ture may result from fibrillation and contraction of the inflammatory tissue with which the walls of this organ and the peri-rectal tissues may be- come infiltrated. Again, ulcers originating within the gut, or extending from a like inflammatory process about the anus and the external tissues, or the presence of gummatous material, may all induce more or less serious contraction of the lumen of the rectum. Of the solid abdominal viscera, the liver is most seriously affected. The pathological changes are—(1) connective-tissue hyperplasia, or chronic interstitial hepatitis, or syphilitic cirrhosis, which may be general or local; (2) gummata in any portion of the organ ; (3) waxy degeneration from long-continued general sepsis. The spleen may undergo similar changes. Slight enlargement may occur from the excess of white corpuscles (leucocythaemia), which is the rule in this disease. The pancreas is rarely affected. Genito-urinary System.—Amyloid degeneration of the kidneys occurs as a result of the long-continued sepsis of syphilis, as with other chronic forms of blood poisoning. In like manner, under conditions favorable to connective-tissue hyperplasia, the fibrous stroma of this organ becomes thickened, with consequent atrophy of the excretory or glandular ele- ments (chronic interstitial nephritis). Gummata of the kidney is not as common as in other viscera. Orchitis, although occurring while some of the secondary symptoms may be present, is essentially a late manifestation of this disease. It is important to recognize it, since several varieties of sarcocele require im- mediate surgical interference. Syphilitic orchitis should be suspected in all cases of tumor of this organ in which there is a history of specific infection. In syphilis, the enlargement is apt to occur in both organs about the same time. The growth is smooth and spherical, and when lifted conveys the sense of unusual weight. It is not painful, excepting always the sense of dragging, which is at times annoying. Slight hydro- cele not infrequently accompanies this form of orchitis. The testicles are not exempted from gummatous deposits. In rare instances these break down, causing more or less destruction of the sub- stance of these organs. The penis is occasionally the seat of syphilitic infiltration in the later stages of this affection. The Eye.—Syphilitic iritis has been given as occurring in the second stage of this disease. It may also occur as a later manifestation. In- flammation of the sclera, choroid and ciliary bodies, lens and capsule, 64 A TEXT-BOOK OX SURGERY. retina, and (though rarely) of the optic nerve, are of varying frequency in the tertiary period. Lesions of the muscles may be due to connective- tissue new formations between the fasciculi, resulting in granular degen- eration of the muscle substance and contraction of the new tissue. It may occur in the second as well as the third stage of this disease. These contractions, if not relieved, may result in anchylosis of the joint in im- mediate anatomical relation to the muscles involved. Gummata are not of frequent occurrence. They terminate by suppuration or by ab- sorption. Inflammation in the tendons and their sheaths may also occur. Fingers and Toes.—The fingers and toes, during the tertiary period of syphilis, in a certain proportion of cases become the seat of gummatous deposits, the skin and subcutaneous tis- sues may be infiltrated, or the bones and cartilages may be involved. When the infiltration is confined to the soft parts, the entire organ will appear swollen and purple or reddish in color. When the bone is the seat of the deposit, it may fig. 68--^P^^Bdu^^ (After be limited to a single phalanx (Fig. 58) or invade all the bones of the finger. The process terminates in ulcer, necrosis, or granular degeneration of the cells of the new tissue, and absorption. Pathology of Syphilis.—The chief feature in the pathology of syphi- lis in all of its stages is the proliferation of an embryonic tissue, usually of a type so low that it is not capable of organization into a definite tissue. From the initial lesion and the primary lymphangitis and ade- nitis to the final lesions of the viscera, this cell-proliferation continues, and the different effects witnessed in different individuals, or in the same individual, in the various stages of the disease, depend chiefly upon the degree of impairment in the nutrition of the tissues. The cell-accumu- lation in and around the capillary loops of the cutaneous papillae, which produce a macular or papular syphilide in one individual whose tissues are in a condition of perfect nutrition, will produce a squamous or vesic- ular eruption in another, or a pustular syphilide in a third who has the unfortunate inheritance of a gouty, scrofulous, or tubercular dyscrasia. Or a papular lesion of the first stage, in which the process of nutrition in the tissues is normal, may be replaced by a rupia in the tertiary period when assimilation is less perfect. If the initial lesion of syphilis is excised and examined with the mi- croscope, the following conditions will be observed: The epidermis in the immediate vicinity of the ulcer is more or less completely destroyed. The membrane which covers the floor of the ulcer is composed of pus cells, fragments of epidermal cells, cells of the Malpighian layer, and fragments of connective-tissue and other detritus. These elements vary in proportion as the process of necrobiosis is limited or extensive. In the deeper portions of the Malpighian layer, and in and around the pa- pillae where these layers are not wholly destroyed, and in the connective- SYPHILIS. 65 tissue layer of the skin, there is a general infiltration with the embry- onic cells of the syphilitic process. The arterioles, veins, and capillaries are more or less completely occluded. The cell-proliferation is especially marked in the arterioles, the adventitia and intima are thickened, the thickening being more marked in the latter, while the lumen of the vessel is more or less encroached upon by the new-formed tissue. The venules undergo analo- gous changes. The walls of the lymph-channels are thickened, and many of these vessels are crowded with cells. The infiltration is, how- ever, limited* to the immediate borders of the ulcer, and the line between this and the uninvaded tissue is sharply defined. As the mass of cells gradually obstruct the vessels, the nutrition of the new tissue is inter- fered with, and it either undergoes granular metamorphosis or breaks down more rapidly as a slough. The absence of pain in the chancre is also explained by the gradual pressure upon the terminal nerves and the comparative dryness of the typical sore by the arterial occlusion. The lymphatics immediately around the ulcer, and those leading from it to the nearest glands, lire more or less filled with the newT cells, and their walls appear thicker than normal. The changes which occur in the glands in the earlier stages of syphi- lis consist in a hyperplasia of the connective-tissue cells of the stroma and thickening of the fibrous framework, together with an increase in the cell ele- ments of the gland substance proper. The cutaneous lesions of secondary syphilis result from the more or less com- plete obstruction of the capillary loops of the papillae by the cells of this in- different tissue. The walls of the capil- laries undergo degeneration ; the coloring matter of the blood escapes, causing the peculiar staining of the syphilides. In the macular syphilide the abnormal cell accumulation is less than in the papular eruption. The changes which occur in mucous patches differ very slightly from those described in the cutaneous lesions. The epidermis soon breaks down ; the Malpighian layer and papillae are infiltrated with the cell elements ; while the eapiilaries, arterioles, and lymphatic vessels un- dergo changes almost identical with those described in the initial lesion. In the later or tertiary lesions of the skin in syphilis the infiltration is deeper. Cutaneous gummata consist of aggregations of the cell ele- ments heretofore described, which are crowded into the subcutaneous areolar tissue, into the connective tissue of the true skin, in the walls of and just outside the vessels, while the endothelia of these vessels under- go proliferation and aid in their occlusion. Ulceration ensues from the rapid arrest of nutrition, and the process of necrobiosis is aided by the 5 Fig. 58.—Section through a hard chancre; a, round-celled infiltration; b, large mononuclear cells ; and c, polynuclear giant cells. Hematoxylin staining. x 300. 66 A TEXT-BOOK ON SURGERY. depressed condition of the tissues which usually exists in the tertiary stage of syphilis. The tertiary lesions of the mucous surfaces are analo- gous to those of the integument. The pathology of visceral syphilis presents two distinct morbid pro- cesses : (1) the hyperplasia of the connective-tissue stroma of the organs (cirrhosis); and (2) the aggregation of the syphilitic embryonic cells (gumma). The character of these changes in the different organs has been given. Diagnosis.—hi a typical case of acquired syphilis a diagnosis may be made upon the following symptoms : 1, an ulcer in appearance and behavior like that described as belonging to the initial lesion of this disease, the sore occurring not less than ten days, and usually about the twentieth day, after an exposure ; 2, induration and enlargement of the nearest lymphatic glands occurring in from eight to fourteen days after the appearance of the ulcer ; 3, after from two to four weeks of seeming arrest of the infection, the development of headache, pain in the back, slight febrile movement, with an eruption (sixth to seventh week after the appearance of the sore) over all or a portion of the body, accom- panied with an unusual sense of dryness or soreness of the mouth, phar- ynx, or fauces ; 4, following or occurring with these symptoms, general adenitis. In the majority of cases, excluding even those in which the sore is concealed, as in the urethra, etc., little value can be placed upon the appearance of the ulcer at the point of infection. The classical "initial lesion" of syphilis, with its well-defined margin of induration, feeling like a " split pea " or piece of cartilage when grasped between the thumb and finger ; the absence of pain and peripheral inflammation ; the pe- culiar «• scooped-out " concavity of the sore, the surface of which is cov- ered with a scanty, serous transudation, is so frequently absent in cases in which the later and unmistakable signs of this disease are developed, that it alone can scarcely be relied upon in arriving at a diagnosis. As stated heretofore, the syphilitic virus may be lodged in and absorbed from a phagedenic ulcer in which not a single feature of the specific sore is present. The same is true of the herpetic ulcer, or that result- ing from traumatism or the inoculation of any form of virus. All of these ulcers are grouped under the heading of " mixed sores " or mixed infection. Induration of the glands is more reliable in a diagnostic sense. When the typical initial lesion is present, the ensuing adenitis is also tvpical. In the inguinal region one £land of the group after another is enlarged and becomes indurated. The process is slow and deliberate. There is no periadenitis, the glands do not adhere to each other and the interven- ing tissues, nor to the integument. Each body may be distinctly made out by palpation and moved beneath the skin independently. There is no tenderness, and the gland is leathery to the touch. Even when the sore is mixed, if the phagedenic or inflammatory process is not severe, the adenitis is more apt to be specific than inflammatory, and will pos- sess the features of syphilitic bubo in a sufficient degree to admit of SYPHILIS. 67 recognition. When the specific infection is complicated with a typical phagedenic ulcer or gonorrhoea, the resulting bubo does not possess a single appreciable feature of syphilitic adenitis. The eruption of syphilis is, of all the symptoms of this disease, the most reliable. When the sore is mixed, and the character of the ade- nitis doubtful, the early cutaneous and mucous lesions are, in the vast majority of cases, appreciable and unmistakable. Headache, rise in tem- perature, pains in the back, etc., are confirmatory symptoms, but inde- pendently of no value. The same may be said of dryness or soreness of the mouth, pharynx, and fauces. Lastly, general adenitis, which occurs in a varying degree in all cases of syphilis in which mercurialization has not been affected at a very early date, is a strong confirmatory symptom, and of great value in diagnosis if all the other lesions have escaped ob- servation. The greatest importance is attached to induration of the epitrochlear, and to the occipital and post-mastoid glands. The former can scarcely be recognized in their normal state. In general adenitis a single body, feeling like a small bean in shape, may be recognized at the inner aspect of the arm just above the elbow, where it lies superficial, and internal to the basilic vein. When any inflammatory process exists in the member beyond the elbow, the enlarged gland possesses no spe- cific diagnostic value. In like manner lesions of the scalp, face, or mouth may cause enlargement of the occipital or mastoid lymphatic glands. A diagnosis of syphilis in the tertiary period must depend upon a careful study of the history of the case and the presence of one or more of the lesions which belong to this stage, and which have been fully de- scribed. Prognosis.—A favorable prognosis in syphilis will depend upon—1, the physical condition of the individual affected at the time of inocula- tion ; 2, the recognition of the disease within the first four or eight weeks of the disease ; 3, the faithful and energetic co-operation of the physician and patient in carrying out the measures to be given. That syphilis is a curable disease there can be no doubt. Under favorable conditions the symptoms disappear, leaving little or no trace of the infection. In common with all diseases, its severe or fatal results are seen in patients with an inherited or acquired dyscrasia, and in those whose nutrition is seriously impaired, or in neglected cases. Even in the worst class of cases the prognosis is not wholly unfavorable if proper treatment is instituted and maintained. The recognition of this disease and institution of treatment at the ear- liest possible moment is very important. The prognosis is more favor- able in the exceptional cases when a diagnosis can be based on the typi- cal initial lesion or the earliest adenitis, for, if this is done, the violence of the infection may be modified and the deeper lesions rendered less severe. Even when, by reason of the uncertain character of these earlier lesions, a positive diagnosis can not be arrived at until the eruption is seen, a favorable prognosis may be made. Treatment.—The treatment of syphilis is divided into—1, measures which tend to destroy the potency of the virus and aid in absorption of 68 A TEXT-BOOK OX SURGERY. the inflammatory products of this disease ; and 2, those which tend to improve the nutrition of the tissues. Both are essential to the successful management of this formidable affection. To the former belong the preparations of mercury, and iodine in com- bination with potassium ; to the latter tonics, the careful regulation of the habits of living, nutritious diet, and healthful and moderate exer- cise. Nothing is more satisfactorily demonstrated in scientific medicine than the power of mercury to neutralize and destroy the virus of syphi- lis. Its administration should usually begin with the positive recog- nition of the disease, and it is always advisable to wait until the diagnosis is assured, rather than to begin treatment with the uncertain recognition of the sore or bubo. The management of a case of syphilis should be carried on for a period of two years. It is of the utmost importance that the person affected should be im- pressed with the gravity of the situation and the certainty of disaster if the rules laid down by the medical adviser are not strictly obeyed. With the proviso of obedience, the prognosis should be as encouraging as pos- sible. Responsibility for the result of treatment in this disease should not be assumed unless the patient consents to keep himself under ob- servation for the period above given. All excesses should be prohibited. The use of tobacco and alcohol in any shape is scarcely allowable. In certain cases, where digestion and assimilation are impaired, a small quantity of whisky, claret, or sherry may be taken with meals. Sexual indulgence, if from no other than humanitarian niotives, should cease for at least a year from the appearance of the initial lesion. The child of parents, either of whom is within the first year of syphilitic inoculation, becomes the victim of a dyscrasia which, if not fatal to life, is fatal to the perfect usefulness of its possessor. In addition to the danger of direct inoculation during the prevalence of the chancre, is that of infection to the mother from the foetus in utero or the child in the act of parturition. A patient under treatment for syphilis should retire early and at a regular hour, avoid excessive use of the eyes, especially at night, sudden changes in temperature, and all articles of diet which are not readily digestible. Of the preparations of mercury, preference should be given to the protoiodide. It is conveniently administered in pills of one quarter grain each. To begin with, one of these pills should be given three times a day one hour after eating. The indications for a diminution in the quan- tity are pain of a cramp-like nature in the stomach or bowels, with or without diarrhoea, and the occurrence of salivation. Clinical experience teaches that salivation does not occur with the protoiodide until after a colicky diarrhoea which should be a timely warning for diminishing the dose. If diarrhoea results, it will be advisable to administer about5 one quarter grain of opium with each pill of protoiodide, or to reduce the daily number of the pills. Under such conditions, inunctions with mer- curial ointment are of great value. Salivation may be guarded against SYPHILIS. 69 by careful observation of the gums. At the earliest indications of ten- derness felt when the teeth are firmly pressed together, or when direct pressure is made upon the alveolus, the dose should be diminished, or, if necessary, discontinued for a few days. It will usually suffice to administer one quarter grain three times a day for the first month, and at the expiration of this time to increase the daily quantity to gr. j. It will rarely be necessary to give more than this quantity, although in some cases the full beneficial effects of the remedy may not be realized until a larger daily dose is given. The mer- cury should be continued without interruption—excepting for the reasons just given—for the first six months after commencing the treatment. At the expiration of this period it is a good plan to discontinue the proto* iodide for two weeks, and then administer the iodide of potassium in doses of grs. x-xx or xxx three times a day for one month. This should in time be stopped, and the pills resorted to for a period of two months, and so on, alternating these two remedies to the end of the first year of treatment. For the first six months of the second year the alternation should be equal—i. e., one month of the potassium salt, and the next the protoiodide. For the last six months of treatment the iodide of potassium should alone be given. In addition to the foregoing it is of great importance that tonics should be administered from the commencement of the disease, and especially in delicate patients. In carrying out this part of the treat- ment much better results will be obtained in the alternate exhibition of several tonics rather than in the continued use of a single remedy. A preparation of iron, quinine, and strychnine on one day, given in the proper dose immediately after each meal ; an emulsion of cod-liver oil with the hypophosphites of lime and soda, each gr. j to the table- spoonful on the next day ; and tincture of the chloride of iron on the third day, will be found a convenient and useful method of rotation. When protoiodide of mercury can not be obtained, the biniodide, in doses of gr. ^V to tV> or bichloride of mercury (corrosive sublimate), gr. sV t0 tw to TV, may be substituted. If, for any reasons, mercurial inunctions become necessary, proceed as follows : Take about a teaspoonful of mercurial ointment and rub it well into the skin of the groin* and under the arms. Or spread the oint- ment on lint and apply it to these parts, holding it in place by lightly fitting clothes or bandages. It should be used only at. night, and re- moved upon rising by washing with warm water and soap. The hypodermic injection of corrosive sublimate in the treatment of syphilis, while objectionable on account of the annoyance produced by the insertion of the solution beneath the integument, may become necessary in certain patients who can not be brought under its influence in any other manner. The injections should be made under the skin of the back and with most careful asepsis. From gr. ^ to £ of corrosive sublimate may be used once or twice a day, watching the effect closely. A few minims of two- per-cent cocaine preceding the mercury will lessen the pain. 70 A TEXT-BOOK OX SURGERY. In the treatment of the tertiary lesions of syphilis practically the same rule of practice should be adopted as just given for the second year following the appearance of the initial lesion. The employment of iodide of potassium in full doses hastens the absorption of the inflamma- tory products of this stage, while the protoiodide destroys the potency of the virus. Both remedies should be administered in doses as large as can be borne without interfering with the functions of the digestive organs or producing any serious constitutional disturbances. In the treatment of gumma and the destructive cutaneous tertiary lesions met with in neglected cases large doses of iodide of potassium are imperative. The dose should be gradually increased until either the symptoms of iodism are present or the lesions disappear. As much as 960 grains a day I have employed with curative effect. Inherited Syphilis.—-The foetus may become syphilitic from a syphi- litic father or mother. If pregnancy occurs within the first year, and especially in the first six months of the disease in the mother, the child becomes inoculated, either dying in utero, or, if carried to term, usually perishes within a few weeks after its birth. If, however, the disease is recognized and proper treatment instituted, a more favorable prognosis may be made. In the second year after infection, if properly treated, a mother may bear a non-syphilitic child, although the chances are against complete immunity. During the third and each succeeding year, under judicious management, the prognosis is still more favorable. A female patient should be advised of the great danger of pregnancy within the two years immediately following inoculation. When she has been under constant and proper treatment for this length of time, and has been perfectly free from symptoms for one year, the gravity of the danger is diminished. If she has not been treated, she should under no circumstances be made liable to pregnancy. In case such a woman becomes pregnant, she should be treated carefully for syphilis, and in this way the infection of the child may be modified, if not prevented. The virus of syphilis may be conveyed by the spermatic elements, and the embryo thus become inoculated.* The prognosis is more favor- able in proportion to the length of time which has elapsed after the initial lesion, and to the thoroughness of «the treatment instituted. A syphilitic man should not beget a child within two years after the initial sore, nor at any later period unless thorough treatment has been insti- tuted and one year has elapsed since the disappearance of all symp- toms of the disease. Symptoms.—The symptoms of specific infection in the child manifest themselves usually within the first eight or twelve weeks after birth. Occasionally the disease is latent, and the symptoms do not appear until * As heretofore stated, a non-syphilitic mother may be inoculated from a syphilitic child in the act of parturition. That the mother is also subjected to the influence of this virus from carry- ing the offspring of a syphilitic father is proved by Colles's law, which is, that a previously healthy mother of such a child can nurse it without danger of chancre of the nipple and syphilitic infec- tion, while a non-syphilitic nurse will become inoculated. SYPHILIS. 71 a variable period has elapsed. Even puberty may be reached before it is evident. Excepting the chancre, the local lymphangitis and adenitis, the evolution of the symptoms of inherited syphilis is not unlike those of the acquired form. The lesions are cutaneous, mucous, and visceral. The macular or papular syphilide occurs in most cases, and may be distributed over the general surface or confined to certain limits. It is usually first seen upon the abdomen, and from this starting point it be- comes more or less widely distributed. At the muco-cutaneous margins, and in the folds of the skin where irritation is greater and moisture exists, condylomata are not infrequent, and are often persistent. Vas- cular, pustular, and tubercular syphilides occur in a certain proportion of cases. The tubercular form is rare. The pustular form (syphilitic pemphigus) indicates a low order of tissue vitality, and justifies an un- favorable prognosis. Lesions of the mucous surfaces occur either before or with the cuta- neous lesions. Papules and excoriations (mucous patches) are found in the buccal cavity, on-the tongue, fauces, and pharynx. Fissures of the lips are not uncommon, and especially in the angles of the mouth. The infection of the mucous membrane of the nose and air passages leads to the distressing coryza and cough so often noticed in syphilitic infants. Gummata of the skin and of all organs occur in the same manner and with the same pathological significance as in the acquired form. Treatment.—The preparations of mercury antagonize the virus in this as in the acquired form of syphilis. The careful mercurialization of the mother during pregnancy is important in preventing the development of the disease in its severer forms. Inunction with the ointment of mer- cury should be first faithfully tried in the treatment of syphilis in the newly born. One drachm of mercury to one ounce of lard is the pro- portion recommended by Brodie. This is spread upon a soft flannel belt and worn continuously around the patient's waist. The ointment should be renewed as needed. If the beneficial effects of the mercury are not secured by this method, the internal administration may be resorted to, but in no case until after a thorough trial of the inunctions. The bin- iodide of mercury in doses of ^o grain, in combination with one quarter grain of the iodide of potassium, is advisable to begin with. The dose may be carefully increased if necessary. The nourishment of the child should be most carefully attended to, and it should have the benefit of pure air and comfortable surroundings. CHAPTER VI. LEPROSY, DIPHTHERIA, TYPHOID, DISINFECTION OF EXCRETA. Leprosy.—Leprosy is a disease exceedingly rare in the United States, and in a practical work on surgery demands scarcely more than mention. It is caused by the Bacillus lepre, discovered by Hansen in 1879. It is incapable of motion, appears as a slender rod with rounded ends, and closely resembles the bacillus of tuberculosis. It is invariably present in leprosy, but is not as yet universally accepted as the specific germ of this disease. It is rarely found in the blood, exists in the skin, spleen, and liver, but is more apt to be met with in the skin, especially around the end organs of the sensory nerves. According to Warren, it is found within the epithelioid cells and occasionally within the leucocytes. The disease occurs in two forms, the tuberculated and the non-tuberculated or anaesthetic. It is difficult to differentiate one from the other except by the loss of sensation in the skin, winch is a feature of the anaesthetic form. The invasion of the disease is slow and insidious and may last for many years. It begins with a general feel- FDacimrxL7oa (Fiagjj? in£ of dePressi°n, loss of appetite, pain in the bones, and progressive prostration. Lesions of the skin are most marked. Tuberculated leprosy is characterized by the appear- ance of nodules which are usually round in form and varv in size from a small shot to an inch or more in diameter. They are usually met with about the face, but may occur on any part of the bodv. In the anaes- thetic form the disease begins with the appearance of blebs of irregular arrangement, with marked hyperesthesia that lasts for a short time&and is followed by loss of sensation. Up to this date no method of treatment has been found efficacious and the disease is considered incurable. It is universally the custom to isolate those affected. It is more than prob- able that the advances made in the treatment of infectious diseases by the use of antitoxine will result in placing leprosy in the list of diseases that can be cured or prevented. Diphtheria.— Diphtheria is a specific, infectious disease, attacking usually the mucous membrane of the respiratory tract and by preference the surface of the tonsils, pharynx, fauces, and^larynx, and occasionally first observed in the nose or naso-pharynx. It is capable, however of infecting any mucous surface or any point of abrasion either upon the skin or mucous membrane. The germ of this disease was recognized by DIPHTHERIA. 73 Klebs in 1883 and more fully demonstrated by Loeffler in 1884, and is knowm as the Klebs-Loeffler bacillus. The Bacillus diphtherie exists as a small rod, generally curved, with rounded ends, two or three p, in length, with a diameter of 0*8 p According to Sternberg, bacilli from the same culture vary greatly in diameter and shape. One or both ends may appear swollen or the cen- tral portion may be thicker than the ends. It is reproduced by fission, never by spore formation. It is classed with aerobic, non-motile, and non-liquefying organisms. Milk is given by Sternberg as a favorable medium for the growth of the Bacillus diphtherie, and he considers this fluid a dangerous medium for conveying the disease to the throat of children. It resists desiccation for several weeks, and, after being thor- oughly dried, may reproduce itself if a suitable pabulum be found. An- other organism almost identical with the bacillus of diphtheria, and prac- tically impossible of differentiation by the microscope, has been found in the mouth and throat and described by Loeffler, Roux, and Y'ersin. This pseudo-bacillus of diphtheria possesses no pathogenic property, but wrhen found, even if the constitutional and local symptoms of diph- theria are not present, it is advisable to treat such a throat or suspected region without delay with the strict antisepsis employed in the man- agement of this affection. The toxic products or ptomaines of the bacillus of diphtheria are absorbed by the blood, and in severe cases rapidly produce an intense anaemia caused by the destruction of the red blood-corpuscles. It seems to exercise also a specific action upon the cells of the tissues, affecting powerfully the nutrition of the nerve cells, hence the frequent paralysis which is associated with diphtheritic sepsis. As given by Prof. Welch, a violent mixed infection often occurs in diph- theria due to the passage into the blood of pyogenic cocci. Symptoms.—The symptoms of diphtheria are local and constitutional. The iocal symptoms consist of a characteristic membrane which in many cases is difficult to differentiate from other non-diphtheritic exudates. It is usually located upon the tonsils, spreading from this starting point down along the fauces and into the larynx or upward into the posterior nares and nose. With the diphtheritic exudate there is usually a pecul- iar odor and irritating discharge, swelling of the nearest lymphatic glands (submaxillary, as a rule\ and a tendency to bleeding where the membrane is becoming detached. The membrane of diphtheria is closely adherent to and incorporated with the superficial epithelia of the mucous membrane upon which it organizes, while non-diphtheritic exudates, rest upon the epithelia and are easily removed without the bleeding which follows removal of the true diphtheritic membrane. The diagnosis can be determined by the presence of the Klebs-Loeffler bacillus, together with the constitutional symptoms, the most positive feature of which is the profound prostration in these cases and which is out of all proportion to the fever and the local manifestations (Dillon Brown). The pulse is usually very rapid, but in certain rare and fatal cases it may be slow. The temperature usually rises high, but may be normal, and often subnormal, in rapidly fatal cases. The kidneys are 74 A TEXT-BOOK OX SURGERY. apt to be involved early in the disease, albumin and casts appearing in the urine within the first five days. There is occasionally an erup- tion of the skin, varying from a transient rash to dark-red spots or patches (maculae), due to extensive extravasation. In summing up the diagnosis, Prof. L. Emmet Holt concludes that— (1) Pseudo-membranous inflammation, if in the larynx, is almost in- variably true diphtheria—i. e., due to the Loeffler bacillus. (2) Pseudo-membranous laryngitis following a primary pseudo-mem- branous inflammation of the tonsils, nose, or pharynx, is in the great majority of cases due to the Loeffler bacillus. (3) Pseudo-membranous laryngitis following pseudo-membranous inflammation of the tonsils, nose, or pharynx, occurring as a complication of measles, scarlet fever, or influenza, is more frequently due to another kind of infection, usually the streptococcus, than to the Loeffler bacillus. Treatment.—Serum therapy must be accorded the first place in the treatment of diphtheria. According to Holt, it is essential that a reli- able preparation be employed. He prefers that prepared by the New York Board of Health or by Behring. It will keep for three to six Fig. 60.—Syringe for serum injection. months without deterioration. A slight turbidity and some floccular deposit are always present in the serum, but when it shows a milky tur- bidity or emits an odor suggestive of decomposition it should not be used. Serum usually comes in phials containing five cubic centimetres and is said not to be injured by freezing or extreme heat, but it should not be sub- jected to extremes of temperature if this can be avoided, and should be kept in a dark, moderately cool place. The most thorough asepsis should be practiced in the injection of this serum into the fat and connective tissue beneath the skin. The apparatus to be used should be thoroughly boiled before each injection. A glass syringe (Fig. 60) with a piece of rubber tubing attached and a good-sized needle, capable of carrying the serum into the tissues, make a simple apparatus which can be thoroughly cleansed by boiling. Dr. Holt prefers to inject a small quantity of a concentrated serum, as it is much less apt to produce rash, joint swell- ings, etc., which larger injections sometimes cause. The dose is to be measured not by the amount of serum, but by the number of antitoxine units it contains. A child under two years of age should receive 1,000 units in a severe case and 600 in a mild case, repeating the dose in from eighteen to twenty-four hours if no improvement is seen, and again after a similar interval if necessary. A child over two years of aroject between the edges. As the threads are being tightened, infolding may be obviated by lifting the edges with a grooved director, while the same instrument may be employed to push any projecting fat or other tissues back under the skin. In tying the knots, the degree of traction should just be sufficient to bring the plane surfaces of the wound together without wrinkling. As drainage invites infection, it should be avoided when possible. In clean wounds, a small wisp of catgut in one or two suitable points will be all that is required. AVhen stumps are closed and dressings with proper compression applied, no oozing will occur and no drainage be needed. When a tube is used, as the stump is kept elevated after the operation, it should always lead from the deepest portion of the wound, and have exit at such declination that the free outflow of all fluids will take place into the dressings. A safety pin should be passed through one side of the tube to prevent its being pressed into the wound by the bandaging, or a suture may serve to hold it in position. A strip of iodoformized gauze is wound around the tube and carried along.the line of approxima- tion, extending about three fourths of an inch on either side. Or a nar- row piece of disinfected protective may be substituted as a covering for the line of sutures. The stump, carefully dried, is now enveloped with sterile gauze to the thickness of about one inch. This should be applied in layers, starting from well above the end of the stump, by carrying a layer around the limb, and following this with a second, which overlaps the first about two inches, and so on until the last layer projects well be- yond the end of the stump. Over the end a large, thick sheet of gauze is laid. A layer of absorbent cotton, about one inch thick, is now '12 178 A TEXT-BOOK ON SURGERY. wrapped around and over the end, and this enveloped by a large sheet of rubber-tissue protective. A roller is carried over all to hold the dress- ing in place, and to make compression sufficient to arrest oozing. It is impossible to say how much pressure should be employed, since this knowledge can only come from practice, but the bandage should be fairly tight. Pressing the flap against the end of the bone should be avoided. As the last bandage is being applied, a short splint, the end of which projects a couple of inches beyond the stump, may be inserted. This steadies the limb, and is useful in keeping the stump elevated, especially when an amputation is made near the trunk. If the last roller is a moistened starch bandage, it will be less liable to slip. Such a dressing, under the strict antiseptic method, is not usually removed before the tenth or twentieth day, and in the majority of cases where an amputation is made through comparatively healthy tissues a single dressing is sufficient. The indications for its removal are haemor- rhage of an alarming nature, great pain, high febrile movement (not counting the reactionary fever which follows within twenty-four hours after the operation), and excessive discharge beyond the zone of anti- sepsis, with decomposition. Ordinary bleeding may be controlled and permanently arrested by an extra tight roller, or Esmarch bandage, loosely applied for an hour or two. A rise in the temperature of 102° to 103° on the second day, or later, suggests inflammation and sepsis. Lastly, when the serum or fluids from the stump seep under the dressing and decompose, the change is necessitated on account of the odor. A\"hen a new dressing is made, the same antiseptic precautions should be employed. Second Method—Oblique Solid Flaps by Transfixion.—Seize the arm with the left hand so that, as all the soft tissues are pinched up on its anterior aspect, the thumb and index-finger on opposite sides will be just above the point at which it has been decided to divide the bone. The point of a long knife is pushed from the outer side (right arm) horizon- tally down until it impinges upon the center of the bone ; the handle is depressed, the point grazes over the bone, the handle is now elevated, and the point made to project exactly opposite and on the same plane with the point of entrance (Fig. 194). By a long sawing movement the knife is made to cut directly along the bone until within from one half to one inch of the AMPUTATIONS. I79 limit of the flap, when it is turned rather abruptly out, shaping a blunt, rounded flap. This is held back by the operator's left hand, the point of the knife is insinuated between the muscles and the bone, is made to glide along the posterior surface of the bone, and to come out at or very near the periosteum on the opposite side. A second symmetrical flap is made in the same way as the first. The retractor is applied, and the operation and dressing completed as before. In making an amputation by transfixion, it is usually advised to cut the non-vascular flap first; but, with a safe tourniquet applied, this pre- caution is unnecessary. Third Method—Oblique Solid Flaps, by cutting from the Surface — Cutting from the surface toward the bone, the first crescentic incision out- lines one flap and goes down to the deep fascia (Fig. 195). After the skin retracts, the muscles and remaining soft tissues are divided from its edge obliquely dowrn to the point of section through the bone. The opposite flap is made in the same manner, and the operation completed as before. Skin-Flaps — Circular, Modified Circular, Oval, Double Crescentic, and Double Rectangular. First Method—Circular.—Before commencing the incision, grasp the arm firmly near the line of incision, and slide the integument upward as far as it will go. In doing this operation, a scalpel will suffice, although the long knife is usually preferred. The incision should go straight down to the fascia which covers the muscles, and directly around the limb, so that the radius of the circle described will be at an angle of 90° with the axis of the humerus (Fig. 196 a). AVhen this is completed, catch the edge of the flap with a mouse-tooth dissecting-forceps, put the connective tissues which attach it to the fascia about the muscles on the stretch by pulling the skin upward, and with well-directed strokes or touches with the point of the knife, which should be kept from wounding the skin, raise the flap throughout the entire circumference of the wound. As this dissection proceeds, the loosened sleeve of integument may be rolled up until the point where the muscles and bone are to be divided is reached (Fig. 196 b). Just at the margin of the reflected flap the soft tis- sues are now divided straight down to the bone, the line of section being 180 A TEXT-BOOK OX SURGERY. perpendicular to the axis of the limb. The periosteum should next be cut through in the circumference of the bone where the saw is to enter, Second Method—Modified Circular.—When, on account of the large diameter of the member, the flap requires to be dissected up for more than two inches, the foregoing method may be modified by a perpen- dicular incision through to the muscles. This renders the dissection more rapid. Third Method—Oval.— It not infrequently occurs that the condition of the soft parts near the line of amputation will not permit of an incision directly around the limb without a too great sacrifice of the member. Under such circumstances, an oval or elliptical incision may be made, and in this way integument enough secured to cover in the stump. The longitudinal slit may be added to this operation. Fourth Method—Double Crescentic.—The circular operation maybe further modified by making two crescentic skin-flaps of equal size, the bases of these being at the line of section of muscle and bone. The same precautions as given above are necessary to secure enough integument to form a hood for the stump (Fig. 197). AMPUTATIONS. 181 Fifth Method—Double Rectangular.—The first step is to go around the limb just as if a circular operation were intended. This being done, two incisions, one on either side and exactly opposite to each other, are made perpendicular to the circular cut, and extending up the limb to a point on a level with the line of section through the muscles and bone (Fig. 198). The two fmps are now dissected up to this line, and the amputation completed as before. The commendable features of this procedure are the rapidity with which it may be accomplished, the small degree of violence inflicted in manipulating the flaps, and the readiness with which a stump is drained when the proximal angles of the lateral incisions are used as outlets for the tubes. Mixed Flaps, composed of integument alone on one side and of all the soft tissues on the other, are the least commendable of all meth- ods. The proper apposition of surfaces so uneven is difficult. AVhen from any cause this operation is adopted, care must be taken to give proper support to the heavy solid flap to prevent dragging upon the sutures. Resume.—In thin and emaciated subjects the solid flaps should be preferred to the skin flaps, for the reasons that the nutrition of the skin is least disturbed by this method. In limbs of large diameter and a goodly quantity of subcutaneous tissue, the skin-flaps are preferable, since a covering under such conditions can be obtained with less sacrifice in the length of the bone. Of the solid flaps, the circular method is better than the oblique, since it divides all the tissues squarely. In making oblique flaps, transfixion is better than cutting from without inward. Of the skin-flaps, the circular incision should be preferred to the other methods where the limb is not very large ; the double rectan- gular flaps where the stump is to be elevated and there is a large surface to drain. Open Method.—AVhen an amputation is made through tissues infil- trated with pus or other inflammatory products, where, in the judgment of the surgeon, the dangers of sepsis would be increased if the wound were closed, the open method should be employed, with constant or in- terrupted irrigation. 182 A TEXT-BOOK OX SURGERY. Before the days of antisepsis the success of this method was thor- oughly demonstrated by Prof. James R. AVood and Prof. Dennis, in Bellevue Hospital, where the rate of mortality after amputations, in wards which had been recently vacated on account of puerperal fever, was reduced to' the minimum in the history of that hospital. I have employed this method in a number of septic cases with great satisfaction. Fig. 199. In performing the amputation, the flaps must be so shaped that irriga- tion can be easily accomplished without moving the stump. A circular cut, with a longitudinal incision on the upper surface, or bilateral flaps, are preferable. AAThen the patient is put to bed the stump is placed in a position suitable for drainage, and rests upon an oil-cloth so arranged that the irrigating fluid runs away from the patient and into a basin at the bedside. The flaps should at first be held well open by a wad of sublimate gauze, and the stump loosely enveloped in a thin layer of this AMPUTATIONS. 183 material, so arranged that, as the water drips on it, it will pass through the gauze and over the raw surface. Fio-. 199 shows a ready-made irrigator in use in my service at Mount Sinai Hospital. A piece of sheet-tin, about a foot wide and of any re- quired length, is shaped into a trough, the bottom of which is punched full of holes with an awi. .V rubber tube leads the water from a tank into this trough, from which it trickles on to the wound in any required quantity. Or, as represented in the cut, the tube—which, in the case of the patient from whom the drawing was made, conveyed the irrigating fluid into a suppurating knee-joint—may also be employed to carry the water into the wound. Sterile water should be used for irrigation. The danger of absorp- tion from an extensive granulating surface precludes the sublimate solutions. The only objection to which this method is open is the slowness with which the process of repair goes on in its employment. This is, however, an objection of little wTeight when the ultimate recovery of the patient is secured. As soon as the temperature shows an absence of sepsis the irri- gation may cease, and the granulating flaps may be approximated grad- ually by bandages or adhesive strips. Special Amputations. Hand and Fingers.—A primary amputation of any portion of the hand is rarely justifiable. If there is only a small strip of tissue, the integrity of which is evident, an effort at the restoration of the nutrition and function of the part beyond should be attempted. If any doubt exists as to the result, the benefit of this should be given to the side of conservatism. It is essential to arrest haemorrhage, cleanse the wounds under strict antisepsis, and especially by thorough immersion in a basin of warm sublimate solution (1 to 3,000), secure drainage, and place the parts in the best position for usefulness in case of recovery.* Amputation may be done when necessitated by gangrene or necrosis. Fingers —Inter phalangeal Operations.—Between the second and third phalanges of the fingers, proceed as follows: Flex the terminal phalanx at about an angle of 90° to the axis of the second bone, and, one eighth of an inch anterior to the angle on the dorsal aspect, with a small, sharp-pointed scalpel make a transverse incision, extending half-way down the sides of the finger. From this point carry the incision forward, parallel with the axis of the digit, to within a quarter of an inch of the end, then across the palmar aspect of the tip to the opposite side, finishing the in- cision at the angle of the transverse cut (Fig. 200). Dissect the palmar flap up, keeping close to the bone, lifting the flexor tendon, with the skin, back to the articulation ; divide the tendon opposite the joint, 184 A TEXT-BOOK OX SURGERY. and disarticulate. The flap is now turned back, tiimmed with the scissors to fit nicely, and stitched with silk or catgut sutures. By this method the acute tactile sense of the palmar aspect of the finger is preserved, and adds to the usefulness of the stump. This, and other amputations of the fingers, may be made without general anaesthesia, and with perfect insensibility, by the local use of cocaine. Just ante- rior to the metacarpo-phalangeal joint insert on each lateral aspect of the finger the needle of a hypodermic syringe, and inject in the entire cir- cumference of the finger twenty minims of a 2-per-cent solution of cocaine hydrochlorate. One minute later constrict the root of the digit with an elastic ligature. In this way a painless and bloodless operation may be performed. If the insensibility is not complete at all points of the incision, inject additional cocaine, and by massage distribute it through the tissues. In dressing these amputations the pressure on the end of the stump should be light, for fear of slough in the long flap. Usually^ no vessels need to be tied. The covering of cartilage does not require to be scraped or sawn off. AAThen only a slight portion of the anterior tip of the second phalanx is involved in a destructive osteitis or injury, the remaining portion should not be sacrificed by a disarticulation at the posterior interphalangeal joint. The line of section through the bone should be about at the junction of the middle and anterior third of the phalanx. The incisions and flap are made as in the preceding operation. In amputation with disarticulation at the posterior interphalangeal joint, flex at an angle of 90°, make a transverse incision over the dorsum of the finger, from one eighth to one fourth of an inch in front of the angle, which includes half the circumference of the member. From the ends of this line carry the incision directly forward on each lateral aspect of the finger to the crease on the palmar surface opposite the anterior interphalangeal joint. A second transverse incision in this fold com- pletes the rectangular flap, which is now dissected back, and the dis- articulation effected by placing the ligaments on the stretch and divid- ing these with a narrow, sharp scalpel. If any difficulty is found in entering the joint from the sides or front, it may be easily done by division of the extensor tendons over the dorsum, for these take the place of posterior ligaments. The method of amputation, as given for the operation at or near the articulation of the first and second pha- langes of the finger, applies also to the thumb in amputation at the last joint, or through the first phalanx, within one fourth of an inch of its anterior extremity. This plan of making the flaps is far superior to that advised by Erichsen, Esmarch, and other authors wiio recom- mend cutting down and through the joint from the dorsum, and then forward along the palmar aspect of the phalanx, making the disarticu- lation and flap with a single stroke. In the first place, this is done with no little difficulty, for, however thin the blade, the character of the joint will scarcely allow an easy passage to the knife. Secondly, by the method of transfixion the flap is apt to be cut too pointed and bev- eled at the end. AMPUTATIONS. 185 At the Metacarpophalangeal Joint—Thumb.—When the condition of the soft parts will permit, proceed as follows : First Method.—Just over the joint, and in the middle of the dorsal aspect of the thumb, commence an incision and carry it along the surface next to the index-finger until half the circumference of the member is included. Along the dorsal and palmar aspects carry parallel incisions forward until near the interphalangeal joint, and connect these by a straight transverse cut across the palmar surface. Dissect the flap back, divide all tendons opposite the joint, disarticulate, tie the dorsales pollicis (one on either side of the back of the thumb), and the arteria princeps pollicis, which lies along the side of the metacarpal bone near- est the index-finger and divides into its terminal branches opposite the metacarpo-phalangeal joint. When the flap is stitched, the scar will be in good part concealed on the ulnar aspect of the stump. Second Method.—A transverse dorsal incision is made over the articu- lation, extending half around and ending at opposite points on the external and internal lateral aspects of the thumb. Parallel lateral incisions are Fig. 201. Fig. 202. Fig. 203. made as far forward as the interphalangeal joint, and the anterior ex- tremities of these are joined by a transverse palmar cut (Fig. 201). The end of the metacarpal bone of the thumb should be left undisturbed, when not necrosed, when there is sound skin enough to cover it in. Under other conditions it may be divided with a fine saw or the exsector. The question of the appearance of the stump should be secondary to the usefulness of the member. It is especially important to a laborer that the end of the metacarpal bone of the thumb be preserved (Fig. 202). When the operation is performed upon one not compelled to do manual work, a more symmetrical appearance may be obtained by an oblique section of the metacarpal bone about half an inch behind the articular surface. When this is intended, the incision through the skin should be such that the long part of the flap is obtained from the radial and palmar aspect of the thumb, while the line of sutures is situated well on the dorsal surface of the stump (Fig. 203). 13 186 A TEXT-BOOK OX SURGERY. Index-Finger—At the Metacarpophalangeal Joint—First Method. —AA^hen possible, the following method should be adopted, the object being to preserve the tactile sense and to leave the scar less prominent: From the ulnar side of the knuckle, and just over the joint, make an incision which extends from this point forward as far as the web between the index and middle finger, and, in case of a large knuckle, a little beyond this point at the side of the digit. From the anterior end of this incision make a second cut directly across the palmar aspect of the phalanx until the middle of the radial side of the finger is reached, and complete the flap by cutting in a straight line from this point to the commencement of the first incision. When the disarticulation is com- pleted, the dorsalis and radialis indicis arteries, and the external digital branches, tied with fine catgut, the corner of .the flap is carried into the receding angle on the dorsal surface of the metacarpal bone and secured by sutures. When the head of the metacarpus is to be removed, the section of this bone should be slightly oblique, and the line of incision a partial oval, beginning at the web between the two fingers, and traveling along the crease formed by flexion of the finger on the metacarpus well up on the dorsum of this bone, about three fourths of an inch back of the joint. An incision, almost in a straight line, should now be made between the ends of this curved line (Fig. 201). Dissect the flaps clear and without making a disarticulation, expose the bone, and with a fine saw divide it obliquely from before backward, and from the ulnar toward the radial aspect. In amputation of the middle or the ring finger, the following method should be preferred : Fig. -204.—(After Esmarch.) Middle Finger.—Locate the articulation exactly, and over this point make a transverse incision extending on either side to the middle of the depression between this digit and the index- and ring-fingers (Fig. 201). From either end of this cut carry a lateral incision directly forward about AMPUTATIONS. 187 half way up the first phalanx, and connect these by a transverse incision across the palmar aspect of the digit (Fig. 202). Disarticulate and fold the palmar end of the flap back upon the dorsal transverse incision where it is stitched. Another method is the oval incision, shown in Figs. 204 and 205. By the first method the tactile surface is better preserved. The head of the metacarpal bone should be left intact for the laboring classes. AATien the round expansion of this bone is removed, the gap between the index- and ring-fingers is not so wide. The bone should be sawed squarely across a half inch behind the articular surface. All that has been said of this digit applies with equal force to the ring-finger. Little Finger.—The method recom- mended in amputation of the index at the metacarpal joint should be pre- ferred in removing the little finger at the same level. The flap should be so shaped that the cicatrix will fall on the dorsum and toward the ring-finger. AA'hen the metacarpal bone is to be di- vided it should be cut with a slight ob- liquity. In this operation the oval in- cision shown in Fig. 206 should be made. AAThen two or more fingers require to be removed at the metacarpo-phalan- geal joint, each one may be amputated by the methods described as especially suited to it, or a common antero-posterior flap may be made. As to the propriety of removing the ends of the metacarpal bones, the same rules apply as already given for the single amputations. Through the Metacarpus.—AVhen the end of the metacarpus can not be saved, these bones should be divided at any point three fourths of an inch or more anterior to the carpo-metacarpal articulation. If the injury extends behind this line, it is better to disarticulate at the carpo-meta- carpal junction. In amputation through the metacarpus, the flap should be made chiefly from the palmar tissues, so that the line of sutures and the scar will be well on the dorsum of the hand, and as much of the tactile sense preserved as is possible. Carpo-Metacarpal Disarticulation.—When all the bones of the meta- carpus require to be removed, on account of a lesion not involving the anterior row of the carpus, the amputation should be made through the metacarpo-carpal line. If the anterior row is involved, the entire carpus should be removed. When the thumb is intact, and the metacarpal bones of the four fingers require removal, the incision as given by Esmar,ch should be followed. A curved incision is made across the palm, beginning at the middle of the web between the thumb and index-finger, and carried outward to the ulnar side of the base of the fifth metacarpal bone (Fig. 207). The dorsal incision commences at the web between the thumb and finger, and is carried obliquely upward toward the carpus Fig. '205.—(After Esmarcb ) Fig. 206. 188 A TEXT-BOOK ON SURGERY. until the junction of the middle and upper third of the metacarpal bone of the index-finger is reached, whence it travels across the back of the hand to join the end of the palmar incision (Figs. 208, 209). Fig. 207. Fig. 208. Fig. 209. Fig. 210. Amputation of the thumb with disarticulation at the carpo-metacarpal junction should be done as follows : Just over the carpo-metacarpal joint on the dorsal aspect of the hand commence an incision, and carry it directly along the metacarpal bone until half way to the metacarpopha- langeal articulation, from which point it is made to travel along the groove between the thumb and index-finger to the middle of the web between these two members, thence on around the base of the thumb until the dorsal incision is reached (Fig. 210). In the case shown in Fig. 211.—Epithelioma of thumb. Fig. 212.—The same, after amputa (From a patient at Mt. Sinai Hospital.) tion at the carpo-metacarpal joint. Figs. 211 and 212 this operation was performed. In amputation of the little finger, at the carpo-metacarpal joint, a similar incision is made (Fig. 213). The character of the injury, the general condition of the individual, AMPUTATIONS. 189 the vitality of the parts involved, may necessitate various modifications of the foregoing methods. In the surgery of the hand, the rule in prac- tice should be never to amputate when possible to avoid it, and never to remove any more than is absolutely necessary. Fig. 214 is that of an amputation after an injury from the explosion of a shot-gun, in which the thumb, in- dex, and middle fingers, and their respective metacarpal bones, were blown off. The line of incision was a lateral one, and the disarticulation was at the carpo-metacarpal joint. Radio-Carpal Joint.—In ampu- tation at the wrist the carpus should be removed, even when all the bones of this group are not involved. The line of incision will depend upon the extent of the healthy tissues available for forming the covering to the stump. The long palmar and short dorsal flaps are preferable on account of the finer tactile sense of the covering thus secured. More- over, the vitality of the palm is so great that, if ordinary precau- tions are observed in its dissection, sloughing will not occur. First Method. —Place the thumb and finger of the left hand respect- ively upon the styloid of the radius and ulna, and make an incision across the dorsal surface of the wrist which shall divide everything straight bones and into the cavity of the joint. Fig. 213. Fig. 214. down to the This incision reaches half-way down the lateral aspects of the wrist. At the radial end of this cut enter the scalpel, and, in shaping the long flap, follow the center of the dorsum of the metacarpal bone of the thumb as far as the meta- carpophalangeal articulation. From this point cut di- rectly across the palm to the ulnar side of the fifth metacarpal bone, and back along this to join the dorsal incision. Dissect the flap closely from the flexor ten- dons, and divide all tendons opposite the wrist-joint. Apply a cloth retractor, and saw through the styloid of the radius and ulna just at the level of the articular surface of the radius, but not necessarily taking a sec- tion from this surface. The radial, ulnar, anterior, and posterior carpal vessels are tied, the palmar flap is trimmed down to fit snugly, and stitched in proper position. The drainage-tubes come out on either side (Fig. 215). Fig. 215. 190 A TEXT-BOOK OX SURGEHY. Second Method.—-If the condition of the soft tissues is such that the long palmar flap can not be obtained, the circular incision shown in Figs. 216 and 217 may be practiced. It is always advisable to make a longitu- dinal split in the cuff along its ulnar aspect. Under other conditions, a lateral flap may be utilized, after the third method (Figs. 218, 219), in the flap from the thumb side ; or the fourth method in which the flap is taken from the ulnar aspect of the hand. Forearm above the Wrist—In amputations through the forearm, the circular or modified circular skin-flaps are, in general, preferable. The exceptions are in cases of marked emaciation when the solid flaps are indicated. The anatomical relations of the parts concerned are admirably shown in Figs. 220, 221, 222, and 223, which, with only slight modifications, I have copied from Prof. Braune's magnificent work. When the line of amputation is so close to the elbow-joint that divis- ion of the bones is necessitated within an inch of the articular surface of the head of the radius, the operation to be preferred is a disarticulation at the elbow, with removal of the olecranon. When the bones can be preserved at the level of the lower border of the bicipital tuberosity of the radius, the joint should not be invaded. Amputation at this level (Fig. 223) should be made subject to the rules just given for other portions of the forearm between the wrist and the insertion of the biceps humeri. AMPUTATIONS. 191 At the Elbow-Joint —First Method. — Make a circular incision through the skin from one inch to one inch and a half below the level of the internal condyle. Along the posterior aspect of the ulna make a second incision, splitting the sleeve of skin as far back as the end of the olecranon. Dissect up the flap from the muscles and deep fascial attachment until the joint is exposed in front, and the olecranon posterior- ly. Extend the forearm fully, enter the articulation between the head of the radius and the humerus, disarticulate, and saw off the articular sur- face at the level of the lower portion of the internal con- dyle. The drainage is from the highest point in the per- pendicular incision. Second Method.—Make a circular incision down to the deep fascia from one to two inches anterior to the tip of the internal condyle of the humerus, and, when the skin has retracted, at the level of the line of retraction divide all the tissues to the bones. Along the posterior surface of the ulna make an incision ex- tending as high as the olecra- non process. Dissect the soft tissues neatly from the perios- teum and capsule back to the condyles on the lateral and anterior aspects of the hume- rus, and along the olecranon somewhat higher, in order to facilitate disarticulation and the complete removal of the synovial bursa, beneath the in- sertion of the triceps. AVhen the disarticulation is completed, apply a cloth retractor and saw a portion of the articular sur- face off at the same level as Fig. 220. *—Transverse section through the right upper ex- tremity, one fourth of an inch anterior to the plane of the radio-carpal articulation. Looking at' the surface of the stump. 1, Eadial artery and veins. 2, Ulnar artery, veins, and nerve. 3, Tendons of deep and superficial flexors. 4, Tendon of extensor ossis metacarpi and primi internodii pollicis. 5, Flexor carpi radialis. 6, Palmaris longus. 7, Fibers of the flexor brevis minimi digiti, from the annular ligament. 8, Flexor carpi ulnaris. 9, 10, Extensor carpi radialis longior et brevior, and tendon of secundi internodii pollicis. 11, Extensor communis digi- torum. 12, Extensor minimi digiti. 13, Extensor carpi radialis. Superficial veins and nerves are seen in the subcutaneous tissues. Fig. 221.—Transverse section showing the relations of the tissues divided in amputation through the lower third of the right forearm. Looking from below upward. 1, Eadial artery and veins. Just below this, tendon of supinator longus, radial nerve, and close to the radius the tendons of the extensor ossis metacarpi pollicis and extensor carpi radialis longior and brevior. 2, Ulnar artery, veins, and nerve. 3, Median nerve. 4, 5, The posterior and anterior interosseous arteries. * All of these cuts represent the surface nearest the patient's body, i. e., the surface over ■ which the vessels are searched for after an amputation. 192 A TEXT-BOOK ON SURGERY. given in the preceding operation. The flaps are now sutured, leaving the drainage-tube out at the upper limit of the incision, over the olecranon. Fig . 222.—Transverse section through the middle of the right forearm. Looking from the periphery toward the center. Showing the relations of the tissues divided in amputation at this point. 1, Eadial artery, veins, and nerve. 2, Ulnar ditto. 3, Median nerve. 4, Anterior interosseous vessels. Fig. 223.—Transverse section through the upper third of the right forearm. Looking from the periphery ;rve. 2, Ulnar and mter- insertion of the biceps is toward the center. 1, Eadial artery, muscular branches, veins, and radial nerve. "2, Ulnar and inter- osseous arteries, veins, and median nerve. 3, Ulnar nerve. The tendon of insertioi seen with the radius. AMPUTATIONS. 193 Fig. 224 shows the anatomical relations near the line of section of the soft parts involved in this amputation. In no amputation is the superiority of the circular or modified circu- lar skin-flap over the mixed flap of older operators more evident than the one under consideration. In the mixed operation, where the anterior flap was made by transfixion, cutting obliquely forward and outward, the large vessels were not evenly divided, nor was it without considerable care that the opposing flaps could be properly adjusted. The older method, in which the olecranon process was left in position, the saw pass- ing through the neck of this process at the level of the lower portion of the articular surface of the humerus as soon as the joint was opened, has also been discarded. It has been demonstrated that nothing was gained by leaving the insertion of the triceps intact, while a second operation was occasionally necessary on account of necrosis of the olecranon. Removal of a portion of the articular surface is not always advised by surgical writers. While it is true that the stump will heal as readily when the cartilage is scraped from the bone as when the saw is used, the latter is preferable, not only from the standpoint of appearance, but also that of usefulness. Fig. 224.—Transverse section of right arm just below the elbow-joint. Looking at the surface nearest the body. 1, Brachial arterv at the point of division into ulnar and radial. 2, Median basilic vein com- municating with brachial. 3, The radial and interosseous divisions of the musculo-spiral nerve and radial recurrent artery. 4, Tendon of biceps. 5, Median nerve and anterior ulnar recurrent artery. 6, Ulnar nerve and posterior ulnar recurrent artery. Arm below the Shoulder-Joint.—The circular skin-flap is always pref- erable, except in cases of extreme emaciation, when, as heretofore given. the solid flaps are recommended. First Method.—Make a circular cut down to the muscles, and a 194 A TEXT-BOOK ON KURCJERY longitudinal incision to the same depth along the outer side of the arm. Dissect the sleeve of skin carefully up to the line of section of the humerus, and at this point divide the muscles and bone. Drainage is effected in the manner shown in Fig. 225. The anatomical relations in the several regions of the arm are shown in Figs. 226, 227, and 228. When the line of amputation is so near the shoulder-joint that sec- tion of the bone is required at the anatomical neck, the head of the humerus should be disarticulated. Second Method.—Make a circular cut through the skin at a point suf- ficiently below the line of section through the humerus to permit a suitable covering. Allow the skin to retract up the arm, and at this point divide everything smoothly and squarely down to the bone. Render the skin and muscles tense, push the point of the scalpel down to the bone on the outer side of the arm, and lay the flap open by an incision which is parallel with the axis of the humerus. Dissect the tissues closely from the periosteum up to the point where the saw is to be applied, and, after protecting **ft#$fH Fig. 225.—Showing sutures applied and exit of drains in amputation at the lower and mid- dle thirds of the humerus. Fig. 226.—Section through the condyloid expansion of the right arm. Looking at the surface nearest the body. 1, Brachial artery and veins, and the median basilic vein. 2, Musculo-spiral nerve and superior profunda artery about the point of anastomosis with the radial recurrent. 3, Median nerve. 4, Biceps tendon. 5, Ulnar nerve. 6, Triceps tendon. AMPUTATIONS. 195 Fig. 227.—Transverse section through junction of middle and lower thirds of right arm. Looking from below upward. 1, Brachial artery, vein, median nerve, and basilic vein. Near by the ulnar nerve and inferior profunda artery. 2, Musculo-spiral nerve, superior profunda artery, and supinator longus mus- cle. Cephalic vein to outer side of the biceps muscle. Fig. ■_'•_"■;.—Transverse section showing the relations of parts divided in amputation just above the middle of the humerus. Eight side. Looking toward the center. 1, Brachial artery. Near this the median nerve and bracliial veins. Internal to it the ulnar nerve and inferior profunda artery. More superficial, the basilic vein. 2, Museulo-spiral nerve and superior profunda artery. 3, Nutrient artery in the sub- stance of the eoraco-brachialis muscle. 4, Cephalic vein. 196 A TEXT-BOOK ON SURGERY. the soft parts with a retractor, divide the bone. The drainage should be from the upper extremity of the perpendicular cut, which, with the stump properly elevated, will be the most dependent portion of the wound. An extra tube may be inserted at the end of the stump. Amputations through the humerus, especially in young and growing bones, not infrequently fail of success by reason of so-called conical stump—a projection of bone through the tissues of the flap. This condi- tion supervenes in a proportion of cases sufficient to justify the surgeon in stating at the time of such an operation that a conical stump may result even with very long flaps. I have met with one case in my own practice in which conical stump recurred after three reamputations. It is not definitely determined whether the projection is due to inflamma- tory changes in the end of the bone or to the growth of the stump of the humerus from the upper epiphysis. Amputation at the Shoulder Joint—The Author's Method. In 1888, at the New York Polyclinic Medical School and Hospital, I removed the outer portion of the clavicle, the glenoid, acromion and coracoid processes, and a small portion of the body of the scapula, to- gether with the upper extremity of a patient suffering from a large sar- —Shoulder-joint amputation. Pins and rubber-tube tourniquet in position. The Esmarch bandage has been removed. (From drawings by H. J. Shannon.) coma of the upper articular end of the humerus by the following original method : With a stout mattress needle I transfixed the skin and a por- tion of the pectoralis major muscle about three inches from the shoulder, and at about the same distance from the joint on the dorsum scapula I introduced a second needle in such a way that when I carried a strong AMPUTATIONS. 197 white-rubber tube four or five times around the shoulder above these needles, making strong traction, the compression was so great that the blood vessels going to the arm were entirely occluded (Fig. 229). I have twice repeated this operation with perfect success in haemo- stasis. It has since been done by Prof. J. H. Brinton, Prof. AAr. AAr. Keen, Prof. Roswell Park, and other surgeons, and has proved entirely Fig 230.—The same after disarticulation and ligature of the vessels. satisfactory in their hands. AA^ith this experience, I can recommend it to the profession as a safe method of controlling haemorrhage in dis- articulation of the shoulder joint or in operations about the shoulder. After the extremity has been exsanguinated by Esmarch's bandage, the pins should be introduced and the rubber constrictor applied, and the Esmarch bandage removed. The incisions for the flap should be made to conform to the conditions which demand the operation. AVhen pos- sible, the ideal amputation at the shoulder is a circular incision through the skin and down to the deep fascia, about four inches beyond the joint. A longitudinal incision is then made from the acromion process directly down to the circular incision, and the flap dissected back to the level of the joint and the latter disarticulated. AVhen permissible, after disarticulation I leave the tissues upon the inner aspect of the humerus a little longer in order to get as much of the blood vessels beyond the constrictor as possible. The operation is completed with the tourniquet in position (Fig. 230). Silkworm-gut sutures with a twist of sterile cat- gut for capillary drainage will suffice for closing and draining the wound, which, as a rule, should be redressed about the fourth day. The old method of Larrey may still be preferred by some operators. 198 A TEXT-ROOK ON SUROERY It consists of a straight incision dividing all the tissues down through the capsule to the bone, from the tip of the acromion process to an inch below the articular surface of the head of the humerus. From the cen- ter of this cut make an incision on either side running obliquely down and forward, dividing all the tissues down to the periosteum, extending about two thirds of the distance from the apex of the shoulder to the axilla. Lift all the tissues from the bone, expose the joint, disarticulate, carry a long, thin knife across and through the capsule, and complete the oval flap by cutting along the under surface of the humerus in the line of the oblique incisions already made. Removal of the Upper Extremity with All or a Portion of the Clavicle and Scapula. AA^hen it becomes necessary to remove portions of the scapula or clavicle, or all of these bones, it is advisable to tie the subclavian artery (third division) and the transversalis colli and subscapular branches of the thyroid axis. AVhen the disease extends so far upon the shoulder that it is impossible to secure flaps sufficient to cover the exposed surface, cut well away from the dis- ease and allow the wound to heal by granulation, relying upon subsequent plastic procedures to cov- er in the stump. In a pa- tient operated on in Oc- tober, 1895, at the New York Polyclinic, I did a preliminary ligation of the subclavian and the two other arteries men- tioned with cocaine an- aesthesia, and at a sub- sequent operation ampu- tated at the shoulder joint, leaving no material for flaps, as the operation was done for sarcoma which involved the soft tissues high up. Three weeks after amputation, and at two subsequent dates, I infected this wound with the streptococci of erysipelas, pro- ducing well-marked specific infection, which ran the usual course.' The Fig. 231.—Author's case of amputation of the left upper extremity for sarcoma. AMPUTATIONS. 199 stump at this date (May, 1897) is well healed, and the patient is seem- ingly in perfect health, having a good color with marked increase in weight. I am acquainted with several cases in which this treatment has been successful. On October 14, 1890, I removed the entire clavicle, the scapula and its muscles, the upper extremity, the outer half of the pectoralis ma- jor, and the pectoralis minor, ligat- ing the subclavian artery in its third surgical division, and the su- prascapular and transversalis colli branches of the thyroid axis in a man fifty-four years of age at the Mount Sinai Hospital. Nine months previous, a sarcoma had been removed from the long head of the triceps, but soon recurred. Three months later he was seen and amputation advised, but refused. As the tissues over the outer end of the clavicle and scapula were involved, it was deemed necessary to remove the scapula, the clavicle, and the muscles immediately con- nected with the shoulder. Arery little blood was lost, and the pa- tient recovered.* Lower Extremity. Amputation of the Toes.—The same methods given for the fingers should be employed in amputation of the toes. The long plantar flap is preferable in these operations, not so much for the preservation of the more perfect tactile sense of this surface in covering the stump, but chiefly to bring the cicatrix on top and away from pressure. AAThen an ampu- tation is necessitated for a lesion near the articulation between the first and second phalanges in which only the anterior extremity of the first Fig. 232.—Author's case of amputation of the left upper extremity with the clavicle and scapula, 1890. * In an article in the "New York Medical Journal." January IT, 1891: I published six other cases of amputation at the shoulder joint—one by Niepce, in 1860, in a man thirty-two years of age, for machine injury; the arm, clavicle, and scapula were removed and the patient recovered. Ferguson, 1860; female, twenty-six years, sarcoma; recovery. Bell, 1885 ; boy, ten years, sarcoma; recovery. Roswell Park, 1889; boy, ten years, railroad injury, shoulder almost torn off; recovery. Roswell Park, 1892 ; male, middle-aged, enormous epithelioma over shoulder; recovery. Ernst Schmidt. 1886: boy, railroad injury; recovery. A remarkable showing of recovery in every case. In thirty-nine cases in which the arm, scapula, and a portion of the clavicle were removed, twenty-eight recovered. 200 A TEXT-ROOK ON SURGERY phalanx is involved, section through the bone should be preferred to disarticulation at the metatarso-phalangeal joint, provided that the line of section is through the anterior third of the phalanx. Disarticula- tion of two or more consecutive toes at the metatarso-phalangeal joint may be effected by a continuous incision. Amputation of all the toes at this articulation is performed as follows : Grasp and forcibly flex the toes, and make an incision, commencing just posterior to the inner aspect of the metatarsal joint of the great toe, curving forward along the side of the first phalanx to a point as far advanced as the web between the toes, and then across the base of each digit on this plane until the outer side of the metatarsal bone of the fifth toe is reached at a point corresponding to that at which the incision was begun. AA^ith the toes now fully extended, a symmetrical flap is next cut along the plantar as- pect by an incision which almost merges into the first line at the ante- rior margin of the web (Figs. 233, 234). Dissect up each flap as far back as the metatarso-phalangeal articulation, leaving the tendons to be divided at this point. The disarticulation may be best effected with a strong narrow scalpel, while the ligaments are made tense by forced flexion. Second Method.—A separate amputation may be made for each toe. Through the Metatarsus.—AThen the loss of tissue requires an ampu- tation behind the metatarso-phalangeal articulation, section of one, or even all, of the metatarsal bones should be effected rather than unneces- sarily sacrifice any portion of the foot by disarticulation at the tarso- metatarsal joint. The line of section should always be as near the anterior extremity as possible, and when it falls within three fourths of an inch from the tarso-metatarsal joint, a disarticulation should be made at this point. Amputation through the entire metatarsus should be made with a long plantar and short dorsal flap, so that the scar will fall on the dorsum of the foot and away from pressure. The dorsal incision should be made almost directly across the foot, and on a line with the plane of section through the bones. The plantar flap should begin on the inner side of the first metatarsal bone, and follow this forward as far as is necessary to secure a flap of sufficient length. It is always wise to make this a little too long, so that it may be trimmed down and made to fit nicely as the sutures are being adjusted. The incision is next carried across the sole of the foot to the outer surface of the metatarsal bone of the little toe, and back along this to the point of junction with the end of the dorsal cut. All of the tissues should be divided directly down to the bones in this incision, and the flap dissected up, keeping the knife- Fio. 233. Fig. 234. AMPUTATIONS. 201 point always in contact with the periosteum, so that the vessels may be avoided. After the bones are sawn through, the lower flap is turned into position and suitably trimmed. The vessels are next secured, the sutures applied, and the drainage-tubes brought out at each side. At the Tarso-Metatarsal Articulation—First Metatarsal.—Amputa- tion of the great toe, with disarticulation of its metatarsal bone at the tarsal joint, is effected as follows : At a point about half an inch behind the articulation of the metatarsal bone with the internal cuneiform, and immediately between the dorsal and internal lateral aspects of this bone, commence an incision which is carried forward to the phalangeal junction. Thence it is continued around the base of the toe, across its plantar sur- face, and back through the web between the first and second digits, and back to the end of the straight incision over the metatarso-phalangeal joint (Fig. 235). Dissect the soft parts closely from the bone, taking care not to wound the plantar vessels, and disarticulate. The preservation of the posterior portion of the first metatarsal bone is always desirable, on account of its giving insertion to the peroneus-longus and partially to the tibialis-anticus muscle, the former being a strong supporter of the trans- verse arch of the foot, and the latter offering the chief resistance to the sural muscles. Fig. 235. Fig. 236. Fifth Metatarsal.—One fourth of an inch behind the tubercle of the fifth metatarsal, and over the center of the dorsal aspect of this bone, commence an incision, which is carried directly forward until near the first phalanx, when an oval is described around the base of the little toe (Fig. 236). Keep close to the bone in the dissection. The disarticulation is more easily effected by division of the peroneus brevis and peroneus tertius, and by entering the articulation from the outer side. The importance of the posterior portion of this bone is less than that of the metatarsal bone of the great toe, but it should never be needlessly sacrificed. One or more of the intervening metatarsal bones may be removed in an amputation of their respective toes in practically the same manner as the preceding. The incision should be begun far enough behind the tarso-metatarsal joint to thoroughly expose the ligaments and facilitate disarticulation—not an easy process when only a single bone is to be removed. The incision should be made exactly along the middle line of the dorsal aspect. 14 202 A TEXT-BOOK ON SURGERY. Amputation of the entire metatarsus should always be made through the articular plane (Lisfranc). The modification of this procedure by Hey, which consisted in disarticulating the four outer metatarsal bones and sawing the end of the internal cuneiform off at the line of the second metatarsal bone, is altogether unnecessary. Method—Dorsal Incision.—-Place the thumb and index of one hand respectively half an inch behind the articulations of the first and fifth metatarsal bones with the cuneiform and cuboid, and at the most con- venient one of these points commence the dorsal incision, carrying it directly forward to the base of the metatarsus, and then across the foot one fourth of an inch in front of the tarso-metatarsal articulation, finish- ing at the opposite side (Fig. 237). This incision should have a slight forward convexity, and should di- vide all tissues down to the bones. Dissect the flap closely from the periosteum to about one fourth of an inch behind the line of articula- tion. Plantar Flap.—From the same point as for the dorsal incision, carry the knife directly forward on the lat- eral aspect of the metatarsal bone to the metatarso-phalangeal joint, where the line of incision should begin to describe a curve until the interdigital web is reached, along which it travels across the foot, and thence back along the opposite metatarsal bone to the level of the tarsus (Fig. 238). This flap should be lifted by deep dissection, keeping close to the under surface of the bones, in order to interfere as little as possible with the vascular supply. An assistant should now hold both flaps well back, while with a narrow, short scalpel the disarticulation is effected as follows: Grasp the metatarsus with one hand and forcibly depress it until the ligaments are put upon the stretch. Enter the knife just behind the tip of the fifth metatarsal bone and carry it inward with a slight forward inclination, disarticulating on this plane, and in succession the fifth, fourth, and third bones, until the knife is arrested by the outer surface of the second metatarsal. The line of this articulation is almost parallel with that just followed, but it is placed from one eighth to one fourth of an inch posterior to it, and may be readily found by moving the meta- tarsal bone upon the cuneiform. The joint between the metatarsal bone of the great toe and the internal cuneiform is about one fourth of an inch anterior to that of its fellow, being continuous with the line of the three outer bones. The flaps should now be trimmed and nicely fitted, and any ragged ends of tendons clipped off by the scissors, after which the Fig. 237. Fig. 238. AMPUTATIONS. 203 Pirogoff. vessels are tied and the sutures adjusted, leaving the drainage-tubes out at each angle. One point of precaution is essential, namely, to avoid division of that part of the tendon of the tibialis anticus which is inserted into the internal cuneiform near its metatarsal articulation. One of the objections to this operation is the elevation of the heel, and the con- sequent depression of the stump by the action of the sural muscles, which action is practically unop- posed if the insertion of the tibi- alis anticus is divided. Should this occur, or should the heel be too greatly elevated, the tendo Achillis should be divided as in talipes equi- nas. The line of section through the internal cuneiform bone is shown in Fig. 239. This—the op- eration of Hey—is objectionable, for two reasons. In the first place, it cuts away a part of the bony framework of the foot, which need not be sacrificed ; and, secondly, it severs the attachment of the tibi- alis-anticus muscle. Through the Tarsus.—AVhen removal of any part of the ante- rior row of tarsal bones is re- quired, the following rules should be adopted : If the internal cunei- form is involved only on its ante- rior articular surface, it may be sawn through on the line of Hey (Fig. 239). If the middle or ex- ternal cuneiform is involved only to a limited extent upon its ante- rior portion, as much as one fourth of an inch of this surface may be sawn or scraped off. Behind this limit a disarticulation from the scaphoid should be made. Through the cuboid the section should pass, as first advised by Dr. S. F. Forbes, of Toledo, Ohio (who performed this operation in 1863), through the middle of this bone on the line of the anterior surface of the scaphoid (Fig. 239). Forbes's Method.— Disarticulation of the three cuneiform bones from the scaphoid, and section of the cuboid parallel with the plane of the anterior surface of the scaphoid (Fig. 239). The dorsal and plantar in- cisions are slightly anterior to and practically the same as in Chopart's amputation. The dissection should be made closely from the bones, and Chopart. Forbes. Hey. ■Lisfranc. I Metatarsus in continuity. Phalanges continuity. Fig. 239. 204 A TEXT-BOOK OX SURGERY. the flaps trimmed and adjusted as in the preceding operation. Section of tendo A chillis may be done later, if necessary. Med io-Tar sal—Operation oft liopart— The dorsal incision is begun on a level with and an inch posterior to the tip of the base of the fifth meta- tarsal bone (for the adult foot). This point is about one fourth of an inch behind the articulation between the cuboid and calcaneum (Figs. 236-240\ AATith a slight forward convexity the incision is carried across the top of |> , \ \ the foot to the posterior margin of I h \ the tuberosity of the scaphoid, and I ;! \ then directly back from one fourth | j ; to half an inch (Fig. 235). The skin, | / •< tendons, vessels, and nerves are di- //.' vided on this line, and the flap lift- I -, \. ..-- ed until the joints between the Vv7(__ astragalus and scaphoid and the calcaneum and cuboid are well ex- Fig. 240. posed. From the ends of this first incision a long plantar flap is fashioned by cutting forward, as in shaping the flap for the operation of Lisfranc (Figs. 235, 236). Disarticulation is effected with a short, strong scalpel, while forcible extension is employed. The flaps are now to be properly trimmed, and the vessels secured. Division of the tendo Achillis may be done later. AAxhen required, this operation may be modified by sawing off the anterior half-inch of the astragalus and calcaneum. The incisions are practically the same. Calceineo-Astragaloid Disarticulation .—[This operation was first sug- gested by Lignerolles, first performed by Textor, but brought into promi- nence by Malgaigne. A\rhen in an amputation of the foot at the medio- tarsal joint it is discovered that the os calcis must also be removed, and if the astragalus is sound, the subastragaloid operation should be pre- ferred to the amputation of Syme at the tibio-tarsal joint. By this method a shortening of about two inches is prevented, and, although the under surface of the astragalus is uneven, experience has shown that the pressure is safely distributed, and a useful stump results. Moreover, the degree of mobility maintained at the tibio-astragaloid articulation adds to the ease and comfort of locomotion. Seize the foot with the left hand, and with a strong scalpel commence the incision by dividing the skin and tendo Achillis just at the level of the upper surface of the os calcis. From this point the incision is continued along the fibular side of the foot forward, dividing everything down to the bone, and curving slightly downward until, as it passes below the tip of the external malleolus, it is four tenths of an inch below this point (Fig. 241). The line of incision is now carried directly forward until near the tuber- osity at the base of the fifth metatarsal bone, where it curves to the dor- sum of the foot, crossing to the inner side over the anterior edge of the scaphoid, and then straight down and under the foot a half-inch beyond the middle of the sole (Figs. 242, 243). From this point a straight incision is made directly back to the point of beginning at the inner edge of AMPUTATIONS. 205 the tendo Achillis (Fig. 243). Lift the plantar flap by deep and careful dissection from the bone, leaving nothing but the periosteum, until the j3 Fig 241. —(After Malgaigne.) Fig. 242.—(After Malgaigne.) I calcaneo-astragaloid articulation is well exposed. The flaps being held by an assistant, the disarticulation is begun by opening the astragalo-scaphoid joint and removing the anterior part of the foot at the medio- tarsal joint. The os calcis should now be seized with a lion-tooth forceps, and the disarticulation of this bone effected. The exposed tendons should be smooth- ly divided with the scissors at the higher portions of the incision. After deligation of the vessels the flap is properly trimmed and sutured, the cicatrix falling upon the dorsal and external lateral asjiects of the stump.* J J Fio. 243.—(After Mal- gaijj-ne.) * Hancock's modification of this procedure, or the su'oastrairaloid- osteoplastic amputation, is as follows: One incision begins beneath and at the posterior angle of the outer malleolus, and is carried along the outer surface of the foot to a point a half-inch anterior to the pro- jecting base of the fifth metatarsal bone. A second incision is made along the inner border of the foot, commencing posteriorly about the center of the internal malleolus and terminating anteriorly at a spot opposite the end of the external incision. The anterior ends of both cuts are joined by a curved in- cision made with its convexity forward across the plaDtar aspect of the foot, and dividing all the tis- sues well down to the bone. Reflect this flap back as far as the projections at the under surface and in front of the tuberosity of the os calcix, and make a fourth incision across the dorsum of the foot imme- diately behind the head of the astragalus. Apply the saw upon the under surface of the calcaneum a little anterior to its center, and cut through the bone ob- liquely from below upward and backward (Fig. 244). With the knife enter the mediotarsal joint, pass the instrument under the head of the astragalus, and, cut- ting from before backward, sever the interosseous ligament and detach the anterior part of the foot, together with the segment of the os calch. Saw off the head of the astragalus, and with a sharp bone-cutter (or saw) remove the two articular cartilages (and a thin slice of bone) from the under surface of the astragalus. As the flaps are adjusted, the sawn surface of the calca- neum is brought into apposition with the under surface of the astragalus. See " Lancet." September, 1866, p. 257. Fig. 244.—Section of os calcix and astragalus in Hancock's operation. 206 A TEXT-BOOK ON SURGERY. Amputation of the Foot— Tibio- Tarsal (Syme's).— When the astraga- lus must be removed, together with the foot, the amputation of Syme, which involves a disarticulation of the tibio-astragaloid joint, and a sub- sequent section of the articular surfaces of the tibia and fibula, should be made. In its successful performance certain precautions are neces- sary, chief among which is the preservation of the proper vascular sup- ply to the posterior flap. The failure to appreciate the importance of making the plantar incision far enough forward, as laid down by Syme, has brought this procedure somewhat into disrepute, for Prof. Stephen Smith, in his comprehensive report, says the necessity for re-amputation is 3 per cent greater in this than in any other amputation. In my "Prize Essay," published in 1876,* I demon- strated that the ar- terial distribution to the calcaneo- plantar flap was chiefly derived from the external plantar artery, and from the posterior tibial so near the bifurcation of this vessel into its ter- minal branches, that any line of in- cision in the forma- tion of this flap which necessitated the application of a ligature at or very near its bifurcation was not justifiable. I do not doubt that the sloughing so often met with at this point is caused by carrying this incision too far back toward the tuberosity of the calcaneum. The arte- rial supply is shown in Fig. 24o, from my "Essays in Surgical Anatomy and Surgery." f Modified Procedure.—With the foot held at an angle of 90° to the axis of the leg, place the thumb at the tip of one malleolus, and the index at the other, and from the center of the malleolus internus carry an incision directly across the sole of the foot to a point one fourth of an inch anterior to the tip of the malleolus externus. This incision should divide all the tissues to the bones, and, as will be seen in Figs. 246 and 247, its perpendicular portion descends in a direction slightly anterior to * "American Journal of the Medical Sciences," April, 1876. t William Wood & Co., 1879 Fig. 245.—Diagram showing the arterial supply to the calcanean region, on the tibial side of the foot. (Drawn by the author, from the average of eighty-seven dissections.) m, Internal malleolus, pmen, Tibio-tarsal quadrilateral, the surgical region of this articulation, k, Posterior tibial artery, o, Its point of bifurcation into g, Internal plantar, and /, Ex- ternal plantar artery. * i i, Calcanean branches of external plantar. _ t, Articular branches from posterior tibial, h, Articular branch from in- ternal plantar. g, Tendon of tibialis posticus muscle, r, Tendon of flexor longus digitorum. s, Tendon of flexor longus pollicis. m c, The line of incision of Gross, ml, md, me, me, Lines 01 incision showing that the nearer the incision approaches the heel, the more danger is in- curred of cutting off the principal blood-supply to the calcanean flap, in amputation, raw, Line crossing the usual point of bifurcation of the posterior tibial, ma, mb, Anterior incision. AMPUTATIONS. 207 the axis of the tibia. The ends of this cut are united by a second, which arches sharply upward about on the line of section of the bones, and should also divide tendons and all intervening structures, opening into the joint. The foot should now be firmly grasped and extended, so as Fig. 246. Fig. 247. to make tense the anterior ligament of the ankle, which is easily divided. Carrying the knife to either side of the articular surfaces of the astra- galus, the lateral ligaments are cut, and the joint thus widely exposed. An assistant now holds and depresses the foot, while the operator care- fully dissects the tissues closely from the astragalus and calcaneum. Care should be taken not to bruise the flap by too great traction. In dissecting along the inner surface of the ankle, the knife should be kept close to the bones, so that when the lesser process of the.calcaneum is reached it will slide behind and under this process, passing between it and the flexor tendon and the vessels. If this precaution is not taken, the arteries may be wounded and the nutrition of the flap seriously im- paired. As the dissection proceeds, I i , the foot is further depressed, and the j J V tendo Achillis separated from its in- /| ] sertion into the tuberosity of the cal- caneum, in doing which care must be taken not to button-hole the flap. The posterior portion of the os cetlcis may now be brought through the joint, and the dissection continued in this direc- tion or finished by working back along the under surface of this bone. After the foot is removed, the flaps are lifted from the tibia and fibula until a sec- tion of these bones can be made just on the level of the anterior articular margin of the tibia (Fig. 248). It is not necessary to remove the articular surface. The flaps should now be trimmed and fitted, and the vessels tied. As the sutures are applied, it will be noticed that there is a redundancy of tissue in the long flap, leav- ing a cup-shaped cavity; but this can be thoroughly drained from the angles of the wound, and disappears when' the stump is healed (Fig. 249). Fig. 248. Fig. 249. — Stump after Syme's amputation. (After Malgaigne.) 2<>8 A TEXT-BOOK OX SUROEKY. Syine's amputation at the ankle has been modified by the osteoplastic operations of PirogofT, Le Fort, Gunther, and others. Pirogoff's Method.—The dorsal and plantar incisions are made from the same points, and are practically the same as in Syme's amputation. However, in order to avoid redundancy of the soft tissues and to expose the calcaneum back to the line of section of this bone, the lower incision should, when it reaches the sole of the foot, be carried back about three fourths of an inch nearer the heel than in Syme's method. The dorsal incision does not ascend so high upon the ankle by the same distance. The joint is opened through the an- terior incision, and the lateral ligaments di- vided until the ante- rior upper surface of the os calcis can be dis- placed forward through the articulation, when it is sawn through on the line indicated in Fig. 251, the instrument running parallel with the edges of the incision. The soft parts are now carefully lifted from the articular ends of the tibia and fibula, and these bones divided horizontally so that all the articu- lar cartilage is removed by the section. The an- gle described by these two lines of section is about 90° (Fig. 251). The flaps are adjusted so that the plane of the calcaneum is brought snugly Fig. 250.—(After Esmarch.) Fig. 251.—(After Esmarch.) Fig. 252.—Stump after Pirogoff'f amputation. (AfterMalgaigue.) in apposition with that of the tibia and fibula. The drainage should be from the dependent angles of the wound (Fig. 252). Le Forts Method.—Three fourths of an inch below the external AMPUTATIONS. 209 malleolus commence an incision which is carried directly forward to within half an inch of the calcaneo-cuboid articulation. From this point it describes a curve with an anterior convexity over the dorsum of the foot, following the line of the astragalo-scaphoid joint until the inner border of the foot is reached (Fig. 253), when it is carried back and ended at a point about one inch in front of the tip of the internal mal- leolus, which point is directly between the tuber- osity of the scaphoid and the tip of the mal- Fig. 253.—(After Le Fort.) Fig. 254.—(After Le Fort.) leolus. From the anterior limit of the straight incision below the ex- ternal malleolus describe a plantar flap also with a forward convexity across the sole of the foot, as shown in Fig. 254. Dissect up the dor- sal flap, in order to expose the tibio-tarsal joint, taking great care in lifting the inner angle not to wound the tibial and plantar arteries. The disarticulation of Fig. 255.—(After Le Fort.) the astragalus from the calca- neum is next effected by intro- ducing a thin knife from the Fm. 256.—(After Le Fort.) fibular side between these bones, and dividing the interosseous ligament. Then remove the front of the foot at the medio-tarsal joint, and complete the disarticulation of the astragalus, and with the saw remove the upper segment of the calcaneum on the level of its articular surface (Figs. 255, 256). The tibia and fibula 21() A TEXT-BOOK OX SURGERY are now horizontally divided just at the level of the articular plane of the tibia, as in Syme's operation (Fig. 248). In adjusting the flaps, the sawn surface of the calcaneum is brought into apposition with that of the tibia (Fig. 257). Or, having exposed the tibio-tarsal joint, divide the ligaments, disarticulate, as in Syme's operation, and, having drawn the astra- galus and calcaneum forward until the upper Fig. 258. Fig. 257.—Stump after Le Fort's amputation. (Le Fort.) portion of the os calcis is exposed, insert a key-hole saw behind the tuberosity, and saw through this bone on the line already indicated. Gunther' s modification of this procedure is shown in Figs. 258, 259, 260, 261, 262, taken from Esmarch's hand-book, and the crescentic section Fig. 259. r> MCuH ,MI A ' \ 1 Fig. 260. of the bones, as practiced by P. Fig. 262. Bruns, is seen in Fig. 263, from the same source. Summary.—In amputations of the foot the following rules should be observed : The terminal phalanges of all the toes should be removed by disarticulation when it becomes necessary to remove a portion of the en- tire thickness of these bones. The same rule applies to all the second AMPUTATIONS. on phalanges, except that of the great toe, which should be sawn through at any point anterior to its middle. If a section posterior to this is re- quired, disarticulate from the metatarsal bone. What has been said of the second phalanx of the great toe ap- plies with equal force to the proximal phalanges of all the other toes. None of the metatarsal bones should be disarticulated from the tarsus when a section is possible not less than three fourths of an inch anterior to each tarso- metatarsal joint. When a section posterior to this line is required, a tarso-metatarsal disarticu- Fig. 263. lation should be effected. Hey's oper- ation is only justifiable when the anterior face of the internal cuneiform is diseased. As much as the anterior fourth of each cuneiform bone, and the anterior half of the cuboid, may be sawn off, in preference to the sacrifice of the bony framework, by Forbes's or Chopart's operation. When the cuneiform bones must be removed, and the posterior half of the cuboid is sound, Forbes's operation should be preferred to Chopart's. Chopart's procedure is next in order. For laborers, the operations of Le Fort and Pirogoff, carefully and skillfully done, should be preferred to the tibio-tarsal disarticulation. I formerly preferred the Syme stump, but when a good union at the proper angle is obtained between the cal- caneum and tibia after Pirogoff's or Le Fort's method, I am of the opin- ion that pressure on the heel and remaining sole is better endured. Even at the risk of a second operation being required, an effort to preserve the greatest possible portion of the foot is justifiable, except when it may seriously threaten the life of the patient. The value of a surface accustomed to pressure can only be thoroughly appreciated in the after-adjustment of an artificial apparatus. Leg.—Amputation at any portion of the leg above the line of section in Syme's operation should be made by one of two methods. AVhen amputation is to be made below the middle third, the bone may be sacrificed in order to obtain flaps. If above the middle third, no bone should be sacrificed, every inch of bone being desirable for purposes of leverage. In amputations just below (within one and one half inch of the knee), bone may be sacrificed to secure flaps. In general, the nearer the ampu- tation is to be made to the body, the greater should be the care to secure bone. 1. Modified Circular Skin Flap.—At a sufficient distance beyond the point at which the bones are to be divided make a circular cut through to the deep fascia, split the flap directly over the fibula, up to the point of section through the bones, and carefully dissect up the cuff. "When the flap is reflected, at the level of its base divide all the soft tissues squarely down to the bones, which are next sawn through. The spine of 212 A TEXT-BOOK ON SURGERY. the tibia should be trimmed down, to prevent too acute pressure and sloughing of the skin at this point, a not infrequent occurrence when this precaution is omitted. The drainage is at the fibular side, and, as the leg should be elevated, the tube should come out at the highest point of the perpendicular incision. When the bones are sawn through within six inches of the knee joint, the remainder of the fibula should be ex- sected. 2. Method of Prof. Stephen Smith.—Commence an incision in the center of the anterior surface, and carry it downward along the side of the leg, so as to make a slightly curved flap, with its convexity below; when the incision passes over the prominent part of the leg toward the posterior surface, incline it upward until the middle of the limb is reached, where it should be continued directly up to the point at which the bone is to be divided; make a similar incision on the opposite side (Fig. 264); the flaps, consisting of the skin and fascia, are dissected up- ward about an inch, at which point the muscles are divided squarely down to the bones. After the bones are divided, the hood is brought over the stump and sutured, leaving the drainage at the upper part of the posterior incision. In very emaciated subjects, to forestall the liability of sloughing in the flaps, the first circular cut should go directly through all the tissues down to the bones, and the perpendicular incision along the fibula also down to this bone. All the tissues should then be lifted closely from the periosteum and interosseous membrane, forming a solid flap, reflected up to the point at which the bones are to be divided. Estes advises as best adapted for artificial support double lateral skin and muscle flaps for the leg. The time to apply an artificial limb is just as soon after an amputa- tion as it can be borne. Waiting means only a loss of time, and causes the stump to become enervated from want of use. If amputation is done for malignant disease, it is better to wait longer in order to see if there will be a recurrence of the neoplasm. When the line of amputation approaches nearer than three inches from the upper articular surface of the tibia, a complete disarticulation at the knee should be performed. • At or below this point the upper por- tion of the bone should be preserved, and the fibula exsected. After recovery from the operation it will be found that the tibia is flexed upon the femur, so that, in the adjustment of an artificial limb, the chief pressure may be comfortably borne upon the normal tissues in front of the patella and the tuberosity of the tibia. The greater pressure in any AMPUTATIOX. 213 Fig. 265.—(Modified from Esmarch.) prothetic apparatus used after amputation, at or above the knee, falls upon the ischio-perineal region.* Knee Joint—First Method—Modified Circular Skin Flap.—About three inches below the patella make a circular sweep around the leg, dividing the skin and fascia. Join this by a perpendicular incision in the middle line of the posterior aspect of the limb, extending through the skin and fascia, and at least as high as to the level of the top of the patella. Dissect the skin back carefully, keeping close to the anterior sur- face of the patella, as the skin over this bone is usually very thin. It is not necessary to dissect the cuff as high on the lateral and pos- terior aspects as in front, since the anterior incision is made to allow Fig. 266.—(After Esmarch.) * The older operations, which consisted in making a long and a short flap on opposite sides of the leg, are now fallen into general disuse. They are the methods of Teale, Lee, Sedillot, and others. Method of Teale—Long and Short Rectangular Flaps.—The long flap, folding over the end of the bone, is formed of parts generally devoid of large blood vessels and nerves, which struc- tures are left in the short flap. The size of the long flap is determined by the circumference of the limb at the place of amputation, its-length and breadth being each equal to half the circumfer- ence of the limb at this point. The short flap is one fourth as long as the other. The incisions and stump, after Teale's method, are shown in Fig. 267. Sedillofs Method—Long Fibular, Short Tib- ial, Flap.—Opposite the point at which the bones are to be divided insert a long, thin amputating knife, the point of which shall graze the spine of the tibia and the outer surface of the fibula, and come out through the outer aspect of the calf. Cut downward close to the bones, and make a long, rounded flap. The short flap is made by an incision with a slight downward convexity (Fig. 268). Lee's Method.—The length of the flaps is determined as in Teale's amputation. The long flap is posterior, and includes the skin and sural muscles. The deep mus- cles and the vessels are divided squarely at the base of the flap Fig. 269.—(Ashhurst's u Encyclopaedia.") (Fig. 269). Fig. 267.—(From Byrant.) 214 A TEXT-BOOK OX SURGERY. Fig. 270.—Transverse section of the right leg just above the ankle joint, showing the relation of the parts on the plane of section through the malleoli in Syme's, Pirogotf's, Le Fort's, Gunther's, and Bruns'a amputations. Looking at the surface nearest the body. 1, Extensor longus digitorum. 2, Anterior tibial vessels and nerve. 3, Extensor proprius pollicis. 4, Tibialis anticus. 5, Internal saphena vein. 6, Tibialis posticus. 7, Flexor longus digitorum. 8, Posterior tibial artery, veins, and nerve. 9, Flexor longus pollicis. 10, Tendo Achillis. 11, External cutaneous nerves. 12, Peroneus brevis. 13, Peroneus longus. Fig. 271.—Section through lower third of right leg. Looking toward the center. 1, Anterior tibial nerve, artery, and veins! 2, Posterior tibial artery, veins, and nerve. 3, Peroneal artery and veins. AMPUTATIONS. 215 of the removal of the patella and dissection of the synovial sac just above it. Divide the tendon of the quadriceps at the upper limit of the patella, turn this down, cut the lateral ligaments and capsule along the edges of the condyles of the femur, flex the leg strongly on the thigh, divide the crucial ligaments, and, as soon as the posterior liga- ment of YYinslow is exposed, introduce a long knife and remove the leg by cutting squarely through the soft tissues at the back of the articulation. A cloth retractor is now applied and a slice of bone Fie;. 272.—Section through the middle of the right leg. Looking from below upward. 1, Anterior tibial artery, veins, and nerve. 2, Posterior tibial artery, veins, and nerve. 3, Peroneal artery and veins. 4, Long saphena vein and nerve. 5, Musculocutaneous nerve. 6, Short saphena vein and nerve. removed with the saw, leaving a smooth surface. Should the articular end of the femur be diseased, the section may be made high enough to remove this, provided the saw does not enter the medullary canal. With the cutting-forceps round off the sharp edges of bone, tie the vessels, and close the flap as in Fig. 266. Second Method (Operation of Prof. Stephen Smith).— With a large scalpel commence an incision about an inch below the tubercle of the tibia, and cut to the bone ; carry it downward and forward beyond the curve of the side of the leg, thence inward and backward to the middle 216 A TEXT-BOOK OX SUROERY. Fie. 273.—Section through upper third of right leg. Surface nearest the body. 1, Anterior tibial vessels and nerve. 2, Posterior ditto. 3, Peroneal vessels. 4, Musculo-cutaneous nerve. 5, Internal saphena vein and nerve. of the leg, thence upward to the middle of the popliteal space; repeat this incision upon the opposite side ; raise the flap, consisting of all the tissues, down to the bone until the articulation is reached, divide the ligaments, and remove the leg as in the previous operation (Fig. 274). The flap should be lifted from the patella, and this bone removed. " Care should be taken that the incision is inclined moderately for- ward down to the curve of the side of the leg, to secure ample covering for the condyles, and that upon the internal aspect it should have addi- tional fullness for the purpose of in- suring sufficient flap for the internal or larger condyle " (Smith).* * The method of Carden—namely, long anterior skin-flap, and the short posterior skin and muscular flap, made by the long knife carried through the joint—is inferior in every respect to Fig. 274. AMPUTATIONS. 217 Fig. 275. After the flaps are stitched the drainage-tube makes its exit through the upper posterior angle of the wound. When in amputation near the knee the femur is the seat of osteo- myelitis, the indications are to thoroughly cleanse the canal by means of a long Yolkmann's spoon and irri- gate with sublimate solution; intro- duce a long drainage-tube the full length of the canal and bring this out through the flap exactly in line with the axis of the canal (Fig. 275). In this way the danger of a high- er amputation is avoided and a longer stump secured. In two instances of amputation just above the knee, after exsection of this joint in which osteo- myelitis occurred in the femur, I car- ried out this practice successfully. Irrigation through the tube should be practiced about the seventh day and every three or four days after this, and the tube gradually shortened. Thigh.—The method to be selected in amputations through the lower two thirds of the thigh will depend upon the size of the member at the point of election. In limbs of ordinary size, and particularly in emaciated persons, the operation advised in the arm should be followed here. First Method.—Make a circular incision through the skin and fascia, joined by a perpendicular cut on the lower external aspect of the limb. Dissect up the flap from the muscles, and divide all the remaining soft tissues squarely at the point of section of the bone. Suture the flap, and drain from the outer upper (and, if necessary, lower) angle. Second Method.—Below the line of section through the femur, at a distance sufficient to furnish an ample flap, by a circular incision divide the integument down to the muscles, allow the skin to retract, and at the line of retraction divide the remaining soft tissues down to the bone. either of the foregoing operations. Carden recommended section through the condyles. Gritti introduced an osteoplastic modification by making a long rectangular skin-flap from the front of the knee and leg, which is dissected up deeply, lifting the patella in the flap. Behind, a short flap is made similar to that in Garden's method. Section is made through the bone about an inch above the tip of the internal condyle, and the articular surface of the patella is then sawn off. This procedure may be best accomplished by grasping the flap with the left hand and stretching it over the knuckles, so that the articular surface of the patella looks directly upward, where it is fixed quite immovably. As the flaps are adjusted, the sawn surface of this bone is brought into contact with that of the femur. Some operators secure it here by transfixing with an ivory pin. The whole procedure is not only difficult and tedious, but wholly unnecessary. 218 A TEXT-BOOK OX SUKOERY. On the anterior and external aspect of the thigh, by a perpendicular incision extending as high as the point of section of the bone, divide everything to the bone, and from the periosteum, with a dry dissector, lift the solid flap. Apply the cloth retractor and saw through the bone. As the stump is placed in an elevated position, with the thigh also Fig. 276.—Section through the right femur at the condyles and at the middle of the patella. Looking at the central surface as exposed after amputation at this point. 1, Popliteal artery, vein, and internal popliteal nerve. 2, External popliteal or peroneal nerve. The capsule and the synovial cavities are admirably shown, as well as the bursa mucosa patella. abducted and rotated outward, the drainage is naturally at the upper angle of the perpendicular incision. At the Hip Joint*—Disarticulation at the hip joint is by far the most formidable in the list of amputations. In 1881 Prof. John Ash- * At Bardstown, Ky., in August, 1806, Dr. Walter Brashear amputated at the hip in a negro lad, seventeen years of age, on account of a severe fracture of the femur and laceration of the soft parts. A circular incision was made, the muscles divided well below the hip joint, and the vessels secured as the operation progressed. Then a longitudinal incision along the outer side of the limb exposed the remainder of the bone, which, being freed from its muscular attachments, was disarticulated at the socket (Prof. D. W. Yandell, " American Practitioner and News," 1890). Dieffenbach's name has been prominently associated with this operation among surgeons, but AMPUTATIONS. 219 hurst, Jr., wrote: "The removal of the lower limb at the coxo-femoral articulation may be properly regarded as the gravest operation that the surgeon is ever called upon to perform, and it is only within a compara- tively recent period that it has been accepted as a justifiable procedure. The most pressing risk is that of ha3inorrhage." In 1890 I applied for the first time, and with success, in an amputation at the hip joint, the method which I had used more than a year previous in amputation at the shoulder joint. Since that date I have performed the operation seven times, and it has been done in a number of instances by other operators. The method is as follows : The patient should be placed with the sacrum resting upon the corner of the operating table, the sound limb and arms being wrapped with cotton batting and thoroughly protected from unnecessary loss of heat. Fig. 277.—Hip-joint amputation. Pins and rubber-tube tourniquet in position. The Esmarch bandage has been removed. The limb to be amputated should be emptied of blood by elevation of the foot and by the application of the Esmarch bandage, commencing at the toes. Under certain circumstances, the bandage can only be par- tially applied. When a tumor exists, or when septic infiltration is present, pressure should be exercised only to within five inches of the diseased portion for fear of driving the septic material into the vessels. After injuries with great destruction—crushing or pulpefaction—one must generally trust to elevation, as the Esmarch bandage can not always be applied. While the member is elevated, and before the Es- march is removed, the rubber-tubing constrictor is applied. The object of this constriction is the absolute occlusion of every vessel above the Dieffenbach did not take his degree in medicine until 1822, sixteen years after the pioneer Ken- tuckian had performed his operation, which was the first hip-joint amputation in the United States. 220 A TEXT-BOOK OX SURGERY. level of the hip joint, permitting the disarticulation to be completed and the vessels secured without haemorrhage and before the tourniquet is removed. To prevent any possibility of the tourniquet slipping, I em- Fig. 278.—The same, showing the soft parts dissected from the bone and the capsule exposed. ploy two large steel needles or skewers, three sixteenths of an inch in diameter and ten inches long, one of which is introduced one fourth of an inch below the anterior superior spine of the ilium and slightly to the Fio». 279.—The same, with the disarticulation complete. Constrictor still in position. AMPUTATIONS. 221 inner side of this prominence, and is made to traverse superficially for about three inches the muscles and fascia on the outer side of the hip, emerging on a level with the point of entrance (Fig. 277). The point of the second needle is thrust through the skin and tendon of origin of the adductor longus muscle half an inch below the crotch, the point emerging an inch below the tuber ischii. The points should be shielded at once with a cork to prevent injury to the hands of the operator. IXo vessels are endangered by these skewers. A mat or compress of sterile gauze, about two inches thick and four inches square, is laid over the femoral artery and vein as they cross the brim of the pelvis ; over this a piece of strong white-rubber tubing, half an inch in diameter when un- stretched and long enough when in position to go five or six times around the thigh, is now wound very tightly around and above the fixation Fig. 280.—The operation completed needles and tied. If the Esmarch bandage has been employed, it is now removed. Excepting the small quantity of blood between the limit of the Esmarch bandage and the constricting tube, the extremity is blood- less and,will remain so. In the formation of the flaps, the surgeon must be guided by the con- dition of the parts within the field of operation. When permissible, the following method seems ideal: About six inches below the tourniquet a circular incision is made down to the muscles, and this is joined by a longitudinal incision com- mencing at the tourniquet and passing over the trochanter major. A cuff that includes everything down to the muscles is dissected off to near the level of the trochanter minor. At about this level, the remaining soft parts, together with the vessels, are divided squarely down to the bone by a circular cut (Fig. 278). At this stage of the operation the cen- A TEXT-BOOK ON SURGERY. tral ends of the divided superficial and deep femoral veins as well as arteries are in plain view and should now be tied with good-sized catgut. This done, the disarticulation is rapidly completed by lifting the mus- cular insertions from the trochanters and digital fossa, keeping very close b'iG. 281.—Section through right thigh at Hunter's canal. Looking at the surface attached to the body. 1, F oral vessels and long Mtphenous nerve. 2, Great sciatic nerve and arUria comes. 3, Long sapheDa ver to the bone with knife or scissors and holding the soft parts away with retractors. The capsular ligament is now exposed and divided, and, by forcible elevation, adduction, and rotation of the femur, it is widely opened, the ligamentum teres ruptured, and the caput femoris dislocated (Fig. 278). If properly conducted up to this point, not a drop of blood AMPUTATIONS. 223 has escaped except that which was in the limb below the constrictor when this was applied. The remaining vessels which require the liga- ture should now be sought for and secured. They are, first, the saphena vein, which, on account of its proximity to the main trunk, should be tied; the sciatic artery, which will be found near the stump of the sciatic nerve ; the obturator, which is situated between the stump of the Fig. 282.—Section through left thigh at its middle. Looking at the surface attached to the body. 1, Superficial femoral artery, vein, and sapheuous nerve. 2, Great sciatic nerve, and the arteria comes nervi ischiadici. 3, Terminal branch of profunda femoris. 4, Descending branch of external circumflex. 5, Long saphenous vein. adductor brevis and magnus, usually about halfway from the center of the shaft of the femur to the inner side of the thigh, the vessel being on a level with the anterior surface of the femur ; the descending branches of the external circumflex, two or three in number, usually found about an inch and a half outward and downward from the main femoral vessels beneath the rectus and in the substance of the crurseus and vastus exter- nus. The descending branches of the internal circumflex are insignifi- 221: A TEXT-BOOK OX SURGERY. cant and are usually found on the level of the femoral vessels in the sub- stance of the adductor longus and between it and the adductor brevis and pectineus (see Fig. 284). In tying the larger femoral vessels, I make it a rule to dissect both the superficial and deep femoral stumps back from a half to three fourths of an inch so that I can apply the ligature behind any of their branches which may have been divided close to their points of origin, and I do not hesitate to include the large veins in the same ligature in Fig. 283.—Section through left thigh in the upper third. 1, Superficial femoral artery, vein, and saphena nerve. 2, Deep femoral vessels; near by the obturator nerve and vessels. 3, Sciatic nerve and vessels. order to save time. With the vessels I have mentioned quickly secured, there is really no necessity for even temporarily loosening the tourniquet. If the operator is not sure that he has found and securely placed the ligatures upon these larger vessels, it is a simple matter to loosen slowly the grasp of the tourniquet until the pulsation of the larger trunks is perceptible. No attention should be paid to the general oozing from the large muscular surfaces which have been divided. If every oozing point were ligatured, from half an hour to an hour would be consumed in securing a dry wound in the majority of instances. In order to hasten AMPUTATIONS. 225 the operation and stop the oozing, I introduce a snug packing of sterile iodoform gauze ribbon into the cavity of the acetabulum and the space between the muscles from which the bone has been removed, leaving one end of the ribbon to pass out between the flaps for the purpose of its re- moval. With a long, half-curved Hagedorn needle, armed with good- sized catgut, deep sutures are passed through the stumps of the divided muscles in such a way that large masses of muscle are brought tightly together when these sutures are tied, taking two or three inches into the Fig. 284.—Transverse section of left thigh through lesser trochanter. Looking from below upward. 1, Saphenous vein. 2, Superficial femoral vein and artery. 3, Profunda femoral vein and artery, anterior crural nerve between the two arteries. 4, Obturator nerve and artery. 5, Sciatic nerve and artery- grasp of each suture. The needle is not passed in the proximity of the large vessels or the sciatic nerve. This effectively and rapidly controls all oozing. Nothing remains but to close the flap with silkworm-gut sutures, dry and cleanse it off thoroughly, seal it with collodion in its entire ex- tent to prevent any infection from the genital or anal region, apply a large, loose dressing of iodoform and then sterile gauze, and a tight band- age over the first light dressing. The pins are then removed and the remainder of the dressing completed. Preliminary pressure of the light dressing prevents oozing and the wound remains dry. 226 A TEXT-BOOK OX SURGERY. When, from destruction of the parts, by accident or disease, or by the proximity of a neoplasm, this ideal method is not practicable, any modification may be employed, preference being given to the incision which keeps farthest from the tumor and gives the healthiest flaps. When there is not sufficient material to cover the stump, it is even safer to err on the side of an unclosed wound and trust to granulation or grafting for ultimate closure. In the first two operations I did, I divided the femur on a line with the incision through the muscles, tying the vessels, removing the tourni- quet, and then dissecting out the upper fragment of the femur. I found it exceedingly difficult to disarticulate the head of the bone, and, at the suggestion of the late Dr. J. B. Murdock, of Pittsburgh, Pa., who wit- nessed the operation, I have since left the femur intact in order to facili- tate Ijie disarticulation. Fig. 285.—Section through the left hip. Looking from below upward. Eeduced from life size. 1, Fem- oral vein, artery, and crural nerve in order from within outward. 2, Great sciatic nerve, artery, and vein. 3, Epigastric vein. 4, Vessels to acetabulum. In regard to the steel pins, Prof. Deaver, of Philadelphia, Pa., has held the rubber tourniquet in place without the pins, substituting a tight strip of roller bandage underneath the tube in front and behind, an assistant making strong traction upward. Prof. Emory Lanphear, of St. Louis, Mo., succeeded in doing the operation with only one, the outer pin, in position. AMPUTATIONS. 227 The fixation pins are not expensive, can easily be obtained in any part of the country, and they obviate every risk of haemorrhage. I see no reason for failing to employ them as directed. I have the histories of sixty-nine cases of amputation at the hip joint in which this method of controlling haemorrhage was employed. There were fifty-six males and thirteen females, of which eleven died, a death rate of 15*9 per cent. Dr. John F. Erdmann, in the "Annals of Surgery," September, 1895, says that from January, 1884, to January, 1895, there were eighteen hip- joint amputations done in Bellevue, Roosevelt, St. Luke's, Mount Sinai, Chambers Street, German, and Presbyterian Hospitals, with eight deaths, a mortality of 44'4 per cent. If from this list are eliminated seven cases done by my method—all of which recovered—it leaves the mortality ratio by other methods in the hospitals of New York 72*7 per cent. I would not imply that such a death rate as this would follow any other method of operation, for I know that in the hands of careful and thorough operators much better results would follow. I need cite no more than the brilliant results of Estes, of Bethlehem, Pa., in his series of successful cases, chiefly after accident and done by tying all bleeding points as the dissection was carried on, of McBurney, with abdominal section and direct digital compression of the aorta, and Tilden Brown, with his ingenious clamp, etc. But I insist that this method of haemo- stasis is so simple, so safe, so universally applicable, that it removes from the operation every possible element of danger as far as haemor- rhage is concerned. Operator. Date. Age. Sex. Diagnosis. Osteosarcoma. Result. Remarks. 1 John A. Wyeth, Feb., 39 Male. Recov- At first operation femur was New York. 1890 ered. divided at level of lesser tro-chanter ; sixteen days later head of the bone was enu-cleated. 2 John A. Wyeth, Feb., 34 Male. Neurosarcoma of Recov- The tumor of the nerve was ex- New York. 1890 internal popli-teal nerve. ered. tirpated in February, 18S8; recurred, and limb was am-putated at lower third of thigh in October, 1888: re-curred again, and amputation at hip joint was performed. 3 John A. Wyeth, 1892 17 Fe- Osteosarcoma of Recov- Amputation through lower New York. male. lower end of femur; ampu-tation and re-currence in stump. Chronic hip- ered. third of femur was per-formed by Dr. Allen, of Cleveland, in February, 1892. 4 John A. Wyeth, Nov., 28 Male. Recov- The femur was so firmly an- New York. 1893 joint disease. ered. chylosed to the ilium that force could not break them apart, requiring a chisel and hammer to effect separation. 5 John A. Wyeth, Aug., 19 Male. Sarcomaof lower Died. Rallied well from operation, but New York. 1894 third of fe-mur. twenty-six hours after, his pulse became rapid and weak, suggesting shock. The sur-geon in whose charge I had left the case injected two pints of hot saline solution, but the patient died forty hours after operation. 228 A TEXT-BOOK ON SURGERY. Operator. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 John A. Wyeth, New York. John A. Wyeth, New York. Operation by J. A. Bodine. Sam. H. Pinker- ton. Sam. H. Pinker- ton, Salt Lake City. Sam. H. Pinker- ton, Salt Lake City. Sam. H. Pinker- ton, Salt Lake City. Sam. H. Pinker- ton. Sam. H. Pinker- ton. A. M. Phelps, New York city. A. M. Phelps. A. M. Phelps. A. M. Phelps. A. M. Phelps. Emory Lanphear. Emory Lanphear Emory Lanphear, Emory Lanphear. H. 0. Walker. H. 0. Walker. H. 0. Walker. C. B. Nancrede. C. B. Nancrede. John B. Deaver. John B. Deaver J. Ewing Mears. A. E. Mallock. Date. Oct., 1895 July, 1895 1892 1892 1892 1892 1892 1892 Dec, 1891 1892 1891 1895 1890 1892 1893 1892 1892 1893 1893 Nov., 1892 1893 1890 1893 1892 1892 Age. 20 18 17 10 42 43 17 6 16 11 9 15 28 14 Sex. Mule. Male. Male. Male. Diagnosis. Osteosarcoma of femur. Osteosarcoma of femur. Tuberculous os- titis of femur. Tuberculous os- titis of femur. Male. Extensive necro- Recov- sis of femur. ered. Male. Male. Male. Male, Male, Result. Remarks. Nfc haemorrhage. Discharged cured. Recov- ered. Recov- No luemorrhage. Nothing of ered. special interest. Recov- ered. Recov- ered. 21 young 32 31 20 20 10 30 Male. Male. Male. Male. Male. Male. Fe- male. Male. Extensive necro- sis of femur Ostitis of femur. Compound com minuted gun shot fracture of femur. Long - standing destructive os teoarthritis. Osteomyelitis of entire femur. Male. man. Male. Male. Fe- male, Male. Male. Male. Osteosarcoma. Osteosarcoma of knee. Osteomyelitis. Osteomyelitis of femur. Osteomyelitis of femur. Osteomyelitis of femur. Osteoma of fe mur penetrat ing sciatic nerve. Osteosarcoma. Chronic hip- joint disease. Chronic hip- joint disease. Osteosarcoma. Osteomyelitis of femur. Chronic osteoar- thritis. Osteomyelitis of femur. Chronic osteoar- thritis of hip. Chronic osteoar- thritis of hip. Died. Recov- ered. Died. Recov- ered. Died. Recov ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Died. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Death twelve hours after oper- tion from shock ; no haemor- rhage. Two hours after operation, death from shock. Death from exhaustion twelve hours after operation; con- dition of patient so bad that operation contra-advised, but performed at urgent request of parents. • Wyeth's bloodless method, by which failure to control haemorrhage seems to me to be impossible." 1 We have in this a safe and re- liable method for controlling haemorrhage which, in my judgment, is superior to any vet offered." Death from exhaustion in four hours; no haemorrhage. Operation lasted thirty-five minutes. AMPUTATIONS. 229 32 33 34 35 Operator. R. L. Swan. G. A. Baxter. W. B. Johnston, J. D. Thomas. 36 I Wm. F..Fluhrer 37 j Charles McBur- ney. 44 Frank Hartley. Merrill Ricketts. C. A. White. W. W. Keen. M. J. Ahem. J. B. Murdoch. J. McFadden Gaston. A. J. McCosh. F. W. Parham. Date. 1892 1891 1892 1891 May, 1890 Mav, 1890 Mar., 1892 Feb., 1893 Mav, 1891 Jan., 1892 1892 Feb., 1892 Nov., 1890 1892 Oct., 1893 Age. Sex. Diagnosis. Result, 19 Fe- Chronic osteoar- Recov- male. thritis of hip. ered. 17 Male. Railroad pulpe-faction of right foot, leg, and left lowei extremity as high as middle of thigh. Died. 39 Male. Railroad pulpe-faction of low-er extremity as high as middle of thigh. Died. 18 Male. Femoral vessels divided in Scarpa's trian-gle by red-hot bar of iron; im- Died. pending gan- • grene. 18 Fe- Osteosarcoma of Recov- male. femur. ered. 34 Male. Osteosarcoma. Recov-ered. 26 Fe- Osteosarcoma. Recov- male. ered. 23 Fe- Osteosarcoma. Recov- male. ered. 23 Male. Osteosarcoma. Recov-ered. 30 Fe- Osteosarcoma. Recov- male. ered. 22 Male. Osteosarcoma. Recov-ered. 17 Male. Osteosarcoma. Died. Male. Osteosarcoma. Died. 27 Male. Osteosarcoma. Recov-ered. 3 Male. Osteosarcoma. Recov-ered. Remarks. Patient rallied well; four hours later raised himself in bed to reach a glass of water, and instantly expired. No bleed- ing after operation. Death ninety hours after oper- ation from shock and exhaus- tion. " There was not one drop of arterial blood, and only a slight venous oozing from the muscular tissue." Great haemorrhage from the accident. On seventh day after injury, amputation; death thirty-six hours later. No bleeding after operation. ' As little blood was lost as in an ordinary amputation at the middle of the thigh." ' No other appliance that had been suggested for the pur- pose could in any way com- pare in utility with that of Dr. Wyeth's." " The operation was entirely bloodless." Patient was up and about after operation, but on the twenty- seventh day was seized with pneumonia, and died five days later. Patient five months pregnant at time of operation. " It was reserved for an American surgeon to devise what is un- doubtedly the best method, and in fact which I think we can now call the only method, of haemostasis in amputation at the hip joint." Death from shock twenty-two hours after operation. " I believe this method to be the best, and the one destined to supersede all other methods for the temporary arrest of haemorrhage." Death on twenty-sixth day from septicaemia. " There was absolutely no trouble from haemorrhage, and I feel satisfied that with this pro- cess all bleeding may be pre- vented in amputation at the hip joint." 230 A TENT-BOOK ON SURGERY. 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 Operator. J. M. Holloway. R. T. Morris, Texas. Date. I Age. H. H. Vinke. J. S. Horsley. George W. Miel. F. Tilden Brown. S. B. Fowler. Robert Weir. F. W. Murray. C. K. Briddon. W. T. Bull. Thomas R. Wright. Thomas R. Wright. A. Schachner. H. H. Grant. Daniel Strock. W. R. Stewart. Nov., 1892 April, 1894 Aug., 1894 Oct., 1894 Nov., 1894 Dec, 1894 1890 Jan., 1895 June, 1894 June, 1894 May, 1895 1895 July, 1896 1895 1895 1894 1895 27 19 16 36 41 22 54 18 23 5 50 55 33 35 35 Sex. Male Male. Fe- male. Male, ne- gro. Male. Male. Male. Male. Male. Male. Fe- male. Male. Male, ne- gro. Male. Fe- male. Male. Male. Sarcoma thigh. Osteosarcoma. Tumor thigh. of of Recurring sar- coma of fe Osteosarcoma of thigh. Osteosarcoma of triceps fem- oris. Traumatic oste- itis of femur; bedridden for fifteen years. Sarcoma of fe- mur. Sarcoma of fe- mur. Sarcoma mur. of fe- Osteosarcoma of femur. Sarcoma of knee Sarcoma of knee Fracture of fe mur; gan- grene. Chondroma with sarcomatous degeneration. Limb pulpefied. Sarcoma. Result. Recov- ered. Died. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Recov- ered. Died. Recov- ered. Remarks. Patient was discharged from hospital on tenth day and went to his home, a distance of seventy miles, on the twelfth day. Died eleven days after opera- tion from tubercular perito- nitis ; cause of death proved by autopsy. " While making the skin incisions it was no- ticed that the limb was not completely exsanguinated, and the tourniquet was re- tightened, after which no bleeding resulted." Used crutches in seven weeks. " Absolutely no loss of blood. There is probably no method which commends itself for simplicity and effectiveness so much as Wyeth's." ;i No more blood was lost than in an amputation through the thigh. It remained for Dr. Wyeth to so perfect these methods as to make this am- putation practically a blood- less operation." " A very satisfactory means of controlling haemorrhage." Haemostatic effect all that could be desired." Recovery without suppuration; no haemorrhage. Patient now living (1896). No recurrence up to February, 1896. Pins were by mistake too small; they bent and caused slight haemorrhage. So little blood was lost that the patient suffered scarcely at all from shock." / Primary union; time of opera- tion, forty minutes. Lost comparatively no blood. Temperature 103° F. and pulse 120 before operation. First dressing six days after operation. Enormous chondroma with sarcomatous degeneration; tumor weighed sixty-five pounds when removed. Oper- ation lasted thirty-five min- utes ; bloodless except for some oozing. " Method leaves nothing to be desired." Railway crush; limb pulpefied, including upper third of thigh; haemorrhage entirely controlled ; patient died of shock; patient bled profusely before admission to hospital. Was well November 19, 1896. AMPUTATIONS. 231 Operator. Date. Age. Sex. Diagnosis. Result. Remarks. 64 Eugene Boise. 1895 21 Fe-male. Sarcoma. Recov-ered. No loss of blood; vessels nearly all tied before tubing was re-moved. " Method of ampu-tation is all that could be desired." 65 D. C. Hawley. 1896 21 Male. Sarcoma left fe-mur, extend-ing to within four inches of trochanter. Recov-ered. No blood was lost. Patient in bad condition at time of operation ; fracture at femur had occurred before amputa-tion. " Control of haemor-rhage perfect." Operation done in thirty min- 66 L. L. Shropshire. 1895 20 Male. Sarcoma lower Recov- ne- middle third ered. utes ; not over one ounce of gro. of left thigh. blood was lost. Patient left hospital in two weeks. Liv-ing and well October, 1896. 67 Howard Lilien- 1896 16 Male. Chondro - sarco- Recov- " Your method was employed thal. ma from tro-chanter down. ered. to my great satisfaction." 68 W. W. Van Arsdale. 1896 13 Male. Osteomyelitis. Recov-ered. Destruction of soft parts of thigh, with suppurative in-fection ; patient was ex-tremely septic. 69 T. D. Rushmore. 1896 14 Fe-male. Sarcoma of fe-mur. Recov-ered. 1 An analysis of these sixty-nine cases as to the efficiency of this method of controlling haemor- rhage shows that it was perfectly satisfactory in every instance but two: In Dr. Morris's case the first incision in the skin demonstrated that the constriction was not tight enough. This was corrected and the operation completed without bleeding. In Dr. Murray's case the pins were not of sufficient strength and yielded to the pressure, causing slight haemorrhage. Of the eleven fatal cases, five had suffered extensive injury with haemorrhage, and were pro- foundly in shock owing to pulpefaction of the limb and loss of blood. In Dr. Baxter's case there was pulpefaction of the right foot and leg and of the entire left lower extremity as high as the middle of the thigh. In Dr. Johnston's case the lower extremity was pulpefied as high as the middle of the thigh. In Dr. Thomas's case the femoral artery had been divided in Scarpa's space and the haemor- rhage had been very profuse and prostrating. In Dr. Strock's case the limb was pulpefied in a railway crush as high as the upper third of the thigh. Dr. Pinkerton's case was one of compound comminuted gunshot fracture, the patient dying of shock. The factor in these fatal cases was haemorrhage before operation, but none occurred during or after the procedure. In none was employed the precautionary injection into the veins of normal salt solution at 110° F., which should be done prior to operation in every case in which shock has been wholly or in good part caused by haemorrhage. Of the other fatal cases, Dr. Murdock's died from shock twenty-two hours after the operation, as there was no other possible cause of death. Dr. Pinkerton's case of necrosis of the femur died in shock twelve hours after the operation. There was no haemorrhage. Dr. Gaston's case died on the twenty-sixth day after the operation from septicemia. Dr. Phelps's case of osteomyelitis was very much exhausted from prolonged sepsis, and died twelve hours after the operation. Dr. Walker's case was a similar one of chronic hip disease, and the patient died four hours after the operation. Dr. Morris's case died eleven days after the operation from tubercular peritonitis, as demonstrated at the autopsy. My own fatal case died partly from shock, yet after the operation he was in better condition than any of my other patients. Twenty-six hours later, while I was absent from the city, my assistant, for what he took to be symptoms of shock coming on, injected two pints of hot saline solution. This patient has lost no blood. The quantity of blood forced out of the limb into the trunk in a patient otherwise plethoric threw more work upon the heart than it could accomplish. In the forty cases of sarcoma for which amputation was done there were four deaths—10 per ■cent; in the twenty-two cases of inflammatory bone disease, three deaths—13-6 per cent. 232 A TENT-BOOK ON SURGERY. The method of amputation at the hip joint just given has been tried for a sufficient number of times and by operators of varying experi- ence to determine the success of the method. If for any reason it can not be applied, I would recommend the method of Estes, of gradual dissection, tying the vessels as the operation proceeds, making digital compression over the pubic rim when the femoral vessels are divided until they are secured. The method of opening the abdominal cavity to permit the introduction of two or more fingers to make digital com- pression of the aorta is not, under ordinary conditions, a justifiable operation. As an indication of the low mortality rate after amputations done by an experienced operator by modern surgical methods, the statistics of Dr. Estes are of great value : Of 307 single major amputations, 27 died, or 8 79 per cent, and these include 13 fatal cases which were in exceed- ingly grave condition at the time of operation. In the last period of six years, in which precautionary measures were carried out to prevent haemorrhage and the operation deferred until the condition of acute anaemia was somewhat relieved, there were 180 single major amputations and only five deaths, or 2*77 per cent mortality, including six hip-joint amputations. Dr. John F. Erdmann, of New York, in the "Annals of Surgery," September, 1895, gives 703 amputations done in Bellevue, New York, Roosevelt, St. Luke's, Mount Sinai, Chambers Street, German, and Pres- byterian Hospitals between 1884 and 1894, with 109 deaths—15 -5 per cent—including among these 18 hip-joint amputations with 8 deaths— 44'4 per cent; shoulder amputations, 24 cases with 6 deaths—25 per cent. Wrist Forearm . Elbow Arm..... Shoulder. Foot..... Leg...... Knee Thigh.... Hip...... Total Per cent. i 4 18 0 25 0 7 8 12 0 13 0 21 0 44 4 15 5 Freshly traumatic cases. 1884 to 1889......................... 47 1889 to 1894................ ;........ 20 Average age. 34 Deaths. 12 4 Average age at death. 43 58 Per cent. 25-5 20-0 Cases. Deaths. Per cent. 1884 to 1889.................................. 114 (51 19 9 16 1889 to 1894............................. 14 AMPUTATIONS. 233 The following tables, from Ashhurst's Surgery, are given to show the diminished ratio of mortality between the method of to-day and that of thirty years ago: I. Summary of Seventy-one Cases of Hip-joint Amputation for Injury in Civil Practice by Old Methods. Nature of Operation. Primary.................... Intermediate................ Secondary.................. Reamputation of thigh stump Not stated.................. Total number of cases ... II. Summary of Two Hundred and Seventy-six Cases of Hip-joint Amputation for Disease by Old Methods. Nature op Operation. Amputation of entire limb.... Reamputation of thigh stump. Total number of cases.... Died. Total. 25 31 7 12 6 11 1 5 8 12 47 71 Mortality per cent. 80-6 58-3 54o 20-0 G6-6 06-1 Recov-ered. Died. Undeter-niined. Total. 136 20 95 10 14 1 245 31 156 105 15 276 Mortality per cent. 41-1 33-3 40-2 17 CHAPTER XIII. SURGERY OF THE LYMPHATIC VESSELS AND GLANDS, VEINS AND ARTERIES. The pathology of the lymphatic vessels closely resembles that of the veins, with which they are intimately associated. The history of the two systems is practically identical. One essential point of difference having a pathological significance is that the lymphatic vessels are closed tubes, since at varying intervals in their route to the center each trunk breaks up into smaller branches until they end in capillaries in the substance of a lymphatic gland. It is believed that there is no direct communication between the afferent and efferent vessels in these glands. It follows that infectious material passing into these vessels can not rapidly enter the systemic circulation. Each gland is a sieve which retards and often arrests its progress and modifies its effect. With the veins, however, there is no resistance to rapid, direct systemic infection, often with wide- spread metastases. Lymphangitis means an infection of all the structures which make up the wall of a lymph-carrying vessel. The endothelial lining, the muscular and connective tissues are alike involved. Hyperaemia and cell proliferation occur, and there may be coagulation of the lymph and occlusion of the ducts. Should the organism be pyogenic in character, suppuration is present. Phlegmon of the fingers resulting from pyogenic infection, so frequently met with (especially in careless surgery), is a type of suppurative lymphangitis, while that variety which results from infection with the Streptococcus erysipelatis is a typical non-suppu- rative lymphangitis. Inflammation of the lymph ducts is rarely of trau- matic origin, and while inflammatory changes evidently result from an injury, as a blow upon the skin which bruises the part, yet this form of non-infective inflammation rarely comes to the notice or care of the sur- geon. It is the infective lymphangitis which is of great surgical impor. tance. The symptoms of acute infective lymphangitis, while varying in intensity proportionate to the virulence of the infection and the con- dition of the tissues infected (normal or diminished resistance), are the same in essential features in every case. Following an inoculation with any septic matter, within a few hours there is a sense of uneasi- ness and burning in the immediate vicinity of the wound. Pain is not usually severe until the swelling is well marked. At the end of from twenty-four to thirty-six hours the injection of the superficial vessels 234 THE LYMPHATIC VESSELS AND GLANDS. 235 which lead from the local inflammation toward the center may be recog- nized. These red lines give a peculiar sensation to the touch. While the outline of the vessel can rarely be made out by palpation, there is often an appreciable thickening and tension in the tissues immedi- ately over and around it. Pain is present in some instances, while in others even direct and strong pressure causes little or no disturbance. When the nearest gland or plexus is reached by the inflammatory pro- cess, by pressure upon these a sharp sense of pain is experienced. The febrile movement, which may ensue within twenty-four hours, though usually not well marked at this early period, is generally introduced by a chill or a series of chilly sensations, characterized by pallor and the "picked-goose" roughness of the skin. The temperature rises rapidly above the normal, and may reach a high degree. Nausea, vomiting, delirium, and the train of symptoms which accompany septicemia may follow; but this is, fortunately, the exception. If the conditions are unfavorable to the progress of the disease, the temperature declines gradually, resolution occurs, and the symptoms of inflammation dis- appear in from one to two weeks. In the diagnosis of lymphangitis it is well to bear in mind that in phlebitis the lines of red discoloration are wider than in the disease under consideration, that there is a more general condition of oedema, that the lines of inflammation follow well-known and appreciable veins, that these veins are very painful to pressure, and that they are easily recognized as hard, semi-elastic, knotty cords. The treatment of acute infective lymphangitis is local and general. Cold applications in the early stages are preferable, and, in general, more agreeable to the patient. An ice bag, cold rubber coil, or cold cloths will suffice. The part affected should be kept in perfect repose. The point of infection should be freely incised, and hot aseptic poultices applied, in order to induce suppuration and to favor the discharge of pus. If the infection is evidently traveling along the lymphatics, any points of induration should be incised or punctured, in order to give vent to septic matter. If complicated with general cellulitis and great ten- sion, parallel incisions should be made to prevent gangrene. It is important to regulate the alimentary apparatus and to support the patient's tissues with the best nourishment, pure air, and cheerful sur- roundings. Subacute or chronic infective lymphangitis is associated with general systemic infection, as in syphilis and tuberculosis. Adenitis (inflammation of the lymphatic glands) always exists with infective lymphangitis. In acute infective adenitis the inflammatory changes go on with extreme rapidity. The cells of the reticulum and endothelia proliferate rapidly, and the presence of pyogenic organisms, with their well-known property of liquefying the tissues, produces sup- puration. The necrosis of tissue is facilitated by the great pressure which rapid cell proliferation causes within the non-elastic, resisting cap- sule of the gland. The symptoms are a sense of soreness and tension, sharp throbbing 236 A TEXT-BOOK ON SUKGERY. pain, increased on slight pressure, swelling, and redness of the super- jacent skin. The suppuration commences in the center of the gland, and gradually extends until the tissues around are involved. ^ The constitu- tional symptoms are similar to those given in lymphangitis. If the in- flammatory process be of the subacute form, the enlargement is more gradual, and pain and the other symptoms of acute adenitis are absent. Later in the history of this process fatty and caseous degenerations may occur, ending in resolution. In chronic adenitis the tumors are more solid and firmer to the touch, since the enlargement is due in greater part to the proliferation and hyperplasia of the connective-tissue stroma. In the treatment of acute adenitis perfect quiet must be enforced. Local applications are indicated as in lymphangitis. If suppuration is evident, early incision is indicated. Frequently one after another of the glands in a group breaks down in the process of suppuration, forming sinuses which undermine the neighboring tissues, when it is necessary to lay each abscess open freely and scrape out every particle of diseased tissue with a Volkmann's spoon. Thus treated, the wound should be packed with sterile gauze, and treated as an open wound throughout. If recovery does not follow, a thorough dissection should remove the diseased glands. Tuberculous adenitis is not only one of the most important forms of lymphangitis, but a lesion scarcely second to any in the domain of sur- gery, since it is an exceedingly frequent form of tuberculosis, ultimately ending fatally in all cases, and requiring for its relief a timely and thor- ough surgical extirpation. While it may be met with in any part of the body, it is vastly more frequent in the glands of the neck beneath the jaw and in the chain of lymphatics following the deep jugular vein. The bacillus tuberculosis, as already given, finds an entrance to the lym- phatic channels through an abrasion of the buccal cavity or face, and trav- els along these channels, producing a mild form of lymphangitis, which rarely attracts the attention of the patient until the germs, reaching the substance of the gland, find their progress arrested and conditions suit- able for development. They immediately precipitate an inflammatory process of mild type, in which all the cells of the gland take part, pro- ducing, as given in the chapter on tuberculosis, "giant cells," epithelioid and the so-called lymphoid cells. In a short while the organisms in the center of the various nodules perish for lack of food, the younger generations growing in the periphery of the inflamed area until the capsule of the gland itself is attacked, leaving in the nodules, which undergo caseous degeneration, the spores of tuberculosis. These may lie dormant for a long period and reproduce the disease when the capsule ruptures and favorable conditions are found for their prolifera- tion. Occasionally the process may arrest itself before the capsule is involved, or until the investing membrane becomes so thickened and indurated that no exit can be found for their further march. At times these undergo calcareous degeneration in the effort to include the infect- ing organisms. When mixed infection occurs, an acute inflammation and suppuration is established with all the symptoms of acute adenitis. THE LYMPHATIC VESSELS AND GLANDS. 237 The symptoms of tubercular adenitis are a gradual and persistent enlarge- ment of the lymphatic glands, directly in line of that part of the body ex- posed to infection, usually, as stated, in the neck. I have met with tubercular infection of the mammary glands through the nipples in which the pectoral lymphatic glands were first involved. They may be slightly tender on pressure ; more frequently do not give pain on touch unless pyogenic infection has occurred, when they are exquisitely sensi- tive. The treatment demands early and thorough extirpation ; and, in the present light of science, the obligation of the surgeon can be conscien- tiously discharged only by advising this. The adenitis of syphilis is due in like manner to a subacute inflamma- tory process in which the so-called lymphoid cells predominate. It does not require surgical interference, but disappears with the proper treatment of the constitutional disease. In addition to the simple enlargement of the lymphatic glands due to pyogenic infection (simple infectious lymphoma), tubercular and syphilitic lymphomata, and lymphosarcoma, there are two interesting and rather obscure varieties which may be classified as leucamic lympho- ma ("Hodgkin's disease ") and malignant lymphoma (Billroth's disease). By some writers these two diseases are considered identical, and it is difficult to differentiate them by a microscopical study of the glands in- volved, but there are certain clinical features which separate them widely enough to justify the classification above given. In Hodgkin's disease, as in Billroth's, young adults from twelve to twenty-five years of age are most frequently affected. The glands in any part of the body may be the seat of lesion in Hodgkin's disease, and from the beginning point of invasion, as a rule, the lymphatic glands of the entire body are progressively involved. The skin becomes pale and waxy, the spleen enlarged, various lymphatic nodules become closely merged together without inflammation, and lymphatic tissue metastases occur in the spleen, lungs, liver, and other organs. The red blood disks are greatly diminished, and there is not only a comparative but an ac- tual increase in the number of leucocytes. There is no pain except that due to pressure. In Billroth's disease the lymphatic glands of the neck are, as a rule, alone involved. Occasionally those of the axilla have been seen to be affected coincident with those of the neck ; but even in these cases the disease is limited to this region and differs from Hodgkin's disease in this clinical feature. The anatomical changes in the glands are seem- ingly identical with those of Hodgkin's disease, but metastases in the va- rious organs have not been observed, and, as will be seen in considering the treatment, the one will yield quite readily to remedies, while the other is hopeless from its incipiency. In the treatment of Hodgkin's disease little can be done by reason of the fact that constitutional treatment is of no avail, and the wide- spread dissemination of the enlarged glands renders local injections im- practicable. The following interesting and typical case was recently treated in my 238 A TEXT-BOOK ON SURGERY. clinic at the New Y'ork Polyclinic Medical School and Hospital by Prof. J. A. Bodine. The patient, a girl, nineteen years of age, had noticed commencing enlargement of the cervical glands. This was at first con- fined to the left side, but gradually invaded the glands of the right side. These were firm, slightly elastic, and movable upon the underlying struc- tures as well as the skin. The submaxillary space on the left side was soon entirely filled with the nodes, and there was great deformity. She had been operated upon in another clinic, under the mistaken diagnosis of tubercular lymphoma, and a number of glands were removed. Ee- currence took place within a few months, and no further operative meas- ures were undertaken. Two years later she came to my clinic on account of the dyspnoea caused by pressure. The case seemed hopeless, but the following treatment was instituted, consisting of injections of a one-per- cent, solution of arseniate of soda (gr. ivss to I j of distilled water). In addition to this she was given every day twenty to thirty drops of Fow- ler's solution by the mouth. Two or three times a week, at stated inter- vals, from three to ten minims of the solution were injected into the sub- stance of the various enlarged glands. She received never more than ten minims of this solution at one sitting, in which not more than three injec- tions were made. The greatest possible care was taken to prevent infec- tion. The syringe used was made perfectly sterile by boiling, as was also the needle, the skin thoroughly prepared, and a fresh solution made of distilled water was employed. The nodes gradually disappeared, and in the course of six months the patient was seemingly cured. Owing to accidental infection, two glands suppurated, and small ab- scesses were opened and the broken-down tissues removed by clean dissection. Filaria (sanguinis hominis).—The presence of this parasite in the lymph channels often leads to obstruction and serious pathological changes in these vessels and the contiguous tissues. From the par- ent nest in the lymph canals the crop of organisms escape into the blood vessels. In the blood they are rarely detected during daylight, but in the night, especially several hours after dark, they leave their hiding places in the deeper viscera and invade the general circulation. The filaria, about -fo of an inch long and constantly in motion, is the embryo of the filaria Bancrofti, which is found only in the lymph chan- nels. The parent female is about three and a half inches long and very slender. The male has not yet been accurately studied. The disease is usually contracted from water, where the ova have been deposited by mosquitoes and other blood-sucking insects. The filariae in the blood do not produce any particular symptoms, but the longer organisms which lodge in the lymph ducts produce obstruction, inflammation, connective- tissue hyperplasia, extravasation of lymph, and general thickening and swelling of the parts, known as elephantiasis. There is no known method of relieving the body of these parasites. It is probable that, as with other parasites of the blood, they may be destroyed by a prolonged high temperature, as in typhoid or remittent fever. Wounds of the lymphatic vessels may occur in common with solu- PHLEBITIS. 239 dons of continuity in other tissues. The escape of lymph, and occlusion of the vessels involved, back to the first collateral branch, is the rule, as with the blood vessels. If the vessel be large, as when the thoracic duct or the deeper channels of the leg are divided, the ligature or compression of the distal end is necessary to prevent a lymph fistula. It has been dem- onstrated that the lymph and chyle can be carried into the circulation by collateral routes, after occlusion even of the thoracic duct. Varicosities occur at times in the lymphatic vessels, as in the veins. The causes and treatment are essentially the same. As a result of ob- struction, in some instances, cystic dilatations occur, which, according to Bellamy, are usually found in the tongue, lips, and about the neck. Hydrornata of the neck are at times congenital. In their structure they are trabeculated, the caverns filled with lynrph. The location is beneath the occiput, and the tumor is symmetrical, the cyst of each side of the median line being lined with lymphatic endothelia. New formations of lymphatic vessels occur occasionally, and blood vessels developing in these give rise to a mixed new growth, known as lympho-angeioma. Phlebitis. Phlebitis means an inflammation of the tissues which form the walls of a vein. Endophlebitis, mesopihlebitis, and periphlebitis are terms used to designate the inflammatory process involving respectively the inner, middle, and outer layers of the vessel wall. This process involves a tubular structure, made up in general of an inner layer of flat, polygo- nal cells (tunica intima), the middle layer (media), composed chiefly of elastic tissue, and the outer layer (externa), containing elastic loops, connective tissue, and unstriped muscle. Blood vessels and nerves traverse the outer and middle tunics, following the connective-tissue bundles. The cells of the lining membrane are smaller than the arterial endo- thelia, and are imbedded in a fibrillated, intercellular substance (Cornil and Ranvier). The elastic and muscular tissues are less developed than in the arteries (Heitzmann). These are so irregularly arranged that any division into middle and external coats is, in great part, artificial and imaginary. Moreover, many of the veins contain no muscular tissue, while their connective tissue varies in quantity in different parts of the body. The sinuses of the dura mater, the veins in bones, and those of the retina have no muscular fibers, while the jugulars, subclavians, and vense cavse have a relatively small quantity, or are entirely devoid of this tissue. Again, the arrangement of the muscular tissue differs in differ- ent veins. The inferior vena cava, the portal and renal veins have an inner, circular, and an external, longitudinal layer, while the femoral and popliteal veins have the longitudinal fibers more internal. This tissue is still more complicated in the saphenous veins, where the internal layers are arranged longitudinally, with a number of alternating, or transverse and longitudinal, layers placed externally to these. The elastic layer begins immediately external to the basement sub- 240 A TEXT-BOOK ON SURGERY. stance which supports the endothelial layer, and is here somewhat iso- lated and well defined ; but from the external surface of this central, elastic lamina springs a network of elastic fibers, through the loops and in the meshes of which are woven the muscular and connective-tissue fibers. The vasa vasorum follow the connective-tissue bundles in their distri- bution to the tissues of the wall down to the elastic layer. Nerves from the sympathetic system have been demonstrated in the larger veins. The valves are delicate reduplications of the internal coat, having a well-defined, elastic reticulum, especially on their distal or convex sur- face (Heitzmann), and muscular fibers at the point of attachment to the venous wall. The vascular area—the outer and middle layers—is first concerned in the inflammatory process. The endothelial tunic, as a result of these structural changes, is subsequently involved. It then appears cloudy, thickened, and rough, and may become separated in shreds (Frey). In the vascular area, during the earlier stages, the capillaries of the vasa vasorum become swollen, the white corpuscles migrate into the extra- vascular spaces, and the normal connective-tissue cells are stimulated into proliferation, resulting in a thickening of the wall, due to. the pres- ence of these embryonic cells and the excessive hyperaemia. As in arteritis, the vitality of the endothelial tunic becomes impaired, and it is more or less projected into the cavity of the vein, the cells of this tunic undergoing proliferation. After a few days granulation buds push out from this embryonic tissue of the endothelia, and new capillaries are developed in the granulation masses, anastomosing and becoming a part of the circulation of the vasa vasorum, as well as leading into the coagu- lum which occupies the caliber of the vein. At the point of contact of the outer surface of the thickened endo- thelial layer with the internal surface of the middle (elastic) layer, large sinuses are developed, which receive the blood from the capillaries of the middle tunic. These sinuses are lined with an endothelial layer, which rests upon the contiguous connective tissue. From these larger vessels fine capillaries are given off, which permeate the thickened internal layer, and some of these also pass into the organizing coagulum. When a thrombus, caused by the sudden coagulation of the blood in a vein, is examined in its recent state, it is found to be composed of suc- cessive lamina? of fibrin and corpuscles, and the more recent of these lamina- are external. When the vein is first occluded by this sudden coagulation of the blood, the pressure from behind is so great that the coagulum is compressed toward its center, while the current, more and more impeded in its progress, flows between the periphery of the clot and the inner surface of the vessel, adding, layer by layer, fresh deposits of coagulation upon the thrombus. A microscopical examination of such thrombi reveals a vast number of white corpuscles in various stages of fatty degeneration, with layers of fibrin intervening. Experiments have shown that not only does the inflammatory process, by reason of its invasion of the intima, produce changes in the blood PHLEBITIS. 241 which lead to stasis, but that there may be also a dangerous endosmosis of septic matter, which is swept along toward the heart and lodged in the capillaries of the various organs (emboli), producing infarctions, abscesses, and, almost invariably, irreparable damage (septicaemia with metesta- sis). The adhesion of the intima, and the formation of a fibrinous clot— which may completely occlude the vessel (occlusion thrombus), or may merely plaster over the endothelial tunic (peripheral thrombus)—&ve efforts toward prevention of this endosmosis. The process of repair in tissues capable of successful resistance, in venous inflammation, is one of organization of the embryonic cells, fibril- lation, and contraction, resulting in partial or complete occlusion. In tissues of low and impaired vitality, infection not infrequently occurs, with pus formation, usually terminating in death. Microscopical sec- tions from such specimens of phlebitis show that the leucocytes and em- bryonic cells have undergone retrogressive changes, and that the tissues are infiltrated with pus corpuscles. Necrotic spots are not infrequent, often opening into the caliber of the vessel. Since phlebitis is a frequent cause of thrombosis, and since venous thrombosis is the most frequent form of intravascular coagulation, a consideration of this process must naturally find a place here. Virchow has endeavored to show that primitive phlebitis is extremely rare, and that, when a clot is produced in a vein which is inflamed, the coagula- tion has more often preceded than followed the inflammation. Cornil and Ranvier do not accept this theory. Fibrin, the immediate factor in coagulation of the blood, does not exist as such in the normal condition of this fluid. Under healthful con- ditions, the blood would circulate always without any deposit of fibrillated fibrin in the economy. So delicate, however, is the sensibility of the blood to mechanical irritation or hindrance in its flow, that the slightest injury or roughen- ing of the endothelial lining membrane may produce a deposit of fibril- lated fibrin. A delicate needle, or wire, or thread, thrust into the lumen of a healthy vessel, precipitates coagulation upon the foreign body. The white corpuscles are found clustered in great numbers on the foreign body, and, when the mass is examined with the microscope, the cor- puscles seem to serve as starting points for the development of fibrin (Reichert). A number of theories have been advanced to account for the coagu- lation of the blood. The views indorsed by Ballance and Edmunds in their classical work on "Ligation in Continuity " (page 145) is that of Hammersten: "that coagulation is due to the action on the fibrinogen of the blood plasma of a ferment derived from the lethal disintegration of blood-platelets, a special variety of white blood-corpuscles of small size." Syphilitic Phlebitis.—-Mr. Hutchinson has called attention to the very few cases of syphilitic phlebitis which have been recorded, and yet he says that most surgeons are familiar with the fact that inflam- mations around varices, and even about otherwise healthy veins, are 242 A TEXT-BOOK ON SURGERY. not infrequent in syphilitic subjects.* Mr. Hutchinson further says: "I think also that I have seen several cases in which the thrombosis and phlebitis were attended by other conditions sufficiently peculiar to justify a belief that they were of specific origin. In some there has been great excesses of inflammation, a large hard mass forming in the cellular tissue, and threatening to slough, much as subcutaneous gum- mata often do. These cases are much benefited by the iodide of po- tassium, so far as prevention of sloughing is concerned, but the throm- botic plugging remains." f Gouty Phlebitis. —Subjects (says Mr. Bryant) who are gouty from hereditary or acquired causes are liable to phlebitis. Paget has described the affection in his "Clinical Lectures," and Mr. Gay has written upon it. In such cases the phlebitis may have no intrinsic characters by which to distinguish it, yet not rarely it has peculiar marks, especially in its symmetry, apparent metastases, and frequent recurrences. Like other forms, it is more common in the lower than in the upper extremities, yet it may be found anywhere. It affects the superficial rather than the deep veins, and often occurs in patches, affecting on one day, for ex- ample, a short piece of the saphenous vein, and the next another por- tion of the same vein, some other distant vein, or a corresponding piece of the opposite vein. The inflamed portions of the vein usually feel hard and are painful to the touch. The soft parts covering the vein become slightly thickened, and often have a dusky, reddish tint. When the deep veins are involved, oedema appears, with the well-recognized results of obstruction : the limb becomes big, clumsy, featureless, heavy, and stiff; its skin is cool, and may be pale, but more often has a slightly livid tint, which may be recog- nized by comparison with the other limb ; and it has mottlings from small cutaneous veins, visibly distended. The limb, thus enlarged, feels oedematous throughout, but firm and tight-skinned, not yielding easily to pressure, and not pitting very deeply. The constitutional symptoms associated with this affection vary from some slight febrile condition to those met with in acute gout, Complete recovery may take place in this as in other forms of phlebitis, the veins becoming pervious in some cases and obstructed in others. The risks of embolism are also the same (Bryant). Causes and Clinical History of Phlebitis.—The classification of phlebitis as traumatic and idiopathic is not strictly scientific. It would be better to consider it as non-infective and infective. A traumatic phlebitis may belong to one or the other variety. As infective phlebitis would be classed all forms which are due to the presence of pathogenic organisms, such as suppurative and tuberculous phlebitis; while that form which occurs, although rarely, in syphilis, known as syphilitic phle- bitis, and the lesion classed by Mr. Thomas Bryant as gouty phlebitis, might, in the present state of our knowledge, be considered as phlebitis due to irritation and disturbed nutrition of the venous walls from the * J. H. C. Simes and J. William White, in Cornil on Syphilis. f Ibid. ARTERITIS. 243 blood charged with toxic (chemical) products. Traumatic phlebitis may be caused by partial or complete solution of continuity of the venous walls from a blow or penetrating wound, or by violent muscular action and pressure, as in lesions of the popliteal vein, from forced flexion of the knee, or varicosities of the lower extremities where great strain or tension is caused by gravitation of blood and the inability of the heart to force it toward the center. The inflammation of the uterine sinuses during and after parturition, which Cornil and Ranvier named "spon- taneous phlebitis," is now known to be a form of infective inflammation of the sinuses due to the entrance of septic organisms. Non-infective phlebitis scarcely demands special consideration, for, unless infection occur, the inflammatory process is so simple that the normal condi- tion is quickly restored without appreciable disturbance. Infective or septic phlebitis is, however, one of the most serious of the surgical diseases. It may involve one or more veins, and the process travels with the vessels in the direction of the heart. The vessels be- come swollen, tense, and resemble the normal veins when the return circulation is arrested, although more cordlike in feel and less elastic. They may be traced by the dull-red color of the skin immediately over the diseased veins. Pain is constant and is rendered intense by pres- sure. The oedema of the parts on the distal side of the lesion is in pro- portion to the obstruction to the return circulation caused by the inflam- matory process, and the infiltration of the perivascular tissues. The febrile movement varies with the violence of the attack, the rapidity of its progress, the intensity of the septic process, and the capacity of the tissues to resist invasion. Treatment—Positive and complete rest is the first great essential. Manipulation or movement is always dangerous, since interference will not only exaggerate the inflammatory process, but may possibly cause the separation of thrombi, which lodge in the lungs, or are dissemi- nated generally through the tissues, producing septicaemia with metasta- ses. If the disease should assume the suppurative form, the inflamma- tion being diffuse and the oedema extensive, free incisions should be made parallel to the veins in order to relieve tension and secure drain- age. To such wounds the balsam-oil mixture of Van Arsdale should be applied, or a moist l-to-5,000 bichloride dressing, with warm irrigations at intervals, until the more urgent symptoms have disappeared. Careful attention to the alimentary canal, good feeding, and a free supply of fresh air will complete the constitutional treatment. When an ex- tremity is involved, it should be slightly elevated to favor the return circulation. Arteritis. Arteritis is a term applied to an inflammatory process which in- volves the entire thickness of the arterial wall. When the inflammatory change is confined to the inner coat, or intima, it is designated as endar- teritis ; when to the outer coat, or adventitia, as periarteritis ; and when to the middle coat, or media, as mesarteritis. 244 A TEXT-BOOK ON SURGERY. Endarteritis, which does not rapidly disappear soon after its incep- tion, is apt to result in lesions of the media and adventitia, and in like manner a lesion of the external tunic will in all probability involve, by the extension of the morbid process, the other coats. There are, however, certain well-defined exceptions. Endarteritis is, as an isolated lesion, capable of demonstration. We shall see that a superficial inflammation of the endothelia, with its resultant fatty de- generation, is not infrequent. And since atheroma and other arterial lesions are due to interference with the blood supply through the vasa vasorum, or to defect in the quality of the blood distributed to the ad- ventitia through which the vessels ramify, we must recognize a periar- teritis as the initial stage of this lesion. Inflammation may be established in any or all parts of the arterial system. One form of arteritis will involve the larger trunks, while an- other will pass these without molestation, and establish itself in the dis- tant arterioles. Simple endarteritis is most apt to occur in the aorta and arteries of the second magnitude, while syphilitic arteritis, the most marked feature of which is an endarteritis, may attack the larger trunks, but chiefly confines itself in its later manifestations to the small and smallest arteries. The internal coat of the larger arteries is composed of two parts: 1. An endothelial lining membrane, consisting of a single layer of flat, po- lygonal, nucleated cells, slightly elongated in the axis of the vessel; in edge view, these cells appear spindle-shaped, on account of the elevation of the nucleus at its center (Heitzmann); 2. A subendothelial layer of flattened, nucleated, anastomosing cells resting in a fibrillated basement substance, the direction of the fibrillse being generally parallel with the long axis of the artery (Cornil and Ranvier). There are no vessels in the middle and internal coats. In the external coat are found arteries, capil- laries, veins, lymphatics, and nerves. Pathogeny of Arteritis.—The causes of arteritis are numerous. A frequent form is that resulting from injury, and known as traumatic arteritis. The pathogeny of non-traumatic (idiopathic) arteritis em- braces every form of dyscrasia. It follows in the train of syphilis, tuberculosis, rheumatism, gout, alcoholism, and nephritis, or any chronic morbid process which poisons the blood or impairs its nutritive qualities. These varieties will be considered under special headings. The sequelae of arteritis, as far as the arteries are concerned, may be fatty infiltration or degeneration, atheroma,, secondary calcification, oc- clusion, dilatation, aneurism, ulceration, and rupture. Remotely, there may occur partial or complete loss of function of the organs beyond the lesion, and partial or general necrosis or necrobiosis. I shall con- sider arteritis under two great heads, traumatic and non-traumatic, sub- dividing these as their pathogeny or pathology may justify in the con- sideration of each separate type. I. Traumatic Arteritis.—Arteritis may result from violence, either from without or within. External violence will produce an inflamma- tion of all the tunics of an artery, in the majority of cases, while vio- ARTERITIS. 245 lence from within is more apt to cause an endarteritis. Arteritis from external causes is never an uncomplicated injury. The perivascular tissue is of necessity involved in the inflammatory process. In the arte- ritis resulting from deligation of an artery, from the forcible compression of a vessel, as in bending the knee, from the pressure of a tumor, or from a blow in the track of the artery, there is always an accompanying inflammation of the surrounding, injured tissues. The pathology of traumatic arteritis does not differ greatly from the inflammatory process which occurs in other vascular tissues. Immedi- ately following the injury there is a marked increase in the vascularity of the adventitia. The vasa vasorum become swollen, the wThite blood- corpuscles crowd into the capillaries, and pass into the extra vascular spaces, while a rapid proliferation of the normal cell elements of the arterial tunics takes place. The connective-tissue cells of the adventitia and the flat and polar cells of the intima all take part in this process. The walls of the vessel become abnormally thickened, while, owing to the projection inward of the intima, the caliber of the vessel is diminished. If the intima has been broken or bruised by the injury, the encroachment upon the caliber of the vessel will be more rapid, for, inaddition to the mass of embryonic tissue push- ing into the lumen of the artery, there will be a de- posit of fibrin upon the roughened and projecting internal tunic. The white corpuscles in the passing blood current adhere to the inflamed surface, while the disintegration of the blood platelets precipitates the fibrin to form a coagulum. This coagulum is found to consist of alternate layers of leucocytes and fibrin. In the meantime, if the inflammation be not so severe that rapid necrosis occurs from the sudden arrest of the blood supply through the vasa vasorum, new-formed capil- laries push through the mass of embryonic cells, into the "granulation buds" which project into the lumen of the vessel (Fig. 286). This form of arteritis may result in permanent occlusion of the vessel (endarteritis obliterans), or the function of the artery may be restored. If occlusion occurs, it results from the organization of the embryonic Fig. 286.—Traumatic arteritis. Transverse section of the carotid artery of a dog, fifteen days after ligature; b, granulation buds formed from projection of the intima. In the center of the figure one of these buds has been completely cut across; m, portion of the media modified by the inflammatory pro- cess ; e, adventitia; V V, vessels cut across, one of which is newly formed in the intima. Magnified 15 diameters. (After Comil and Ranvier.) 246 A TEXT-BOOK ON SURGERY. cells into a new tissue which undergoes fibrillation and contraction (a process of cicatrization) to such an extent that the new-formed capillaries are more or less occluded, and the artery shrinks to become a fibrous _ _ cord (Fig. 287). Or the coagulum may undergo fatty degeneration, and be swept away with the current of blood, the vessel remaining pervi- ous and bearing but lit- tle trace of the inflam- matory process through which it has passed. The microscopical ap- pearances of a localized traumatic arteritis are typically represented in Fig. 288, which is copied from a section made from the carotid of a horse. The animal was in a healthy condition at the time of the op- eration. I tied the ar- tery with a broad car- bolized ligature, the sciatic nerve of a calf. In the fifth week the animal was killed. The artery was pervious. The location of the ligature was easily recog- nized by the peculiar, whitish, pearly appearance of the intima at the point of tying, where it B was slightly elevated. The /skv^K-^-"?:?:^^ b A adventitia did not show any changes to the naked eye. The ligature had evidently slipped soon after the opera- tion, probably within a few hours. The intima was not broken, but simply bruised within the grasp of the liga- ture. Active proliferation of the cells of the intima had resulted from this irritation. Not only is the intima seen to Fio. 2e bulge into the lumen of the vessel, but the mass of embry- onic tissue encroaches out- ward upon the media, which is thinner at this point than Fig. 287.—Endarteritis obliterans, not syphilitic. Transverse section of the basilar; a, muscular layer; b, elastic layer. The lumen of the artery is entirely filled with a new formation, which has become canalized by new vessels at d d f ; c, blood pigment; e, hyaline material, part of the new formation encroaching on the media at e, and seen elsewhere. (Drawn by Dr. W. L. Wardwell,from a speci- men borrowed from Prof. W. H. Welch. Magnified 60 diameters.) "'% --:, D £L2&~&2^^: Traumatic endarteritis. Section from the common carotid of a horse, tied with a broad nerve ligature, show- ing1 at b b the proliferation of the intima. The inflam- matory new formation is projected into the lumen of the vessel, and has caused partial atrophy of the media, c; ab, the intima; b b, portion of the intima in the grasp of the ligature ; d, the adventitia, slightly changed, with small-cell infiltration. (Drawn l>y Dr. W. L. Ward well, from the author's specimen. Magnified about 40 diam- eters.) ARTERITIS. 247 elsewhere. At one point the media has entirely disappeared, leav- ing the intima and externa in actual contact. The adventitia has not undergone much change. A few inflammatory corpuscles are found among the connective-tissue bundles. If, after an injury which induces arteritis, the vessel be not occluded throughout the extent of the lesion, and the injury or resulting septic infection be so severe that rapid occlu- sion of the capillaries in the arterial wall takes place, suppuration or necrosis occurs, with haemorrhage. Or particles of septic matter may pass into the vessel and lead to infarctions, or septicaemia with metastasis. Treatment.—No definite plan of treatment can be outlined for trau- matic arteritis. The circumstances of each case must be separately con- sidered. To prevent gangrene, and to guard against haemorrhage, are the indications most to be regarded. Rest, position, quiet, and careful nutrition are the most important points of treatment. Traumatic arteritis resulting from causes within the vessels usually begins as an endarteritis. Many cases of acute traumatic endarteritis are described as idiopathic inflammations. They are none the less due to violence—to the impinging force of the blood current; for this lesion occurs at those points in the arterial system where blood impact is great- est. Endarteritis and the fatty degeneration resulting from it (Figs. 289, 290) are most frequently seen in the sinus magnus of the aorta, in the Fig. 290.—A form of fatty degeneration after arte- ritis. Fatty degeneration of the internal coat of the aorta. Minute yellowish-white patches scat- tered over the lining membrane of the vessel. A very thin layer peeled off and magnified 200 diameters, showing fat molecules and the distri- bution of fat in the intima. (From Green.) transverse segment of the arch of the aorta, at the aortic bifurcation into the two common iliacs, and in the arch of the innominate. The arteries of athletes, which are subjected to prolonged distention, result- ing from violent muscular exercise, are prone to suffer from this disease. Vegetations from the heart may produce traumatic endarteritis when they are extensive enough to pass through the aortic valves, thrashing the intima with each heart systole. Fragments from whatever source, carried along the vessels, produce arteritis at the point of lodgment. If we examine the intima of an artery which has been the seat of recent endarteritis, it will be seen to be swollen, and thicker and softer than normal. The swelling is not usually general and continuous, but g - -\i'- : ■ "i IP- $$■ S"7 1 Fig. 293.—Showing calcareous degeneration of the media, a, in- tima ; c c, media ; i>, adventitia ; b b, calcareous patches. Ul- nar artery. Magnified about 60 diameters. (From a specimen prepared by Dr."W. L. Wardwell.) aged, enormous dilatations occur. The dilatation is not uniform, as a rule, but the walls of the dilated artery (usually the aorta and the arte- ries of the second class) are pouched in many places. The calcareous matter will be found to be thickest in those portions of the wall which are less dilated, while the dilated pouches have undergone a more complete fatty degen- eration. This condition is commonly known as arte- ritis deformans. The middle coat may be in places entirely destroy ed, when the changed intima will be joined with the ad ventitia by a connective- tissue new formation, which contains vessels passing directly to the in- tima. Loss of the elastic tunic is one of the immediate causes of spon- taneous aneurism (Cornil and Ranvier). This condition of atrophy of the elastic lamina is well shown in Fig. 293, which was drawn from one of my specimens. Calcification of arteries has been especially studied by my former pupil, the late Dr. W. L. Wardwell, of New York city, in Conheim's Laboratory. His experience includes examinations made from twenty-five cases at the request of Conheim, who ap- proved his conclusions. Dr. Wardwell says all authorities recognize a morbid change in the arteries known as calcifi- cation, and the majority look upon it as a change second- ary to atheroma or endarte- ritis. Few of these recognize a primary calcification not dependent upon a preceding inflammation. This condi- tion is, however, the chief change in the senile calcifica- tion of arteries. The micro- scopic appearances of pri- mary calcification are well shown in Fig. 294. Conheim states that in senile arterial calcification sometimes the media, sometimes the interna (its outermost layer), is affected, and that in them the lime salts are deposited. Moreover, that this deposit of lime i ig. '294.—Arteritis with primary calcification. Section from human radial artery, showing at b primary calcification of the media, c. a, the intima comparatively unchanged. (Drawn from specimens prepared by Dr. W*L. Wardwell, at Conheim's Laboratory. Magnified about 350 diameters.) 252 A TEXT-BOOK ON SURGERY. Fig. 295.—Arteritis with coagulation necrosis. Section from human artery treated with acetic acid, showing at d spots of coagulation necrosis which contained calcareous salts before"being treated with the acid ; a, intima; b, media; c, adventitia. (Drawn from specimen prepared by Dr. W. L. Wardwell. Magnified about 40 diameters.) takes place here because these tunics have been subjected to the greatest strain. Weigert* describes a "hitherto undescribed" process known as co- agulation necrosis. He argues that all tissues have the power of spon- ...g-aBE^—=_, taneously coagulating, it be- *^~' -" --''•—~r.^^^— --^-—y,*r — _ a ing necessary for such an oc- currence that the cells should , * d ,. ;■ * A die, give up their ferment and fibrino-plastic material, and then become saturated with a fibrinogen - holding lymph. This morbid process he holds may occur in tissues the most diverse in character, as in cheesy glands, infarcts of the spleen or kidneys, tumors, the inflammatory material around parasites, tubercle, etc. Macroscopically, these coagulated spots have a peculiar, stiff ap- pearance, and, microscopically, they are recognized by the fact that the cell nuclei have disappeared, and can not be made to appear by reagents or by the material used for staining in microscopical examination. These conditions are shown in Figs. 295 and 296. Syphilitic Arteritis.— Arteritis is a part of the pathology of syphilis. The first danger to life in this disease comes from the changes in the capac- ity of the arteries. No part of the arterial system is exempt, though the most serious lesions are found in the vessels of the brain, and next in the aorta. They become grave in the larger trunks on account of the atheroma resulting from the syphilitic poison (inducing aneurism), and in the smaller arteries (especially those of the brain) from occlusion or atheroma. Even in the initial lesion of syphilis (the chancre), according to Biesiadecki, the capillaries of the papilla? have in their thickened walls Fio. 296.—Posterior tibial artery. Section showing coagulation ne- crosis, a, intima; b, media ; c, adventitia; n, spot of coagula- tion necrosis. Magnified 300 diameters. prepared by Dr. W. L. Wardwell.) (From a specimen * Virchow's " Archiv," Bd. lxxix, S. 87. ARTERITIS. 253 many nuclei, some of which are seen to project into the lumen of the vessel. The arteries of the base of the brain, especially the basilar and those at the commencement of the fissure of Sylvius, are often seriously in- volved. I have seen two cases in which death resulted from anaemia of the medulla, due to a more or less complete thrombosis of the basilar artery. One of these died in my presence. A few days previous to his death he had complained of dizziness, and of a sensation as of insects crawling over the integument of the extremities. Death was quite sud- den, and was due to respiratory failure. He became quickly unconscious, the respiratory movements were irregular, and co-ordination of move- ment between the expiratory and inspiratory muscles was seemingly lost. The mode of death was different from anything I had ever wit- nessed. At the autopsy, the basilar, just where it divided into the two posterior cerebrals, was found almost completely occluded by a throm- bus. There was no other lesion which could have accounted for death. Syphilis had existed for several years. In the second case syph- ilis had existed for nineteen years, with right hemi- plegia for the last sixteen years of life. This patient was under my care for near- ly five years. She would never consent to take the iodides or any medicine. Her mind was clear up to the time I last saw her before death, which oc- curred suddenly one night. I did not see her until life was extinct, but, from the description of the mode of death given me by Dr. F. J. Ives, who was present, I was led to express the belief that a similar condi- tion existed as in the case first referred to. On examination, I found a thrombosis of the basilar artery in exactly the same location. Fig. 297 represents a section of the artery near the thrombus. The lumen of the vessel is seen to be about two thirds occluded. The adventitia is slightly thickened, and the cell elements in it are distinctly fusi- form, and regularly parallel with each other and with the contour of the adventitia. The wavy elastic layer is easily recognized, and in that portion of the artery in which the syphilitic inflammatory ma- terial is deposited the waves of the media are more numerous and shorter than in other portions of the vessel. In the center of the mass, occupying a portion of the caliber of the artery, is found a hyaline-look- Fig. 297.—Syphilitic arteritis. Section of basilar; e, lumen of vessel about two thirds filled with new formation at a b ; c, media; d, muscular layer and adventitia. From a patient dead from syphilis. (Specimen of the author's, drawn by Dr. Wardwell. Magnified about 40 diameters.) 054 A TEXT-BOOK ON SURGERY. ing spot which took the carmine stain more readily than the general mass of the thrombus. It contains embryonic cells in about the same quantity as the surrounding tissue. The adventitia is not regularly thickened, being three or four times as deep in some portions as in others, and pre- senting in the section a nodulated appearance. Viewed with a magnify- Fio. 298.—Syphilitic arteritis. Shows section of small Fig. 299.—Syphilitic arteritis. Section of cerebral artery near a gumma, magnified 30 diam- small artery of cerebellum, magnified 30 eters. a, lumen of vessel; b, boundary of inner mid- diameters, a, lumen of vessel; e, thick- die coats ; c, thickened inner coat; d, middle coat; ened inner coat; d, muscular coat; e, e, external coat; f, infiltrated pia mater. (After outer coat. (After Greenfield.) Greenfield.) ing power of about five hundred diameters, that portion of the arterial wall external to the wavy line (the elastic layer), seen in Fig. 297, pre- sents the following appearance: In the most external limit of the section of the adventitia there are found clusters of embryonic cells, round, and larger than the cells found in any other portion of the specimen external to the elastic lamina. These cells are somewhat smaller in size than those found in the new-formed tissue of the intima, though they differ in shape, since ARTERITIS. 255 those in the intima appear both round and fusiform, while the cells in the outer edge of the externa appear almost invariably round. It may be possible that they are fusiform cells cut transversely in the section ; though after careful examination I am led to conclude that they are round. At various points these cells do not exist, the external layer being that of fusiform cells arranged with great regularity parallel to the contour of the wall of the artery. Where the wTall of the vessel external to the elastic lamina is thickest, these spindle cells are more numerous, and have a greater transverse diameter than at the narrower portions, where they seem to have elongated and become thinner—seem- ingly a true process of fibrillation and contraction of embryonic (inflam- matory) cells. Continuing the examination farther inward, as the white, wavy, elas- tic zone is crossed, just within and almost in exact apposition with this is a somewhat irregular and thin layer of cells, fusiform in section, vary- ing in depth from a single row to two or three rows, and in some points entirely absent. These are doubtless a remnant of the original endo- thelia of the intima ; just internal to these, and in fact continuous with them, is the great mass of new-formed, inflammatory tissue which juts into the lumen of the vessel. This mass is composed of large, mostly fusiform, cells, distinctly nucleated and occupying about as much space as the intercellular substance in which they are imbedded. According to Greenfield, the inflammatory process in and around the perivascular canals in syphilis is entirely different from that in tuber- cular infiltration of these canals. In vessels examined by Barlow, the same changes are reported as those given above (Figs. 301, 302). The adventitia and muscular coats 256 A TEXT-BOOK ON SURGERY. were more or less affected, "but obviously the principal changes have taken place in the intima." Rheumatic Arteritis.— Arteritis may occur in connection with acute rheumatism. Bryant states that this is a rare form of disease. Rheu- matic endocarditis is not so rare, and it is possible that en- darteritis may exist in the aorta in many cases of endo- carditis. This and the arteritis of gout and nephritis (Fig. 303) belong to the domain of medi- cine rather than to that of sur- gery, and will not therefore be considered in this work. The treatment of arteritis resolves itself simply into the Fig. 303.—Arteritis with chronic nephritis. Section from treatment of the disease of posterior tibial artery of patient dead from Bright's dis- m m ease, showing at a great thickening of the intima, the which it IS a part. It WOUld result of chronic endarteritis. The elastic lamina, d, , Jt,#»w«ic>« +1-.^ unchanged. The muscular layer, b, slightly thickened. be USeleSS tO increase tile c, adventitia greatly thickened at places by small-cell i -l j? 4-V.ia orrinlp hvfiTP infiltration. Brawn from specimens prepared by Dr. lengtn 01 tniS arilCie Dy a re- W. L. Wardwell, at Conheim's Laboratory. (Magnified capitulation of the VarioUS about 40 diameters.) c ¥ i . , methods and remedies which have been employed. If the pathogeny and pathology of the affection are understood, its therapy is not difficult. Arterial Thrombosis and Embolism.—Though not as frequent as in phlebitis, thrombosis and embolism often result from arteritis. The pathology of thrombosis has been given in the section on phlebitis. The process in the arteries is closely analogous to that in the veins. The perfect type of thrombosis from acute, traumatic arteritis is found after the application of an occluding ligature around an artery. By reason of arrest of the blood current and disturbance of the equi- librium normally existing between the blood and the containing vessels, coagulation takes place on the cardiac side of the ligature, extending back as a rule to the first collateral branch. Immediately following the injury to the vessel, under aseptic conditions, the process of inflamma- tion—arteritis—commences. The tension of the ligature to such degree as to divide the inner or middle coat, or both, is unnecessary.* The coagulation thrombus disappears by fatty degeneration. The permanent occlusion is due to new-formed tissue springing from the normal cells of the intima and the fixed cells of the adventitia. 0. Weber held that the clot became organized into a true tissue, into which * The author's researches are confirmed by the classical work of Ballance and Edmunds on " Ligation in Continuity," page 4G8 : " Wyeth says the tension of the ligature to such a degree as to divide the inner or middle coat, or both, is unnecessary. I have tied arteries (carotid and sub- clavian) in human beings and in horses and dogs, and have specimens which demonstrate success- ful occlusion of the vessel without division of either of the three tunics. Scarpa advanced this idea years ago, but surgeons generally have decried it. None the less it is true, and I am fully convinced by experience that it is safer than the division of one or two coats of a vessel by tightly drawing a narrow cutting ligature around the artery." ARTERITIS. 257 blood vessels were projected from the vasa vasorum (Fig. 304). But Cornil and Ranvier long since disproved this. Bubnoff held that the white blood-corpuscles emigrated through the walls of the ligatured ves- Fio. 304.—Longitudinal section of the artery of a dog fifty days after the ligature. Clot injected. Magnified 40 diameters. (After O. Weber.) sels, permeated the clot, and caused its organization ; but Durante (Cornil and Ranvier) demonstrated that the leucocytes only traverse the walls of the vessel when this has been tied with a double ligature, causing a death of the included vessel, and that the leucocytes travel through this dead tissue. They do not permeate the walls of an other- wise healthy artery which has been tied with a single liga- ture. Cell proliferation takes place rapidly in the intima ; granulation buds project into the territory occupied by the clot (Fig. 305); blood vessels derived from the vasa vaso- rum permeate the projecting granulation tissue, invade the dot, meet with vessels from the opposite side, and join with these in a continuous cir- culation; the embryonic tis- sue organizes, gradually con- tracts (process of cicatriza- tion), and the walls of the vessel are permanently oc- cluded by this fibrillation. Afterward the new-formed vessels disappear to a great degree, being ob- literated by the process of contraction. Fig. 305.—Traumatic endarteritis. Transverse section of the femoral artery of a dog eight days after the application of a ligature. e',the elastic lamina ; p. the media ; b, granu- lation bud projecting from the intima into the lumen ; v, new-formed vessel running through the inflammatory tissue. At a the elastic layer has partly disappeared. Magnified 30 diameters. (From Cornil and Kanvier.) 258 A TEXT-BOOK OX SURGERY. Thrombosis from acute arteritis is rare. Chronic arteritis is not in- frequently the cause of occlusion. Syphilitic arteritis is apt to develop thrombosis of the cerebral arteries. Arterial thrombosis (excluding the vessels to the brain and walls of the heart) is not as dangerous to life as venous thrombosis. The process is usually so gradual that the collateral circulation is established before occlusion of the main trunk occurs. This may, in- deed, escape observation until the enlarging superficial arteries attract attention. Vascular Tumors. We may recognize six varieties of vascular tumor, apart from true aneurism. These are: 1. Arterial varix ; 2. Cirsoid arterial tumor (cir- soid aneurism); 3. Arterial cutaneous tumor ; 4. Capillary cutaneous tumor; 5. Venous cutaneous tumor (these three varieties are usually classed together under the name of angeiomata); and 6. Venous varix, or simple varix (varicose vein). Arterial Varix may be defined as a dilatation and elongation of an artery of the second magnitude (as the external iliac or common carotid), of the third (as the external carotid or posterior tibial), or of the fourth (as the temporal, facial, superior thyroid, or palmar branches of the ra- dial and ulnar). Cruveilhier has reported a case of arterial varix of the external iliac artery. I have made one dissection of arterial varix of the superior thyroid artery, in which this vessel was greatly elongated, and as large as the external or internal carotid. It was tortuous, but not sacculated, the dilatation being general. Tillaux* reports a case of cirsoid aneurism of the hand, with dilatation of the arteries of the fore- arm and humeral region. Treatment.—Arterial varix may be treated by compression, or by the ligature, when such a procedure becomes necessary. In a case which I saw after the patient's death, and in which the superior thyroid artery was involved, the ligature would have been advisable. -The artery was in a healthy condition, with the exception of its increased length and caliber. When connected with cirsoid arterial tumors, the solidification of these by ligature, cautery, or injection, will usually cure or palliate the arterial varix. Cirsoid Arterial Tumor (Cirsoid Aneurism).—The cirsoid arterial tumor is an elongation and dilatation of the terminal subcutaneous arte- rioles (normally of a diameter of about one fiftieth of an inch). These tumors may be general or circumscribed. A single arteriole may be affected, or many arterioles may be involved. The causes of cirsoid arterial tumors are not positively known. They occur most frequently upon exposed surfaces of the body, as on the neck, head, and hands. The face and head are most frequently the seat of all forms of vascular subcutaneous and cutaneous tumors. * "Gaz. des hopitaux,*' 1882, p. 10S3. VASCULAR TUMORS. 259 Excluding those of the orbit, I have collected more than ninety cases in which the carotid arteries were tied for these lesions. Either peripheral or central disturbances of the functions of the vaso- motor nerves may lead to loss of tone in the muscular walls of the ar- teries. Frostbite and blows have been mentioned as causes of cirsoid aneurism. Berger reports a case of cirsoid tumor of the hand caused by irritation, from constant pressure of an instrument which the patient used in his trade. The disease may be congenital, or may result from the increased growth of a cutaneous naevus. It is met with most fre- quently between the ages of fifteen and thirty. Symptoms.—Abnormal pulsation is the first symptom of cirsoid aneu- rism. Petit describes the sensation imparted to the palm of the hand as similar to the vermicular motion of a mass of earthworms. With the stethoscope, a bruit etc souffle is distinctly audible. Pain is not constant, and is only due to the pressure of the growth upon the cutaneous nerves. As the tumor progresses in size, more marked inflam- matory changes occur; adhesions to the skin take place; and ulcera- tions, with alarming haemorrhage, are not infrequent. In some instances, especially in cirsoid tumor of the scalp, pressure of the growth upon the calvaria may interfere with the nutrition of the skull. Treatment.—It may be said of the treatment of cirsoid arterial tu- mors, in common with arterial, capillary, and venous cutaneous tumors, that no method is as safe or sure as direct local treatment. For a long time deligation of the main trunk or trunks was the favorite practice. Sometimes this was done to arrest haemorrhage due to ulceration or acci- dent, in some few cases to arrest haemorrhage after or during an attempt at removal, but most frequently the intention was to cut off the blood supply. Since the vast majority of vascular tumors occupy the neck, face, and scalp, the carotids have been often tied in the treatment of these growths. In my "Essays in Surgical Anatomy and Surgery"* I have collected 98 cases of ligature of the carotid for vascular growth above the claviele, and chiefly of the head. This number does not include 60 cases of pulsating vascular tumor within the orbit. The results are not such as to encourage the careful operator in a repetition of the procedure. Even in the nine cases in which both common trunks were tied,f only one was cured (not, however, until after compression was made over the tumor), and two were improved. Mussey's patient was only improved after the second ligation, but was cured after a bloody excision. The tumor was exceedingly large, and the dilated arteries were tied one by one. More than twenty ligatures were applied, and the haemorrhage is said to have been dangerously profuse. Other surgeons besides Musseyi who have practiced excision of cir- soid arterial and other " vascular tumors " are Busch, % Heine, % Cliaefe, # * Xew York, 1879. t The operators were Blaekman, Gunderloch and Muller, Kuhl, Mussey, Pirogoff, Robert, Rodgers and Van Buren, Ullman, and Warren. X See the author's " Essays in Surgical Anatomy and Surgery," Xew York, 1879. * Holmes's "System of Surgery," second edition, vol. iii, p. 540. 260 A TEXT-BOOK OX SURGERY. Gibson,* Buchanan,f Sydney Jones,X Warren,* Weitzer,* Gueniot, * and Hart,* The latter froze the tumor, and cut well into the sound tis- sue ; little blood was lost. The late Prof. Spence, of Edinburgh, cured a deep-seated erectile tumor of the hand by galvano-puncture. || Nelaton operated in a cirsoid tumor of the forehead in a similar way, and with like success. Direct local compression has been tried by patient and expert sur- geons, but has not met with success. In carefully performed excision through the sound tissues and near the limit of disease will be found the safest procedure. Angeiomata.— The three next varieties of "vascular tumor," which may be grouped together under the name of Angeiomata, are: (1) The Arterial Cutaneous Tumor, or Aneurism by Anastomosis, composed of dilatations or elongations of the arterioles, either normal or new-formed, in the skin; (2) the Capillary Cutaneous Tumor, consisting of dilata- tions and elongations of the normal or new-formed capillaries of the skin; and (3) the Venous Cutaneous Tumor (Cavernous JSTcbvus), com- posed of dilatations of the normal or new-formed venous radicles of the skin. The angeiomata are considered by some writers as strictly new forma- tions of blood vessels. There is little doubt, however, that many vascular tumors are chiefly made up of normal vessels which have undergone dilatation or hypertrophy. Other names that have been given to angeio- mata are congenital naevus, erectile tumor, telangiectasis or plexiform angeioma, aneurism by anastomosis, cavernous naevus, and fungus haema- todes. According to Depaul, one third of the children born in one of the eleemosynary institutions at Paris had congenital naevi, the greater number of which disappeared spontaneously during the first few months of life. They occur chiefly in the skin, and are especially apt to appear on the forehead, face, ears, and neck. Structure and Symptoms.—Angeiomata commonly form flattened, slightly projecting tumors, varying in size from a mere speck to as much as an inch in diameter, and are composed of new-formed, dilated, freely anastomosing capillaries, arterioles, and veins, in irregular, labyrinthine masses. They vary in color, being at times grayish blue or red. Often the only indication of their presence is the appearance of a diffuse red- ness over a considerable surface. Examined microscopically, the walls of the vessels are crowded with cells, and the vessels are imbedded in a network of fibrous and adipose tissue. The superficial and deep cutane- ous vessels—including the vessels of the hair follicles, sweat glands, and adipose tissue—join in the formation of these tumors. The disease may extend into the muscles and deeper tissues. The majority of angeiomata are soft and yielding, and can be emptied * Holmes's "System of Surgery," second edition, vol. iii, p. 540. f "British Medical Journal," June, 1875. p. 835. X " Lancet," 1882. * See the author's "Essays in Surgical Anatomy and Surgery," New York, 1879. [ " Medical Times and Gazette," August 21, 1875, p. 209. VASCULAR TUMORS. 2(51 by pressure; but when of great vascularity and long standing, when there has been an extensive proliferation of the perivascular connective tissue, pressure will not cause their disappearance. Some are very pain- ful, and others entirely free from sensibility. Venous cutaneous tumors are composed, in great part, of new-formed, erectile tissue, analogous to that found in the corpora cavernosa. Their structure is white and dense, the caverns communicating freely with each other. In rare instances they are known to contain chalky concretions (phlebolites). The circulation is active in these tumors, and their vol- ume variable. The walls of the sinuses contain a dense, fibrous stroma, involuntary muscular tissue, and striated muscular fibers when the tumor is encroach- ing on the muscles. They are lined by the same endothelium as the normal veins. These tumors are not all erectile, and some which have been erectile for a time lose this property. Gross describes a form of naevoid tumor as na. void elephantiasis, consisting of a hypertrophied condition of the skin and subcutaneous connective tissue. The affection, which is either congenital or comes on soon after birth, is found usually in the lower extremities, though it may occur elsewhere. jaws, and scapula, being often very painful, and grave as to prognosis. Angeiomata are not infre- quently situated on the labia of women. The question of the relation of these tumors to carcinomata and sar- comata is worthy of consideration. J. Miiller has reported a malignant (recurrent) angeioma. A case of melanotic degeneration of a congenital naevus in a woman aged forty has been reported. The vascular dilata- tions in osteo-sarcomata, and in other forms of carcinoma and sarcoma, are analogous to those found in cavernous angeiomata. Some of the malignant tumors pulsate like the angeiomata. An angeioma may be diffuse or encapsulated. The prognosis depends upon the size and location of the neoplasm. The diagnosis is not difficult in the superficial tumors, but in those 2(|2 A TEXT-BOOK OX SURGERY. deeply situated, and in the track of large vessels, the differentiation from aneurism is not easy. The arterial and capillary cutaneous tumors are almost always con- genital ; the venous tumors are rarely so. Angeiomata may be distin- guished from osteo-sarcomata, which have perceptible pulsation, by the crackling impression conveyed to the sense of touch from the malignant tumors of bone. Several consecutive telangiectases may occur in the same individual. Hutchinson, reports the case of a child which had over one hundred naevi, all distinct and superficial. Vascular tumors on the scalp have an element of danger not present in angeiomata elsewhere, in that they at times grow to such an extent as to cause necrosis of the calvaria. Treatment—Angeiomata have been known to heal without surgical interference, as a result of an infectious inflammation. Angeioma of the face, or of any exposed surface where a scar is to be avoided, is best relieved by the clean cut of the knife, since the cicatrix is less deforming than that produced by other modes of treatment. I have removed a number of these growths from the scalp and face. The in- cision should be made along the edge of the tumor, cutting only through healthy tissue. When this precaution is taken, haemorrhage is not dangerous. Of course the operation is not justifiable if telangiectasis involves more surface than can be covered by stretching or sliding the sound integument, or when it requires removal of the eyelid, ala nasi, or too much of the lip or ear. In such instances galvano-cautery needles should be employed. In cavernous tumors of large size the following method, recommended by Prof. Esmarch, of Kiel, should be recom- mended : Immerse a middle-sized silk thread for half an hour in tinct. ferri. chlor. ; remove and dry and sterilize by heat. The tumor surface is carefully cleansed and a round, straight, or slightly curved needle is armed with this thread and passed through the tumor in all directions at intervals of about one fourth of an inch. The first series of threads should be passed through the deeper portions and parallel. If the naevus is considerably elevated, a second layer should be inserted at a right angle to the first. The threads are cut off a half inch from the surface of the tumor and left in position. A light sterile gauze dressing should be laid on, and over this a layer of borated cotton, held in place without too much compression by a bandage. In from two to four days complete coagulation occurs and the threads are to be removed. If absorption is not rapid, the coagulated mass may be removed by dissection. By this procedure I succeeded in consolidat- ing and removing an enormous cavernous naevus of the face. The disfig- urement was very slight. Venous Varix, Varix, or Varicose Vein.—This variety of "vascular tumor" consists of a dilatation and elongation of the deep or subcutane- ous veins. This condition may exist in any portion of the body, even in the bones (Cornil and Ranvier). It may involve a small portion of one vein, superficial or deep, or, as is most usual, a chain of veins. It is most VASCULAR TUMORS. 263 frequently observed in the superficial veins, though Verneuil says that varix is really as common in the deep-seated as in the superficial vessels (Bryant). It is especially prone to occur in the saphena veins. Haemor- rhoids and varicoceles are common forms of varix. Unusual types are the dilatation of the jugulars from stenosis of the vena cava descendens, and that of the superficial abdominal veins from stenosis of the ascending cava. Such conditions are described by some authors as simple hyper- trophies or dilatations of veins. Any long-continued dilatation consti- tutes a varix. Hyperplasia of the normal tissues of the venous wall is the natural sequence of prolonged pressure and increased function. The hypertrophy of the wall is not always equal to the resistance of the in- creased pressure; hence sacculated pouches occur when the vessel wall becomes much thinner than normal, not infrequently resulting in rupture. Varix is of frequent occurrence in women who have had repeated preg- nancies (Billroth). Poorly fed and hard-wTorked persons, especially those who work in the upright posture, are more prone to varix than others. There can be no doubt that gravitation is the chief and immediate cause of this dis- ease. The veins most subject to the greatest, prolonged blood weight, and least protected by pressure, are involved in the great majority of cases. Paralysis of the muscular wralls, either by atrophy of the muscles or interference with the function of the nervi vasorum, may cause varix. This is proved by the fact that a small segment of a single vein in the upper portion of the body, where the anastomosis is free and gravitation can not be considered as a factor in the dilatation, may be the seat of this affection. In well-marked varix the veins are greatly increased in caliber and in length, so that they seem coiled and twisted upon themselves in knot- ted masses. They are narrowed in caliber at frequent intervals, these contractions opening into expanded pouches, in general appearance not unlike the sacculated large intestine. The valves are wholly inefficient, often flattened against the wall, or at times partially destroyed. At the level of the valves the walls are exceptionally thickened. The thicken- ing is due to a multiplication of the muscular elements and hyperplasia of the connective tissue. The connective-tissue new formation is abun- dantly distributed in the meshes of the elastic network, and the bundles of fibers are usually arranged parallel with the long axis of the vessel. This accounts for the longitudinal ridges seen on the inner surface of the affected veins (Cornil and Ranvier). Even the nutrient vessels of the walls of these varicose veins—the vasa vasorum—have undergone hypertrophy, and are themselves the seat of varix, forming at times venous caverns in the wall of the vessel, which communicate with the vein. The internal tunic is not, properly speaking, thickened, except at the points of attachment of the valves, or where a thrombus has formed. Immediately external to the middle elastic tunic, the muscular tissue appears increased in quantity, arranged in transversed and perpendicular laminae, separated by bundles of hypertrophied connective tissue, which are not infrequently stained with granular pigment. Calcareous depo-its 264 A TEXT-BOOK OX SURGERY. occur primarily within or between these connective-tissue bundles (Cornil and Ranvier). Hyperplasia of the connective and other tissues in the immediate vicinity of the varix of long standing presents the usual appearances of elephantiasis. Small spots of ulceration occur as a result of malnutri- tion, and, coalescing, form the large and obstinate ulcers seen so fre- quently in varix of the legs. The veins become greatly elongated and assume different shapes, irregularly sinuous or corkscrew-like, twisted upon their axes, and frequently, on account of perivascular inflamma- tion, matted together by new-formed connective tissue into venous tu- mors. Occlusion of varicose veins may result from thrombosis, and a cure may thus ensue. Frequently concretions are found in varicose veins, at times adherent to the walls. These concretions are called phlebolithes or phlebolites (Dunglison). Treatment.—Varicose veins may be treated radically or conserva- tively. Occurring in young or middle-aged subjects, the operation of deligation or excision should be performed. In the case of a student at the United States Military Academy at West Point, who, at the end of his second year, developed large varicosities of the right saphenous vein, for which he was about to be discharged, I operated by excising this vein in its entire length, applying ligatures to the collateral branches. It was first tied about two inches below the saphenous opening in the thigh, and an incision through the skin made the entire length of the vein. The collateral branches were tied off, the main trunk and the varicosities ex- cised, and the wound closed with catgut and covered with a dressing of sterilized gauze. The patient recovered cured. When the varicosities are confined to the leg, if large and tending to inflammation, they should be excised. Small varicosities may be oper- ated upon with cocaine anaesthesia and catgut ligatures applied at two or more points along the course of the vein. In the conservative treatment an elastic stocking properly fitted gives great comfort and prevents the formation of ulcers. When this can not be obtained, an Esmarch elastic bandage may be employed or a tight-fitting flannel bandage may be applied. Moles. Closely connected with the more superficial forms of vascular tumor are the abnormal, circumscribed hypertrophies of the skin, which are known as moles. They may be, and usually are, congenital, or they may be developed at any period of extra-uterine life. All portions of the cutaneous surface may be the seat of this form of hypertrophy, but the exposed surfaces, such as the face, neck, and hands, are most fre- quently affected. The hypertrophy which constitutes the mole may involve all or any one of the tissues which enter into the anatomy of the integument. The most frequent variety is that which occupies the face, as a simple elevation from which a few stiff hairs grow. It is not stained with pigment, and differs very slightly, if at all, in color from the normal skin. The lesion here is a true hypertrophy of all the tissues MOLES. 265 or the skin, chiefly in the derma and papillary layer. The vascularity is slightly increased, and the sebaceous glands connected with the hair follicles take part in the hypertrophy. On other portions of the body this form of mole (ncevus vulgaris) will have no hairs growing from its surface. Navies pigmentosus is not usually a thickening of the entire cutis, as is the simple mole just described, but its pathological condition is an excessive deposit of pigment in the Malpighian layer and in the epider- mis. It varies in color from a slate-gray to a blue, mahogany, reddish- brown, or wine-color. At times the pigment mole will extend over a large area, occupying as much as one third or one half of the face. The lobule of the ear, and the integument between the eyes and over the tem- ple, is the most common location of this deformity. Another name for these spots is ^port-wine mark." When the hypertrophied area of skin is studded with hairs, it is known as ncevus pilosus, or hairy mole. It follows from the name that this kind of hypertrophy can only occur on those portions of the etitis in which the hairs grow. The plantar surfaces of the feet and the palms of the hands are never affected. They may or may not be stained with pigment. The majority of hairy moles are not colored. Moles, whether simple, hairy, or pigmented, are benign. As a result of irritation and infection, they may become ulcerated, or may develop into malignant growths. Carcinomata, especially of the melanotic va- riety, are frequently described as having resulted from inflamed pigment moles. Alarming haemorrhage has been known to occur from a mole more than usually vascular, in which ulceration had been established by friction of the clothing. Treatment—As long as no deformity or inconvenience results from these formations, it is better to let them alone. When situated upon the face, of such size or position that they become offensive to the eye, they may be removed by simple excision. The incision should be elliptical, and well away from the growth, going entirely through the thickness of the skin. The wound should be closed with fine sutures, or drawn nicely together with adhesive strips. The simplest method of procedure is to produce local anaesthesia'by cocaine, and operate quickly. Port-wine marks may also be excised. If a mole should at any time take on inflammatory action, or give any indication of malignancy, immediate excision would be imperative, and the incision should be wide of the supposed area of the disease. 19 CHAPTER XIV. ANEURISM. Fig. 307. An aneurism is a sacculated tumor, the cavity of which communicates with an artery, and in rare instances also with a vein. They may be classified as spherical, fusiform, and elissecting. A spherical aneurism is one in which the tumor is well defined, its diameter being larger than that of the opening of communication with the'vessel. It may spring from any portion of the arterial wall (Fig. 307, e), or, in rare instances, the vessel walls may yield in all directions to form the tumor (Fig. 307, c). A fusiform aneurism is one in which there is a gradual and gen- eral dilatation of an artery in its entire circumference (Fig. 307, a, b). A spherical aneurism may occa- sionally develop from the wall of a fusiform dilatation. A dissecting aneurism is one in which, owing to pathological changes in the intima, the blood insinuates itself between the inner coat and the adventitia, dissects the intima from the media and adventitia, and re- enters the vessel at a distant opening. Aneurisms are further divided into the true and false. To the for- mer belong all tumors the walls of which are composed of the walls of the vessels from which they spring ; to the latter belong those tumors the walls of which are composed of inflammatory new-formed tissue. Cause.—A true aneurism is always preceded by arteritis, which re- sults in atheromatous degeneration of the normal elements which com- pose the arterial wall. The pathology of arteritis and the relation of this condition to vari- ous dyscrasiae—as syphilis, nephritis, gout, rheumatism, etc.—have been fully dwelt on in a preceding chapter. Syphilis improperly treated in- duces aneurism in a large proportion of cases. The relation of violence to these tumors must not be lost sight of. No matter how severe the dyscrasia and the general condition of arteritis, which is a part of it, it is well known that in the large majority of cases aneurisms develop at those points in the arterial system which are subjected to the greatest violence from heart action, or muscular or mechanical pressure. Thus the arch of the aorta, and that portion of the arch in the direct axis of 2G6 AXEURISM. 267 Fig. 308. Varicose aneurism. Fig. 309. :\neurisinal varix. the left ventricle, is very prone to aneurism, as are the great vessels near their origin from the aortic curve. The popliteal arteries, subjected as they are to violence in forced flexion of the legs, are frequently the seat of aneurismal dilatations. From a study of the various conditions which produce aneurisms, it is evident that the normal wall of an artery can not form the sac of the aneurism. Some of the normal anatomical elements may be present in the sac, but the integrity of the whole is impaired. An aneurism may in rare instances communicate with a vein (varicose aneurism) (Fig. 308). The direct communication of a vein and artery without a sac is known as aneurismal varix (Fig. 309). If an aneurismal tumor be examined, it will be found to contain coagulated blood in all stages of fibrillation. The peripheral portion of the clot is composed of irregular laminae, and, if examined with the micro- scope, the laminated appearance is found to be d ue to alternate layers of white corpuscles, and upon these a deposit of fibrin. As the center of the tumor is approached, the coag- ulation is evidently more recent, while in the cavity of the aneurism a soft post-mortem clot is usually found. Fusiform aneurism occurs most frequently in the thoracic aorta, with especial preference for the arch. It may affect the entire aorta, and the great vessels derived from it. Not only is the diameter of the arteries increased, but the hypertrophy results in a considerable increase in their length. Not infrequently a group of fusiform expansions may be seen with strips of sound and non-dilated artery intervening. Calcareous deposits occur in patches, and seem to give strength to the walls, since those portions give way more readily which are not the seat of calci- fication. Coagulation is not apt to occur, as in sacculated aneurisms ; in fact, it is a rare condition. Fusiform aneurisms develop slowly, and, as a rule, are painful and dangerous only when, by reason of their large growth, they exercise undue pressure upon important organs. Thus, in dilata- tion of the transverse arch, or of the right subclavian, spasm of the glottis occurs from irritation of the recurrent laryngeal nerves, or respi- ration and deglutition may be seriously embarrassed by direct compres- sion of the trachea or oesophagus. Fusiform dilatation of the abdominal aorta may produce serious results from disturbance of the vaso-motor system, by compression of the sympathetic ganglia near the diaphragm, by partial or complete occlusion of the thoracic duct, etc. Dissecting aneurisms are rare as compared with the other two vari- eties. The dissection or lifting of the thin lining membrane of the artery from the media usually occurs in the long axis of the vessel. If the middle and outer coats do not become involved in the degeneration which 268 A TEXT-BOOK OX SURGERY. has affected the inner coat, this form of aneurism may continue indefi- nitely, without leading to a fatal termination, although the danger of embolism can not be overlooked. If the other layers give way, a sacculated aneurism is formed, with the adventitia for the sac, or rupture may occur, leading to fatal extrava- sation. A false, or so-called "diffuse," aneurism results from the solution of continuity in all the coats of the vessel wall, and the sudden diffusion of blood into the peri-arterial tissues. The extravasation continues until the resistance of the surrounding tissues is equal to the pressure of the column of blood within the vessel. As a result of the extravasation, an inflammatory process, of variable intensity and usually non-infective, is established, which results in the formation of a limiting membrane, or aneurismal sac. The prognosis in aneurism varies under widely differing conditions. In general it is a grave affection, the gravity depending, in a great de- gree, upon the location and character of the tumor and the physical con- dition of the individual affected. An aneurism of the cranial cavity will produce rapidly serious effects by compression of the brain. The gravity of a prognosis diminishes as the location of the tumor is removed from the cavities. Aneurism (especially the sacculated variety) of the aorta, innominate, subclavian, or iliac arteries, is an exceedingly dangerous affection, while the same condition in the distal arteries yields readily and safely to surgical interference in the great majority of cases. The prognosis may also, in part, depend upon the degree of discomfort expe- rienced by the patient, from the effects of pressure upon contiguous organs. Neuralgia of the most painful and obstinate kind, resulting from pressure of the tumor upon a neighboring nerve, may hasten a fatal termination by loss of sleep and rest, and the general impairment of nutrition. Occlusion of the accompanying vein may occur, producing oedema and gangrene. Again, the gravity of the prognosis is increased when, by reason of its location, the sac of an aneurism is in contact with a bony surface, since rupture is not infrequently precipitated by attrition against the roughened bone. The symptoms of aneurism are, in great part, local. They refer to the direct development and effect of the tumor. A sense of unusual throb- bing pain, more or less severe, and swelling in the line of an artery (when the aneurism is outside of a cavity) which pulsates with the cardiac systole, which, when not resting upon a hard surface, is expansile in all directions, and which gives to the sense of touch a tremor not easily described but readily appreciated, are symptoms which point, in general to the diagnosis of aneurism. The stethoscope, applied to the tumor, conveys to the ear the peculiar sound ("bruit") caused by the passage of the blood current from the narrow vessel into the expanded aneurismal sac and out again. If the tumor be situated upon one of the arteries of the extremities, compression upon the cardiac side will cause a cessation of the pulse tremor and bruit, and diminution of the swelling, while pres- sure upon the distal side will temporarily exaggerate these symptoms. AXEURISM. 269 When an aneurism is developed as a result of a wound of an artery, the immediate symptoms of haemorrhage and swelling, with the pulsat- ing character of the tumor, will clearly indicate its presence. The differ- entiation is chiefly between solid or cystic tumors, which develop along the line of the artery, and are lifted by the arterial pulsation. Abscesses, or serous cysts, are the most difficult to recognize. In the formation of an abscess there is a previous history of inflammation. An aneurismal tumor expands equally in all directions, while any other tumor travels with the arterial pulse in one direction only—that of least resistance. In cases of great difficulty of diagnosis it will be justifiable to aspirate the tumor with the finest hypodermic needle. Left to nature, the progress of an aneurism is, with rare exceptions, to a fatal termination. The deposit of fibrillated fibrin within, and the inflammatory new-formed tissue without, may retard, but rarely arrests, the progress of the disease. Added to the danger of death from rupture of the sac, or compression of neighboring organs, is that of inflammation and sloughing as the result of infection or overtension of the skin as the tumor approaches the surface. The hope of recovery is in the gradual deposition of fibrin within the sac, causing its ultimate occlusion, or that of the vessel or vessels immediately connected with it. The danger of gangrene in the parts beyond the tumor is lessened with the gradual establishment of the collateral circulation, while the sac and its contents are less apt to inflame than when the occlusion is sudden and the clot recent. The treatment of aneurism is constitutional and local. The constitu- tional treatment is directed tow7ard the judicious support of the physical powers of the patient, the relief from pain, and the production of a condition of the blood favorable to a deposit of fibril lated fibrin in the tumor. The local measures are directed to the mechanical control and arrest, either gradual or immediate, of the circulation in the aneurism, with the same end,in view, namely, the formation of fibrin within the sac. Constitutional measures alone offer little hope of a cure, and are ap- plicable only to cases where the dangers of operative interference are sufficient to contra-indicate any surgical procedure. In this plan of treatment rest in bed is the first and essential requirement. In conjunc- tion with this there may be administered certain remedies which dimin- ish the rapidity of the circulation, or affect the blood vessels or blood in such a manner that the gradual deposit of fibrin in the sac is produced. Valsalva's method of rest in bed, venesection, and gradual starvation, in order to slacken the blood current and thus cause coagulation in the aneurism, is now almost entirely abandoned. Though heroic, this plan of treatment is not without good results, as will be showTn in the report of cases of special aneurism.* Tufnell modified Valsalva's method by omitting bloodletting and substituting a restricted diet, with the minimum of fluids. Rest in the * See " Subclavian Aneurism," fourteen cases by Valsalva's method. 270 A TEXT-BOOK OX SURGERY. recumbent position must be rigidly enforced. Among the remedies which have been recommended for internal administration, iodide of potassium is most important. It is especially efficacious in syphilitic aneurism, and it is often essential to combine mercury with it. Among the many surgical procedures instituted for the relief of aneurism, those two which deserve the first consideration are compression and the ligature. Compression may be employed on the cardiac side of an aneurism, close to the tumor, without an intervening collateral branch, or at a dis- tance from the sac, with one or more intervening branches. It may be employed on the distal side, with or without intervening anastomosis, or directly to the surface and back of the tumor, or, again, on both periph- eral and central sides, with or without direct compression of the aneurism. The ligature may be applied on the cardiac side of the tumor, there being one or more branches given off between the ligature and the sac Antyllus's method. Wardrop's method. Anel's method. Hunter's method. Brasdor's method. Fig. 310. (Hunter's method), or without an intervening branch (Anel), or on the distal side without (Brasdor), or with an intervening branch (Wardrop), or close to the tumor on both the distal and cardiac side, with or without extirpation of the tumor (Antyllus) (Fig. 310). AVhen interrupted pressure upon the main trunk, on the cardiac side of an aneurism, is possible, it is the first method of treatment to be adopted. It can only be contra-indicated when the tumor is so near to the great cavities from which the arteries emerge that there is not snffi- AXEUR1SM. 271 cientroom for its accomplishment, or when, on account of the anatomical , arrangement of contiguous nerves and veins, compression is painful or inexpedient, or when, as will occur only in exceptional instances, rupture is imminent; then the ligature is demanded. Compression may be manual or instrumental, and continuous or in- terrupted. Given a popliteal aneurism, as an illustration, compression on the cardiac side, with an intervening branch, may be employed as fol- lows : Digital or Manual.—The patient being placed in a position comfort- able to himself and convenient to the operator, is, if the necessity de- mands, put under the infiuence of an opiate or anaesthetic. Compression is then made with the pulp of the thumb laid upon the femoral artery, just where it crosses the rim of the pelvis, until pulsation in the tumor is diminished or arrested. Additional force is gained by pressing the thumb or fingers of the opposite hand on the dorsum of the thumb first employed. When from fatigue further compression is impossible, the operator is relieved by the next of the detail, and so on. After a lapse of from two or three hours to at times as much as three days, the tumor ceases to pulsate, becomes firm and inelastic, and remains permanently occluded. Mechanical.—A method less tiresome to the operator, no more annoy- ing to the patient, and almost, if not equally, as effective, is as follows : One or two sticks of hard wood about an inch in diameter, and from four to six feet in length (small-sized hoop poles or a crutch will suffice), are covered at one end with an India-rubber tip, or compress of some soft substance. The other end is tied to the ceiling with a string or to a bar Fig. 311.—(After Esmarch.) over the bed, and allowed to descend until the tipped extremity rests with the required weight upon the vessel to be compressed (Fig. 311). It may be convenient to employ two poles, so that one may press a few inches lower down than the other. If one is employed, the assistant or A TEXT-BOOK OX SURGERY. Fio. 312.—Briddon's compressor. patient can be directed to change the point of pressure at intervals, in order to prevent pain or excoriation. For this same purpose the late Prof. Alpheus B. Crosby successfully employed an elastic tube par- tially filled with shot to give it the requisite weight. The tube was suspended above the bed and the pressure regulated by the quantity of shot. Virious tourniquets, with one, two, or three compression pads, have been used with the same object in view, and with varying success. Among the better of these in- struments is Charles K. Brid- don's compressor (Fig. 312). Compression with the mech- anism just described may also be employed on the distal side of the aneurism, although with less hope of success than in pressure on the cardiac side, which is among the most suc- cessful of the conservative methods at the surgeon's com- mand. Direct pressure upon the aneurismal tumor has been em- ployed in a few instances with a fair degree of success. Six cases of subclavian aneurism treated in this manner will be given hereafter, with description of the mechanism. Pressure on both the distal and cardiac sides, with or without direct pressure on the tumor, has been practiced by the employment of Es- march's bandage. The method is inferior to digital or mechanical com- pression on the cardiac side of the tumor, and is decidedly more dan- gerous. In the application of the ligature the method of Hunter is generally preferable. The advantages of this method over that of Anel may be enumerated as follows: The ligature is applied at a distance from the aneurism where the artery is more apt to be in a healthy condition, thus diminishing the danger of secondary haemorrhage. The existence of one or more collateral branches between the ligature and the tumor renders the process of coagulation in the sac less rapid, and consequently firmer. The only objection to this method of operating is the possibility of fail- ure due to too free anastomosis, whereby the necessary diminution of the circulation is prevented. The method of Anel is rarely performed, for the reason that the walls of the vessel are apt to be diseased so near the aneurism. Deligation upon both sides of, and close to, the tumor (method of Antyllus) is not practiced, except in particular cases, where the aneuris- mal tumor has numerous anastomoses connecting directly with the cav- ity of the sac, as is not infrequent in popliteal aneurism, in which the sac is usually dissected out. That part of the operation of Antyllus ANEURISM. 273 which consisted in incision of the tumor and packing the sac is not advised. The operations of deligation upon the distal side of an aneurism, so close to the tumor that no collateral branch intervenes (Brasdor). or at a point more remote with one or more collateral branches intervening (Wardrop), are procedures which have been frequently employed, espe- cially within the last few years. Preference is given to Wardrop's operation.* Aseptic catgut prepared strictly after the method of Van Horn and Ellison, as given on another page, is the safest and most reliable of all materials in the deligation of arteries. The larger sizes should be used for the larger vessels: Nos. 4 to 6 for the Macs, femorals, subclavians, and carotids, and proportionately smaller ligatures for the smaller ves- sels. Should it ever become permissible to tie the aorta, I would prefer twists of a number of filaments of No. 3 or 4 catgut, rather than one large solid cord. Among the methods of treatment of aneurism which have been prac- ticed with varying degrees of success are teasing the inner surface of the sac wall wdth a long aseptic needle, as practiced by Macewen, of Glasgow; the introduction of a large ■number of silver pins plunged into the sac as in a pincushion, and left in from twelve to twenty-four hours, as practiced by myself; massage or kneading; flexion; and the introduction of wire or horsehair into the sac. Teasing the Sac.—Macewen successfully practiced this method, which consists of the introduction of a long, delicate sterile needle into the cavity of the sac, bringing the point of the needle along the wall in various directions, by this means exciting more rapid formation of co- agulum in the roughened wall. In aneurisms at the root of the neck, as of the ascending or transverse aorta, of the innominate or carotid arteries, or of the subclavians close to the carotid, the danger of clot being washed into the vessels leading to the brain should not be over- looked. Acupuncture consists in the introduction of needles or, preferably, silver pins. In one case cf large thoracic aneurism of the ascending aorta, in which I was afraid to employ Macewen's method for fear of clot being carried to the brain, under careful aseptic precautions, I introduced about two dozen silver pins, two inches long, to their full depth into the aneurismal sac, the pins being about one fourth of an inch apart. They were left in from twelve to twenty-four hours, and produced well-marked coagulation. The operation was repeated twice in this case; the aneurism diminished rapidly in size, and the patient * There is no evidence that Brasdor pycr did more than suggest the distal operation. Des- champ was the first to perform it (October 6, 1T!)S). but without success. Wardrop modified the operation and established it by successful practice in lSSo. (Sec article by the author, " American Journal of the Medical Sciences." January, 1881. p. 155 : and '• Prize Essay of the American Medi- cal Association," 1878. p. 94.) The general results of this procedure have been such as to en- courage its repetition, although the manner in which a partial arrest of the circulation through the aneurism by deligation on the distal side of the tumor induces coagulation in the sac is diffi- cult of explanation. 274 A TEXT-BOOK ON SURGERY. was discharged much improved. He returned to his work, and a year later died from dislodgment of a clot which was swept into the carotid artery, causing fatal cerebral anaemia. Massage or kneading has been successfully performed in a few in- stances. The aneurism is manipulated with the intention of detaching from the sac enough of the fibrillated clot to plug up the efferent vessel and thereby practically tie the artery on the distal side (Brasdor). It is of doubtful propriety except in small aneurisms situated in the arms or legs. The danger of embolism in the cerebral circulation is too great to justify this or any similar iirocedure upon an aneurism connected with a vessel leading toward the brain. Flexion or posture is practically a method of direct compression, using the normal tissues for a pad. It is employed in popliteal aneu- rism, where the knee is flexed and fastened so as to compress and par- tially occlude the tumor between the tibia and fibula, and the femur. It is a justifiable method in rare instances. The same practice may be instituted at the elbow, but is impracticable at the axilla on account of the arrangement of the nerves. The introduction of watch-spring, silver-wire, horsehair, catgut coil, or any other foreign solid substance into the cavity of an aneurism will rarely be justifiable except as a last resort in cases where the ligature or compression is impossible. For its execution a pointed canula is usually employed, which, having been introduced into the sac, the wire or gut is pushed through. The quantity used varies from two or three feet up to several yards. More of the catgut may be introduced than of the metal, and the animal ligature should always be preferred if this procedure is adopted. Special Aneurisms. Aneurism of the Thoracic Aorta.—The ascending and transverse portions of the arch are most frequently affected. If the dilatation is fusiform, both of these segments are apt to be involved ; if it is a sac- culated aneurism, it is usually confined to one or the other segment. Sacculated aneurism of the ascending arch high up, or of the transverse arch, usually involves the orifice of one or more of the great vessels which originate here, although, as in the specimen figured below (see Fig. 313), not infrequently the mouth of the sac opens close to these vessels, but does not involve them. The diagnosis of aneurism of the arch is generally obscure until the dilatation has advanced to such an extent that pressure symptoms are evident. Pain of varying intensity may be present in the earlier stages of development of both fusiform and sacculated aneurism. A symptom of great diagnostic value is disturbance of the laryngeal muscles, due to pressure upon the recurrent laryngeal nerve of the left side. This occurs in dilatation of the transverse or descending segment of the arch. The aneurismal bruit may be recognized as soon as the sacculation is well advanced. Interference with respiration, or deglutition, or the return cir- culation in the veins, is among other and important pressure symptoms. SPECIAL ANEURISMS. 27.1 The appearance of a tumor with an expansile pulsation synchronous with the cardiac systole, in the upper thoracic region, determines the diagnosis of aneurism. The differentiation of dilatation of the arch, from a similar condition of the innominate, left carotid, or left subclavian in the thorax, is difficult, and at times impossible. A number cf errors in diagnosis by competent and honest observers are on record. The following points will aid in arriving at a diagnosis : The tumor in aneurism of the ascending arch is usually first appreciated to the right of the sternum, between the clavicle and the third rib. The pressure symptoms do not affect the voice until the tumor is recognizable in the right side of the root of the neck, where it involves the right recurrent laryngeal nerve. Respiration may be interfered wuth, or cough produced by compression of the right bronchus. This condition will be recognized by the hissing rales distributed over the area of the right lung. Aneu- rism of the transverse arch is usually first recognized to the left of the sternum on about the same plane as for the ascending segment. Laryn- goscopical examination will demonstrate that whatever of muscular paresis exists is confined to the left vocal bands. If the tumor rises into the heck, its appearance will have been preceded by pressure symptoms of longer duration and greater severity than in either innominate, carot- id, or subclavian aneurism. Innominate aneurism usually appears at the upper margin of the sternum in the space between the two tendons of origin of the right sterno-mastoid muscle, or in the interclavicular notch. The disturbance of the circulation through this vessel so affected may be recognized by the difference in the force and character of the pulse wave in the radial arteries of the two arms. In aortic aneurism, when the innominate is not compressed by the tumor, the pulse wave will be the same in both arms. It must, however, be borne in mind that in sacculated aneurisms, springing, as they not infrequently do, from the arch in immediate prox- imity to the orifice of the innominate, and rising to the root of the neck, in front of or behind this artery, a positive diagnosis is scarcely possible. The pressure on the innominate may retard or weaken the right radial pulse, when this vessel is not involved, while the aneurismal bruit is present in the exact location of this vessel. Aneurism of the left carotid artery will first appear at the left sterno- clavicular articulation in the line of this vessel. The murmur will be transmitted toward the distribution of this vessel, and will not be heard in its fellow opposite. When the left subclavian is involved, the swelling wdll usually appear to the left of the sterno-mastoid muscle, and the pulse in the left radial will differ from that of the right. AVhen the descending aorta is the seat of aneurism, the diagnosis is still more obscure. The peculiar murmur is most easily recognized by placing the stethoscope to the left of the vertebral column in the interscapular space. The chief pressure symp- toms are those which affect deglutition and lift the heart forward. The clinical history of aneurism of the thoracic aorta usually ends in the death of the individual. In addition to the symptoms given in the 276 A TEXT-BOOK ON SURGERY. method of diagnosis, the gradual expansion of the tumor leads to more painful and graver conditions. Anxiety, loss of sleep, pain, and cough usually prostrate the patient; erosions of the ribs, sternum, clavicles, and vertebras occur, and sloughing, septic absorption, or haemoirhage may produce a fatal termination. The medical treatment is rest in bed, and the safe and judicious com- bination of Valsalva's and Tufnell's methods as given. The surgical treatment is of the most heroic order, and should not be instituted until Fig. 313.—The author's case of aneurism of the ascending aorta. a reasonable trial of the other methods has proved them as inefficient, as death is inevitable. This treatment is the deligation of one or more of the great vessels which are derived directly or indirectly from the arch—- i. e., the distal operation. That this operation is justifiable, under certain conditions, has been demon- strated. Among a number of cases in the statistics of this procedure, the following are from personal experience : On the 21st of September, 1880, I tied the right carotid and subclavian arteries SPECIAL ANEURISMS. 277 simultaneously for the relief of an aneurism of the ascending portion of the aorta.* The history of the aneurism dated back sixteen months. Having developed rapidly, it projected through the right second intercostal space, causing such pain that the operation was undertaken. This was the second operation which had knowingly been undertaken for the relief of aneurism of the ascending aorta. Despite the prostrated condition of the patient, she recovered, the tumor diminished perceptibly in size, became more solid, and her general condition was much improved. One Fig. 314.—Section through the long diameter of the tumor. month after the operation she was discharged from the hospital, and traveled to a neighboring State, where she died/one year later, from acute diarrhoea. I secured an autopsy, which revealed an aneurism (Figs. 313, 314) as large as an orange springing from the ascending aorta, at its junction with the transverse segment. Hie orifice of the tumor was an oval, about half an inch by one inch in extent. The tumor was solidified with permanent clot on its lateral and posterior aspects. On the upper anterior surface, which had worn away the sternum and second rib, the sac was thin, with a recent clot which filled a cavity not quite an inch in diam- * For a full report of this, and all the other cases up to that date, see paper by the author in "American Journal of the Medical Sciences." January, 1881. 278 A TEXT-BOOK ON SURGERY. eter. The tumor was practically solidified, and had this patient not returned to her dissipated practices (alcoholism), I do not doubt that her recovery would have been complete. Prof. H. B. Sands performed the same operation, in 1866, for a supposed innomi- nate aneurism.* The tumor diminished after the operation, and visible pulsation ceased. The patient died, thirteen months later, from the pressure of the tumor which sprang from the junction of the ascending and transverse segments, just in front of the innominate. C. F. Maunder's patient died, on the fifth day, from occlusion of the aorta by a clot which projected from the aneurismal sac. The tumor sprang from transverse segment, a- little to the left of the innominate.! Heath's patient lived four years after the double distal ligature. The aneurism diminished in size, and the general condition was much improved. The sac ulti- mately burst, with a fatal result. The tumor originated from the ascending aorta.J Mr. Richard Barwell and Mr. Lediard have also performed this opera- tion for aneurism of the arch. Mr. Barwell's patient died fifteen months after the operation, dying from dissipation and " general wearing out." The aneurism was completely filled with laminated clot. Mr. Lediard's patient survived ten months.* Hobart tied the right subclavian in its first division, and the right common carotid, for a supposed innominate aneurism. Fatal haemorrhage occurred from the seat of ligature on the carotid on the sixteenth day. The autopsy showed a pyriform aneurism originating from the aorta, just to the left of the innominate. The sac was filled with a firm coagulum. || Thus, of seven cases of simultaneous deligation of the right carotid and right subclavian arteries, two died on the fifth and sixteenth days, respectively, from the effect of the operation. The remaining five recovered, with evident improve- ment. A point of great interest is to notice the effects of the operation upon the, tumor. In my case there was no immediate change in the aneurism. Within twenty- two hours the diminution was evident, and by the fourth day it had shrunk from an elevation of one inch and a half above, down almost to the level of the skin upon the thorax. In Sands's case " the tumor diminished after the operation, and visible pulsation ceased." There was no diminution in Maunder's case, but after death the sac was almost completely filled with recent clot, which had even occluded the aorta. In Heath's case "the tumor gradually diminished in size." The symptoms so far disappeared in Barwell's patient that that surgeon informed me, " The aneurism is, judging from symptoms, cured." In Lediard's case the " laryngeal symptoms dis- appeared ; the tumor had a more consolidated feeling." The sac in Hobart's case " was filled with firm coagulum." The evidence in these cases, in which the right subclavian and right carotid arteries were simultaneously tied for aneurism of the arch of the aorta, involving the last portion of the ascending segment, or the first portion of the transverse segment, or both, points to the conclusion that, in sacculated aneurism, affecting the arterial limit just given, the double distal ligature tends to produce consolidation of the tumor, and to relieve the symptoms of distress caused by its presence.A In the study of cases in which one or the other primitive carotid has been tied for uncomplicated aortic aneurism I am enabled to collect but nine instances. In the * See " American Journal of the Medical Sciences," January, 1881. t Ibid. % Ibid. * Ibid. || Tbid. A See autnor's case of deligation of the left subclavian and left common carotid arteries for aneurism of the transverse portion of the arch, page 303. SPECIAL ANEURISMS. 279 limits of a text-book it will be impossible to give a detail of such cases, however interesting to the student. I refer him to my article on this subject in the u American Journal of the Medical Sciences," January, 1881. The operators were Montgomery, T. Holmes, Barwell, Tillanus, Rigen, O'Shaugnessy, Annandale, Heath, and Bryant. The left carotid was tied in six cases, and all recovered. Mont- gomery's patient died, four months after operation, from purulent pericarditis. The tumor had solidified and sloughed. Holmes's case was much improved, and, in answer to my inquiry concerning this case, in 1880, five years after the operation, he writes that the patient is still living, that there is pulsation and bruit in the thoracic portion of the aneurism, but there is no longer any tumor perceptible in the neck. Barwell's case was greatly relieved, dying four months later of another affection. Tillanus's operation was followed by recovery and diminution of the tumor, dying suddenly five months later (probably from cerebral embolism). The sac was com- pletely filled with coagulum. Rigen tied the carotid, February 21, 1829. The patient was relieved, and the tumor diminished considerably in volume. On May 9th was operated on for strangulated hernia, and died June 13th, as was supposed, from asthma. The tumor was solidified. In Heath's case the relief for a long period was marked and undoubted. The patient lived nearly four years, dying ultimately of rupture of the sac. O'Shaugnessy tied the right carotid, with fatal rupture of the aneurism into the mediastinum on the tenth day. Annandale performed the same operation with immediate relief and success. Mr. Bryant's patient died on the tenth day. The right carotid was tied, with no effect on the aneurism. The results in these instances also lead me to conclude that, in sacculated aneurisms of the aorta, near the origin of the innominate and left carotid, deligation of one carotid, especially the left, is a justifiable procedure when the conservative method of rest and restricted diet has failed. Aneurism of the thoracic aorta beyond the transverse segment is not amenable to surgical treatment. Aneurism of the Innominate Artery.—The symptoms of this for- midable lesion have been given on a preceding page. It is frequently complicated with aneurismal dilatation of the aorta, or of the two vessels into which it usually bifurcates. It will be interesting to study the re- sults of operative procedures under the following subdivisions: 1. Innominate Aneurism. 2. Aortic innominate Aneurism.—For in- nominate aneurism, (a) the double simultaneous distal ligature (carotid and third division of the subclavian); (b) the double non-simultaneous distal operation ; (c) distal deligation of the carotid artery alone ; (d) distal deligation of the subclavian artery alone. Simultaneous Deligation of the Bight Common Carotid and the Right Siib- rlavian Artery (Third Division) for the Belief of Innominate Aneurism*—Prof. •h L. Little performed this operation in 1877. The patient recovered, was much improved, and died from pleuritis, not associated with the aneurism, three years later. The carotid and subclavian were slightly involved. Durham's patient died on the sixth day, as was reported, from "shock." The possibility of cerebral em- bolism is worthy of consideration in explaining the sudden death of this patient. * For more complete details, see preceding reference. 280 A TEXT-BOOK ON SURGERY. M'Carthy's case died, on the fifteenth day, from haemorrhage on the proximal side of the subclavian ligature. Prof. Eliot's patient died, on the twenty-sixth day, from haemorrhage from the sac. Prof. L. A. Stimson's patient recovered, with marked improvement and consolidation of the aneurism. The tumor became very much smaller, and the symptoms were relieved. Death occurred, twenty-one months after the operation, from phthisis. The sac was filled with firm clot. In the case operated upon by Prof. R. F. Weir, death resulted, from rupture of the sac, on the fifteenth day. Rossi's patient died on the sixth day, most probably from cerebral anaemia, since, at the necropsy, the left vertebral was the only pervious artery lead- ing to the brain. Elisor's case ended in death, from rupture of the sac, on the sixty-fifth day. Barwell operated, with recovery and marked improvement. Kind's patient died, from haemorrhage from the aneurism near the carotid ligature, on the one hundred and eleventh day. Gerster's case recovered, with gradual improve- ment.* McBurney, 1887 : Male, thirty-five years, probably syphilitic; noticed tumor in the neck at inner end of clavicle and voice became affected ; diagnosis of aneurism involving the innominate and origins of carotid and right subclavian. Rest in bed and potassium iodide did not affect the development. Operation; catgut ligature to right carotid and third portion of subclavian; pulsation in tumor almost entirely ceased. Method of Tufnell carried out. Nine months after operation the tumor was at least one fourth its original size and the voice only slightly hoarse. The patient made a complete recovery, and died of Bright's disease three years and eight months later, and suffered from no pressure symptoms until a few weeks before death. The aneurismal sac was filled by a large laminated clot Of these twelve cases, recovery, with a cure more or less perfect, took place in five, while death occurred in seven. It is very probable that, if in some of these fatal cases the operation had been performed earlier, the rate of mortality would have been lower. The double distal operation, with varying intervals between the deligation of the carotid and the subclavian arteries, has been performed in the following instances: Prof. A. B. Mott tied the subclavian artery in a patient who had had the right carotid deligated one year previously. The patient died, three years after the Fast operation, from phthisis. The aneurism was cured. In Heath's case the carotid was first tied, with temporary amelioration of symptoms. Two years later the sub- clavian was operated upon. The aneurismal bruit disappeared, and the urgent symptoms disappeared. Four months later the patient died from traumatic pleu- ritis, caused by a fall while drunk. The tumor was consolidated. In Wickham's case the interval was two months and nine days. Immediate and temporary relief followed both operations. Death ensued from rupture of the sac on the forty-fourth day. Malgaigne's patient was not materially benefited by the first operation. Three months later the subclavian was tied, followed by death, from rupture of the sac, on the twenty-first day. A glance at these cases, and a careful study of their more complete histories, can not but impress one with the gravity of the surgical pro- cedure under consideration. The postural, dietetic, and medicinal method should be thoroughly tried in all cases where the disease has not pro- gressed so far that death is imminent from pressure, or the suffering so intense that life becomes intolerable. Under these last conditions the operation is justifiable. If the conservative method, after a courageous * " German Hospital Records,'* 1883-84, Xew York city. SPECIAL ANEURISMS. 281 and faithful trial, does not arrest the disease, then again the operation is demanded. There is little choice between the simultaneous deligation and the operation with an interval. The carotid should always be first tied, to prevent the danger of cerebral embolism. Innominate Aneurism treated by Deligation of the Carotid, or the Subclavian. (The Single Distal Operation.)—The records of surgical literature contain fourteen instances in which, for the relief of aneurism involving the innominate artery alone, the distal ligature was applied to the right carotid. In one single instance (Evans's) a cure was effected, and this after suppuration occurred in the sac, which discharged twenty-four ounces of pus. Of the fourteen cases, eight ended fatally. Seven of these died be- tween the second and twenty-first day, and in one of these it is evident that death was caused by the consolidation of the aneurism. Another surgical procedure for the relief of innominate aneurism, which has received the sanction of eminent practitioners, is that of single deligation of the subclavian artery in its third division. The operators are Wardrop, Broca, and Thomas Bryant. Each case recovered, with marked improvement. Wardrop's patient lived two years, and died partly from the effect of pressure of the aneurism and partly from gen- eral systemic failure. The tumor was firmly soldified, with the excep- tion of a small central channel which led into the carotid. Broca's case died, from pulmonary gangrene, five months later. Consolidation was also almost complete in this case. Bryant's patient was living one year after the operation, and there was evidence of solidification in the tumor. While it is scarcely possible to base a definite opinion upon a study of such a limited number of cases, the evidence seems to be in favor of the operation of tying the subclavian in preference to the carotid for innominate aneurism. It would be natural to infer that the danger from cerebral embolism wTould be great after such a procedure, yet it evidently did not occur in any of these instances. In aneurism involving both the innominate and the aortic arch, the double distal operation is recorded in eight instances. In the following cases the two vessels were tied at the same operation, excepting one in which there was an interval of only twenty-four hours. Mr. Barwell, in one instance, with a recovery and very great improvement. The patient died, nineteen months later, from bronchitis. The tumor was firmly consolidated. The same surgeon, in a second case (with an interval of twenty-four hours), with recovery and great improvement. Death from broncho-pneumonia three months later. The tumor, as large as a tennis ball, was solid, excepting a central globular cavity one inch in diameter. The same surgeon, in a third case, which ended fatally, from asphyxia, in thirty hours. Mr. Holmes's patient died from exhaustion two months after operation. The sac was full of recent clot. Mr. Lane's case terminated fatally within three mouths, from rupture of the sac. The patient operated upon by Mr. Hodges died, with symptoms of broncho-pneumonia, on the twelfth day. There was no sacculated aneurism, but an extensive fusiform dilatation of the in- nominate and aorta. Ransohoff's case ended fatally, from asphyxia, in seven days. 20 282 A TEXT-BOOK ON SURGERY. In one instance Mr. Bickersteth operated, with an interval of forty-nine days, but without benefit, as the patient died from the progress of the disease in three months. The results in these cases do not encourage a repetition of this opera- tion in well-marked instances of aorto-innominate aneurism. The con- servative methods offer the best hope of palliation. The deligation of one of the primitive carotids has been performed in six instances for the relief of aneurism involving the innominate, compli- cated with dilatation of the aorta or the first portion of the right sub- clavian or carotid. Pirogoff tied the left carotid in two cases. One died within a week, from hemi- plegia and coma; the sac was completely filled with clot. The other recovered, and was improved up to two months, when the history ceases. In the remaining four cases the right carotid was tied. The operation by Hewson terminated fatally on the tenth day, from asphyxia, due to pressure from the consolidated tumor. The *two terminal branches of the innominate were also involved. Campbell's patient suffered a like fate, from the same cause, while Key's was also fatal m four hours, from coma. Hutchison's died on the forty-first day from asphyxia due to pressure of the enlarged and consolidated aneurism. In six cases, jive died within a few days after the operation, and three of these seem to have ended fatally from consolielation of the aneu- rism, the very object for which it was performed. Aneurism of the Common Carotid Artery.—Aneurism of the carotid may occur in any part of the course of this vessel, being in rare instances intra-thoracic (when the left trunk is involved). The diagnosis of aneurism of the left carotid, low down, depends upon the presence of the aneurismal bruit at the site of the tumor, this murmur being carried along in the distribution of the artery. Pressure symptoms are referable to laryngeal interference from compression upon the pneumogastric ; or distention of the left internal jugular, and in rare instances the left subclavian vein. The presence of the swelling is usu- ally first recognized in the space between the two tendons of origin of the left sterno-mastoid muscle. Aneurism of the right carotid, within the first inch of its course, gives rise to the ordinary symptoms of this lesion, just beneath the sterno-mastoid muscle, at and immediately above its clavicular origin. Aneurism of the vertebral artery, in its lower portion, may be differ- entiated from- that of the carotid by compression of this latter vessel high up. If the thumb be placed over the carotid, at its bifurcation, and pressed firmly and directly backward against the vertebral column, such compression will not affect the circulation in the sac of a vertebral aneu- rism, while if involving the carotid it would be visibly affected. Then, again, vertebral aneurism is, in nearly every instance, of traumatic origin, and the traumatism is usually a stab wound, while aneurism of the carotid is almost always idiopathic. In the differential diagnosis of these two lesions higher in the neck, the same method is applicable. It should not be forgotten, in the effort SPECIAL ANEURISMS. 283 to form a diagnosis, that careless manipulation of a cervical aneurism is not allowable, on account of the danger of detaching a clot, which may pass up into the brain. If the tumor involve the carotid or its branches compression of the primitive trunk, low down, will arrest the pulsation in the sac. This is best accomplished by relaxing the sterno-mastoid muscle of that side, and grasping the vessel between the thumb and finger carried behind the muscle. On account of the deep seat of the vertebral artery its compression by this manoeuvre is impossible. This last vessel may be compressed by placing the thumb one inch directly below the transverse process of the sixth cervical vertebra, and pressing backward. Above this point it is impossible, since the vessel runs into the vertebral foramina. The treatment of carotid aneurism is surgical and palliative. The lat- ter method refers to the postural, dietetic, and medicinal treatment of aneurisms in general. The only surgical procedure which should be rec- ommended is the ligature. While it is true that some cases are recorded as cured by digital compression, I can not but consider this method as dangerous, for the reason that, in the process of consolidation where the circulation is only temporarily interrupted, cerebral embolism may occur. The animal ligature, with antiseptic cleanliness, offers the safest means at our disposal. The operation varies with the seat of the tumor. It may be divided into deligation upon the distal and cardiac side of the aneu- rism. The distal ligature has been applied in seven recorded instances—five on the right and two on the left carotid. Two deaths occurred from haemorrhage: one from the distal side of the (silk) ligature on the sixty-first day, the second case from rupture of the aneurism on the sixty-seventh day. A third case recovered, but the progress of the disease was not arrested, and death followed the rupture of the sac on the ninety-first day. The remaining four cases were either much improved or cured. The use of the catgut ligature would probably have saved the patient operated upon by Lambert, in which silk was used, causing death from haemorrhage on the sixty-first day. Deligation upon the cardiac side is always preferable when a suffi- cient extent of sound artery can be secured around which to apply the ligature. In my " Essays on the Surgery and Anatomy of the Great Vessels of the Neck " I have recorded 106 cases in which the artery was tied on the cardiac side of the aneurism; 69 recovered; rate of mortality, 35 per cent. For aneurism of the ex- ternal carotid or its branches, 17 recoveries and 5 deaths. Of the if recoveries, 16 were cured. For aneurism involving the common carotid alone, the death rate was ■U per cent, When the aueurism involves the common, external, and internal carotids, the ligature should be applied to the common trunk, on the cardiac side, while the distal ligature may be applied to the external trunk, at the same time securing the larger branches derived from this vessel between the ligature and the bifurcation. By this operation the circulation through the tumor, and in the direction of the brain, is practically arrested. Aneurism of the external carotid demands the deligation of this vessel and no other, when by a careful dissection it is discovered that 284 A TEXT-BOOK ON SURGERY. there is a half or three quarters of an inch of this trunk between the bifurcation and the sac. In three instances I have placed the ligature around the external carotid exactly at the crotch of the bifurcation, tying also the superior thyroid branch. All recovered without accident. In the event that this method is impracticable, the common trunk must be tied. Aneurism of the internal carotid, in the neck, should be treated by the deligation of this vessel, between the sac and the common trunk, if possi- ble. When a sufficient surface of healthy artery can not be obtained, the common and external carotid should be tied, together with all branches derived from the external, on the cardiac side of the ligature. I performed this operation in one instance, resulting in the rapid and permanent cure of a large extra-cranial aneurism of the internal carotid. The common trunk was first tied, then the superior thyroid, and exter- nal carotid, just above its origin. Aneurism of the internal carotid may occur in the cavernous or cere- bral portions of this vessel. In the petrous canal dilatation is practically impossible. Not infrequently an arterio-cavernous aneurism occurs from the giving way of the septum between these two vessels. The cause may be traumatic, as in fracture at the base of the skull, or the communi- cation may be established without appreciable cause. The symptoms of aneurismal dilatation here are of two kinds : those referable to pressure upon the brain and nerves, and those due to inter- ference with the return venous current through the ophthalmic vein. If the arterio-venous communication has occurred, exophthalmus is marked, and the eyeball is projected forward with each arterial pulse. Singing in the ears, dizziness, with varying loss of function due to pressure, are other symptoms of this condition. The ophthalmic artery may be the seat of aneurism, within the cranial cavity or in the orbit. True sacculated intra-orbital aneurism of this artery is extremely rare, only two cases being recorded,* although pul- sating tumors, as arterio-venous aneurisms, angeiomata, cirsoid arterial tumors, etc., are not infrequent in this locality. The chief point in the diagnosis, and the one which has an important bearing in treatment, is compression of the carotid. If pulsation ceases, and the other symptoms disappear, the indication is clear that the ligature should be applied to this vessel. The common trunk should be tied, in order to cut off the free communication between the branches of the external carotid and the ophthalmic fn the orbit. In my Essays are given fifty-two instances in which this operation was done for pulsating non-malignant tumors of the orbit, with a death rate of 11-5 per cent.f About 75 per cent of recoveries after this operation result in cures. In severe cases extirpation may be necessitated. Aneurism of any branch or branches of the external carotid should he treated by the ligature of the branch involved, or the external trunk. * Prof. Sattler's classical paper in Graefe and Saemisch's '• Handbuch der gesammter Augenheilkunde," Leipsic, 1880. t " Prize Essays of the American Medical Association, 1878," William Wood & Co., New York. SPECIAL ANEURISMS. 285 Aneurism of the Subclavian Arteries.—The subclavian arteries may be affected in any portion of their extent, although, on account of the pressure exercised by the two scaleni muscles, between which their second portion lies, this division is less frequently involved in aneuris- mal dilatation. The seat of this disease is by preference in the third portion, the first division being next in order. Exposure to violence or muscular effort undoubtedly has much to do with the development of subclavian aneurism, since males are very much more frequently affected than females, while the tumor is found on the right side in the great majority of cases. The first portion of the right subclavian is not infrequently involved in the progress of an innominate aneurism. Upon the left side aneurism of the thoracic portion of this vessel is rare. Subclavian aneurism, as it usually develops, is first recognized as a pulsating tumor, felt rather than seen behind the clavicle, and to the outer side, or behind the sterno-mastoid muscle. It may be mistaken for a glandular or other tumor of the soft tissues. The symptoms which have been already detailed will serve as a guide for proper differentiation. Difficulty may arise, even after the aneurismal character of the swelling has been recognized, in determining from what vessel the tumor springs. As has been said, the progress of aortic aneurism gives rise to pulsation and pressure symptoms, located in the thorax for a considerable period prior to the approach or appearance of the tumor at the root of the neck. In fact, aneurism of the aorta, in many instances, produces death before it attains such magnitude. On the right side, this knowledge will aid materially in recognizing the seat of the lesion, and, fortunately, aneu- rism of the arch and subclavian occurs most often on this side of the body. The differentiation of aneurism of the thoracic portion of the left artery, from the same lesion of the arch, near the origin of the subclavian, is somewhat more difficult. When the tumor involves the subclavian its appearance in the neck is more rapid than in the aortic aneurism, while interference with the return circulation in the arm, which may appear early in the history of subclavian aneurism, is rare when the aorta is the seat of this lesion. Again, in aneurism of the second or third portion of the arch, which does not involve the subclavian, the pulse wave in the left radial will be of equal force and synchronous with that of the right side. The treatment of subclavian aneurism is a subject of great impor- tance, and one which, from a study of a number of cases, has led to great diversity of opinion and practice.* The methods may be divided into the surgical; the postural, medical, and dietetic; and the palliative or expectant. The employment of any of these means will, again, be in great part determined by the portion of the artery involved in the disease. The surgical treatment comprises the ligature or compression on the cardiac or distal side ; or pressure applied directly to the sac, and massage. * See classical paper by Prof. Edmond Souchon, of New Orleans, " Annals of Surgery,"' No- vember and December, 1895. 286 A TEXT-BOOK ON SURGERY. The application of the proximal ligature for the relief of subclavian aneurism presents an array of disasters which should attract the atten- tion of the surgeon. In a former edition and in my essays on the arteries I tabulated 17 cases in which the innominate, either singly or with the carotid and vertebral, had been tied, with 16 deaths; and in the " Boston Medical and Surgical Journal': of August 8, 1895, Dr. H. L. Burrell supplements these with 12 cases additional, or 29 in all, as follows : Innominate Near Bifurcation involved with the Carotid and Sub- clavian. No. 1 (Valentine Mott, New York, 1818).—Death, twenty-sixth day, by haemor- rhage. Silk ligature. No. 2 (Graefe, Berlin, 1822).—Death, sixty-eighth day, from haemorrhage. Oper- ation for subclavian aneurism. No. 3 (Norman, Bath, 1824).—Death, third day, from haemorrhage. Operation for subclavian aneurism. No. 4 (Arendt, St. Petersburg, 1827).—Death, eighth day, from sepsis. Oper- ation for subclavian aneurism. No. 5 (Hall, Baltimore, 1830).—Death, sixth day, from haemorrhage. Operation for subclavian aneurism. No. 6 (Bland, Sidney, 1832).—Death, eighteenth day, from haemorrhage. Oper- ation for subclavian aneurism. Ligature, thread. No. 7 (Dupuytren, Paris, 1834, reported but not performed by him).—Death, third day, from haemorrhage. Operation for subclavian aneurism. No. 8 (Lizars, Edinburgh, 1837).—Death, twenty-first day, from haemorrhage. Operation for subclavian aneurism. No. 9 (Hutin, Paris, 1842).—Death, twelve hours after operation, from haemor- rhage. Operation for secondary haemorrhage after a penetrating wound. No. 10 (Gore, Bath, 1856).—Death, seventeenth day, from haemorrhage. Oper- ation for subclavian aneurism. Hemp ligature. No. 11 (Pirogoff, St. Petersburg, 1856).—Death, forty-eight hours, from prob- able septicaemia. Operation for subclavian aneurism. No. 12 (Cooper, San Francisco, 1859).—Death, ninth day, probably from sepsis. Operation for subclavian aneurism. No. 13 (Cooper, San Francisco, I860).—Death, thirty-fourth day, from haemor- rhage. Operation for subclavian aneurism. No. 14 (Smyth, New Orleans, 1864).—Recovery. Operation for subclavian aneurism. Carotid and innominate ligated, and fifty-four days later the vertebral also. No. 15 (Lynch, 1867).—Death, twelfth day, from haemorrhage. Operation for secondary haemorrhage after gunshot wound. No. 16 (Porter, Dublin, 18--Hyoid branches, Superior thyroid. Descending cervical. ' ->. The external carotid and its branches. The average arrangement of one hundred and twenty-one dissections by the author. (Life size.) The usual arrangement of these branches is seen in Fig. 325, which ls the average of one hundred and twenty-one dissections. Abnor- mal deviations from this relation of the branches to the parent trunk 316 A TEXT-BOOK ON SURGERY. occur occasionally, and types of these may be seen in Figs. 326 and 327. The relations of the veins to these arteries are shown in Fig. 324. Operation.—The external carotid may be tied in the majority of cases at two points, viz., between the origins of the thyroidea superior and lingualis, about one quarter of an inch above the septum of bifurcation (see Fig. 325), or between the origins of the maxillaris externa and auri- cularis, about one inch and a half above the thyroid cartilage. At the lower point of election the operation is the same as for ligature of the internal carotid on the same plane, except that the external carotid is usually from one quarter to one half inch nearer the median line than the internal. Notwithstanding that the analysis of one hundred and twenty-one consecutive dissections has convinced me of the propriety of ligaturing Fig. 326.—Unusual arrangement of the branches of the external carotid. 1, The lingual and facial from a common origin. 2, The lingual and facial superior thyroid from a common origin. 3, Close relation of first five branches to each other. this vessel, and that the history of the cases in which it has been tied shows a rate of mortality far below that of ligature of the common carotid, yet the proximity of large and important branches to each other, or to the bifurcation of the common carotid in many instances, makes it of the utmost importance that the surgeon should proceed with great care and discretion. The wound should be thoroughly cleansed, and the vessel LIGATION OF ARTERIES. 317 examined with scrupulous care above and below the ligature, and any collateral branch or branches within less than one quarter of an inch should be also secured. Should the artery be found to be normal (as in Fig. 325), I would place the ligature nearer the lingualis than the bifurcation, and tie this vessel separately. If (as in Fig. 326, 3) a rare form should exist, I would ligature close to these branches, and tie each of them in its turn. This same conservative rule must apply to every case. The operation at or above the posterior belly of the digastric is com- paratively safer, and is applicable to all lesions above this point. The incision should extend from the lobule of the ear along the ramus of the jaw, down to the level of the thyroid cartilage. Cutting through the superficial structures, the artery will be found just behind the posterior belly of the digastric muscle. Above this level—that is, after the artery enters the parotid gland—it is so situated that it should not be cut down upon. The incision would involve the facial nerve, causing paral- ysis of the muscles of expression. In malig- nant disease of the parotid, where this gland is removed, the vessel may as well be secured here as not, since the operation itself usually destroys the facial nerve. It is a remarkable fact that, notwithstanding the close proximity of the branches of the ca- rotid, in a number of instances in which it has been ligatured without the precaution of secur- ing immediate collateral branches, there has not followed secondary haemorrhage. No explana- tion of this fact has appeared so definite as the one given by Prof. H. B. Sands, "which takes into account the remarkable reparative power of the tissues surrounding this vessel. Suppu- ration is extremely rare, the wounded tissues soon become consolidated by plastic material, and secondary haemorrhage is prevented by changes occurring outside of, as much as by changes taking place within, the vessel liga- tured." On account of the importance of maintaining the integrity of the circulation to the brain, ligation of the common carotid, for a lesion in the distribution of the external carotid, should never be performed when a sufficient distance remains between the lesion and the bifurcation of the common trunk to allow of the application of the ligature. I have the histories of ninety- three cases of ligature of the external carotid, in sixty-nine of which this vessel alone was tied. Of these sixty-nine cases only three died, while Fig. 327.—An enlarged superior thyroid artery. 318 A TEXT-BOOK OX SURGERY. the death-rate after ligature of the common trunk, for the same period, was 41 per cent. Ligation of the Superior Thyroid Artery—Anatomy.—This branch was present in every instance in one hundred and twenty-one dissec- tions. It originated almost invariably on a level with the thyroid notch. In one of twenty-five cases it will be found to have a com- mon origin with the lingual, or the lingual and facial. See Fig. 326, 1, 2. Operation.—With the neck in the surgical position, i. e., with the head thrown back and the face turned to the opposite side, make an in- cision two inches long, parallel with, and one fourth of an inch in front of, the carotid line. The center of this incision must be on a level with the thyroid notch. Immediately beneath the skin and platysma myoides will be seen the thyroid, lingual, hyoid, and other veins, which may assume either of the forms or relations shown in Fig. 324, A, B, being most common. These being tied and divided, the artery will be found opposite the point above indicated. The thyro-hyoid nerve will occasionally be seen passing across this artery, although usually nearer the median line. The external laryngeal passes beneath it. Ligation of the Lingual Artery—Anatomy.—From its origin, usu- ally opposite the cornu of the hyoid bone, it ascends obliquely upward and inward, and is superficial until it passes underneath the stylo- hyoideus and digastricus (posterior belly), and then more deeply behind the hyo-glossus. In two of one hundred and twenty-one cases it originated in common with the superior thyroid, and in two other instances with this vessel and the facial. In thirty-one of one hundred and twenty-one cases it arose from a trunk common to it and the facial, being abnormally associated in one in every three and a half dissections. Operation.—The lingual artery may be secured either below the digastric or above this point, where it passes beneath the hyo-glossus. For the low operation make an incision as in the case of the superior thyroid, except that its center should be opposite the os hyoides. The artery will be found in the lingual triangle, bounded posteriorly by the external carotid, above by the eh'gastric muscle, below by the os hyoides. The middle constrictor muscle is behind it; the platysma myoides in front, and under this the veins above noted. The hypoglossal nerve is usually just above it as it crosses the carotid, while the thyro-hyoid branch of this nerve crosses the artery on its way to the muscle it supplies. The high operation is one of considerable difficulty. The face should be well turned to the opposite side, the chin elevated, and held per- fectly immovable. Beginning immediately over the os hyoides, near the median line of the neck, an incision is made outward, and parallel with this bone as far as the great cornu, where it is curved upward to the angle of the jaw (Fig. 328). This crescentic flap is turned up, and with it the sub-maxillary gland, in a groove on the under surface of which LIGATION OF ARTERIES. 319 the facial artery runs. As soon as the hyoid bone is exposed it should be fixed with a tenaculum and drawn steadily down. The posterior ..: : 10. Mb. Ligation of the right subclavian in its third surgical division; the facial in the neck and the lingual beneath the hyo-glossus muscle. helly of the digastric will now be seen passing obliquely downward and forward to the central tendon in the hyoid bone. Passing beneath this muscle, and superficial to the hyo-glossus, is seen the hypoglos- 07781210 320 A TEXT-BOOK ON SURGERY. sal nerve, which runs parallel with and above the artery. Depress the posterior belly of the digastric, insert a director beneath the posterior fibers of the hyo-glossus, and divide these. The artery will be found just beneath this muscle, resting upon the middle constrictor of the pharynx. The ligation of this artery is frequently practiced preliminary to ex cision of the tongue for malignant disease, and occasionally to arrest haemorrhage. Ligation of the Facial Artery—Anatomy.—The facial artery was present in one hundred and twenty of one hundred and twenty-one dis- sections. In the instance in which it was missing its facial distribution was taken by the transverse facial from the temporal, and its cervical by branches from the lingual and the external carotid. Its origin is usually about one fourth of an inch above the lingual. It is the long- est branch of the external carotid. In thirty-one of one hundred and twenty cases it arose in common with the lingual, and in two in- stances it was from a trunk in common with this artery and the supe- rior thyroid. Operation.—In its cervical distribution this vessel will require to be tied at or near its origin from the carotid. The incision along the axis of the carotid, as given before, with its center a quarter of an inch above the hyoid bone, will lead to the facial. The posterior belly of the digas- tricus will be found with its center usually above the origin, but soon crossing the artery. The ninth nerve is just below. For lesion of this vessel in the face it can be readily secured as it crosses the inferior maxilla in the depression at the anterior border of the masseter (Fig. 329). Before making the incision, which should be parallel with the horizontal portion of the inferior maxilla, the skin should be well pulled up from the neck, so that, after healing, the cicatrix will fall be- low the jaw. Ligation of the Ascending Pharyngeal—Anatomy.—-This artery was derived from the external carotid in one hundred and eleven of one hundred and twenty-one cases, and from the internal ca- rotid in four others. It usually comes off at a point opposite the origin of the lingual, and occasionally from the bifurcation of the primitive carotid. A pharyngeal branch is not uncommon from the occipital. Operation.— The external carotid must be exposed by an incision the center of which is opposite the level of the hyoid bone/ The vessel will be seen ascending between, and parallel with, the external and internal carotids. One fatal case is recorded from haemorrhage after a wound of the ascending pharyngeal. Ligation of the Occipital Artery—Anatomy.—The occipital was present in one hundred and twenty of one hundred and twenty-one dis- sections, and it was found to be opposite the facial in the majority of cases. In the subject in which it was missing, a large branch from the inferior thyroid (not the ascending cervical) took its distribution. Not LIGATION OP ARTERIES. 321 infrequently the posterior auricutar or a pharyngeal branch arose from this vessel. Operation.—It may be secured near its origin, or behind the mastoid process. For the low operation, make an incision in the carotid line, the center of v/hich is about one inch above the thyroid notch. After divid- 10. 329. Ligation of the posterior temporal at the zygoma, and of the facial upon the inferior maxilla. mg the deep fascia the hypoglossal nerve will be seen, which, if followed backward, will lead unerringly to the artery, underneath which it winds. The posterior belly of the digastric muscle will usually require to be luted upward. Behind the mastoid the occipital may be tied where it passes beneath 23 322 A TEXT-BOOK ON SURGERY. the cranial attachment of the sterno-mastoid muscle (Fig. 330). From one half to three fourths of an inch behind the mastoid process an in- cision about two inches long should be made, extending upward and backward. The aponeurosis of the sterno-mastoid muscle is divided on a director, and the artery exposed. The constant relation of this vessel Fig. 330.—Ligation of the occipital behind the mastoid process and the common temporal near the zygoma, also showing the relations of the facial nerve to the terminal portion of the external carotid. to the groove on the under surface of the mastoid process will serve as a valuable guide. The common carotid has been tied in several instances for lesions of the occipital. This should never be done. Ligation of the Posterior Auricular—Anatomy.—In eleven of one hundred and twenty-one dissections this vessel arose from the occipital, and in four it was absent. Its origin is usually one inch and four fifths above the thyroid notch. LIGATION OF ARTERIES. 323 For anatomical reasons, in lesions of this artery the external ca- rotid should be tied, just above the posterior belly of the digastric, between its origin and that of the occipital. It runs under the pa- rotid gland, is crossed by the facial nerve, and has beneath it the spinal accessory. Ligation of the Temporal and Internal Maxillary Arteries—Anat- omy.—The temporal and internal maxillary arteries begin at the termi- nal bifurcation of the external carotid, in the substance of the parotid gland, at an average distance of two inches and nine tenths from the thyroid notch. Operation.—The temporal artery may be secured by a perpendicu- lar incision immediately in front of the tragus of the ear, where it crosses the zygoma superficially (Fig. 330). For lesions of this vessel above the temporal fossa, and often in wounds in this region, the ligature will be unnecessary, since direct com|U'ession, by means of the knotted bandage, will suffice. When either this artery or the internal maxil- lary are wounded in the substance of the parotid gland, the external ca- rotid should be tied at the posterior belly of the digastric. The same procedure is indicated in lesions of the interned maxillary, in its deep- er portions. Ligation of the Internal Jugular Vein.—The intimate relation of this vein to the internal and common carotid arteries renders it accessible by the same incisions laid down for the ligation of the arteries. The vein is contiguous to the artery, and is external and slightly superficial to it. On the left side, at the root of the neck, the jugular comes more to the front, while on the right side it tends to the outer side. The rules which apply to the ligation of arteries apply with equal force to the ligation of veins. The jugulars should be encircled with an animal ligature, not tied with a lateral loop, as has been practiced. The aneurism-needle should be passed from the inner side.* The anterior, external, and posterior jugular, and other veins of the neck, do not demand especial consideration. When, in operations in the neck, it becomes necessary to divide them, a double catgut should be applied, and the vessel divided between the two ligatures. The Subclavian Arteries and their Branches—Anatomy.—The right subclavian, larger, shorter, and more superficial at its origin than the left, is derived from the innominate behind the origin of the carotid, about the level of the upper margin of the clavicle (more frequently above than below this line), behind the interval between the two tendons of the sterno-mastoideus. It is the direct continuation backward, upward, and outward of the arch of the innominate, and is continuous with the axil- lary artery, at the lower edge of the first rib. Its average length is 2*83 inches. The left subclavian, derived 1*23 inch beyond, to the left of, and more deeply situated in the thorax than, the innominate, travels almost verti- * See Prof. S. W. Gross's admirable article in "American Journal of the Medical Sci ences," 1867. ^24 A TEXT-BOOK OX SURGERY. cally upward, until it mounts above the upper surface of the first ribt when it curves very abruptly outward and downward, passing behind the scalenus anticus and thence to the lower edge of the first rib. Its length, in the average, is 3'74 inches. Each subclavian has three surgical divisions. The first division of the right artery is from its origin from the innominate to the inner bor b Fig. 331.—Belation of the great vessels to each other at their origins from the arch of the aorta, and the rela- tion of the branches of the subclavian arteries to each other. From the author's dissections. der of the scalenus anticus. That of the left artery, from its origin at the arch of the aorta to the inner border of the left scalenus anticus (Fig. 331). The second and third portions of both vessels are identical as re- gards direction and relation, being different in the origins of their respective branches. The second surgical division of each is entire- ly to the inner side of the inner border of the first rib. The third portion rests chiefly on the upper surface of the first rib, and extends from the outer border of the scalenus anticus to the lower border of this rib. The first portion of the right subclavian varies from three fourths to one inch and a half in length, the average length being 1°15 inch. The first portion of the left artery varies from one inch and a half to three inches, the average length being 2'06 inches. LIGATION OF ARTERIES. 325 Trans verse Cervical The second portion of the right subclavian averaged °58 inch, the same division of the left subclavian being '56 inch in length. The third portion of the right artery is a little less ; the same division of the left subclavian a little more than I'll inch in length. Nine important branches arise directly or indirectly from the subcla- vian arteries: the vertebral, internal mammary, transver salts colli, suprascapular, inferior thyroid, cervicalis ascendens, superior inter- costal, profunda cervicis, and posterior scapular. The right vertebral, the branch most constant in origin, arises from the superior and posterior aspect of the main trunk (Fig. 332) and passes upward to the verte- bral foramen, in the Ascend ing Cervical sixth cervical verte- bra; at times to the fifth; less frequently to the fourth. The relation of this branch is important. In the vast majority of sub- jects it will be found between one fourth and three fourths of an inch to the inner side of the inner mar- gin of the scalenus anticus. The left vertebral (Pig. 331) arises, in 4 per cent of cases, from the aorta. In most subjects it will be found within three fourths of an inch of the left scalenus muscle. The internal mammary artery arises at the inner border of the sca- lenus anticus. It is occasionally from the thyroid axis. The phrenic nerve passes usually in front, occasionally behind it. Behind the costal cartilages it runs parallel with the edge of the sternum, about half an inch external to it. The thyroid axis arises also just within the scalenus. The inferior thyroid branch arises from the axis, in almost every case on the left side. On the right, in twenty-six cases examined, it originated from the in- nominate in three, and directly from the subclavian in three instances. It passes upward (inclining at first a little inward) until it arrives at a point between the third and seventh (incomplete) rings of the trachea, where it turns abruptly inward, going behind the common carotid and jugular, in front of the vertebral, and is distributed chiefly to the lower portion of the thyroid body. The transver satis colli passes outward in front of the scalenus muscle and the phrenic nerve, underneath the omo-hyoid, and in front of or Fig. 332.—Plan of the right subclavian artery and its branches. the author's dissections. (After Quain.) From ;$:><) A TEXT-BOOK OX SURGERY. between the cords of the brachial plexus, and is distributed to the tra- pezius muscle, sending a branch in the direction of the posterior border of the scapula, vrhich anastomoses with the posterior scapular artery; and, when this last vessel is not present, this descending branch is con- tinued along the border of the scapula to anastomose with the subscapu- lar branch of the axillary. The suprascapular artery, intimately associated with the preceding, travels suddenly downward and outward from its origin near the inner edge of the scalenus anticus, passes between the subclavian artery and vein, in front of the phrenic nerve, crosses in front of the third division of the main trunk, and goes to the suprascapular fossa under the protection of the clavicle, anastomosing with the dor sails scapula of the sub scapular is. It gives off a branch (frequently wounded in operations in this vicinity) which passes behind the sterno-mastoideus and along the upper border of the manubrium. (It is not usually men- tioned.) The right superior intercostal artery comes from the second division of the subclavian in almost every instance ; occasionally from the first. The left is usually from the first division. The posterior scapular, one of the most important branches of the subclavian, in a surgical view, since it must be in dangerous proximity to a ligature applied in the third surgical division (not given in many standard text-books, except as an occasional branch of this artery), was present in thirty-six of fifty-two dissections, or 69 per cent. It was present in nineteen of twenty-six on the right side, and in seventeen of twenty-six on the left. In twenty-three of the thirty-six cases in which it wras present it was derived from the third division ; in the remaining thirteen, from the second division, close to its outer limit. On the right side 74 per cent came from the subclavian, within one fourth of an inch to the outer and inner side of the external border of the scalenus muscle; 26 per cent external to this. On the left side 82 per cent were within one fourth of an inch to the outer and inner side of the line dividing the middle and external thirds of the main trunk ; 18 per cent were to the outer side of this. The tend- ency of this important branch is to originate near the scalenus, i. e., within one fourth of an inch of its outer edge. AVhen this vessel is present the transversalis colli is small, and when absent the descending branch of the transversalis takes its distribution. Passing outward be- hind the most superficial cords of the brachial plexus, it turns sharply downward, along the posterior border of the scapula, to anastomose with the subscapular branch of the axillary. Operation—The Right Subclavian in its First Surgical Division — The incisions are the same as for the arteria-lnnomlnata (Fig. 318). When the sterno-hyoid and sterno-thyroid muscles have been divided on the director, the Internal jugular vein will be seen directly in front of the artery. It may be drawn to the inner side (or outer, if more convenient), carefully using for this purpose a dull retractor. Care must be exercised not to injure the pleura which rises against the LIGATION OF ARTERIES. 327 artery in deep inspiration. A dull-pointed aneurism-needle may now be passed around the vessel, taking care not to wound the subclavian or innominate vein, or the recurrent laryngeal nerve. The vertebral, internal mammary, and branches of the thyroid axis, should also be secured. The conditions wdrich will justify this operation will rarely occur, yet, when the operation is demanded, every source of danger from haemor- rhage should be avoided. The necessity of securing the carotid at the same operation must be determined by the operator. I am of the opinion that it is safer to occlude this vessel also. The subclavian artery has been tied in its first surgical division eight- een times, and all fatal. In five of these cases the common carotid was also tied. In only one case was the left subclavian tied. Of the thirteen single operations, two (Ayres and Bullen) were for the arrest of haemor- rhage from shot wounds in military practice, with one death in half an hour and one on the eighth day, from haemorrhage. The other eleven cases are given on another pa°;e. In only five of these thirteen cases is the source of haemorrhage stated, and in each of these the bleeding was from the distal side of the ligature, the proximal side being closed. A knowledge of this fact leads me to insist'upon the ligation of the verte- bral and other branches of the first division. In five instances the right carotid was also tied simultaneously by Liston, Parker, Hobart, Cruveilhier, and Kuhl. In three of these, fatal haemorrhage ensued from the distal side of the ligature. The left subclavian artery was tied in its first division once by Rodgers, and fatal haemorrhage occurred from the distal end of the artery, and by Halsted successfully. Ligation of the Left Subclavian Artery in its First Surgical Divis- ion—Operation.—From a point on the clavicle one fourth the distance from the center of the interclavicular notch to the acromion process commence an incision, and carry it to the inner border of the sternal tendon of the mastoid muscle. From the inner extremity of this line carry a second incision for three inches along the anterior border of the sterno-mastoideus. In dissecting this flap lift with it the mastoid muscle divided upon the director, then divide the sterno-hyoid and thyroid muscles, and feel for the pulsation of the artery, which ascends deeply behind and a little outside the sterno-clavicular articulation. The internal jugular vein will be drawn outward, and, passing the finger along the inner border of the scalenus muscle, the artery will be felt to pulsate. The thoracic duct usually is to the right of and a little behind the artery opposite the upper border of the sternum. On a level with the insertion of the scalenus it arches to the left, crosses in front of the subclavian, in front of the scalenus, behind the internal jugular, and curves downward to empty into the subclavian at its junction with the jugular to form the left innominate vein. On ac- count of the intimate relations of the thoracic duct to the left sub- claviein artery as this vessel goes behind the scalenus, the ligature should not be attempted close to this muscle, nor should the dissec- 328 A TEXT-BOOK OX SURGERY. tion be carried fully to the sceilenns. The artery should be tied as low down as possible, the duct being less likely to be injured here, since in passing behind the aorta it is deeper than the artery. It will be found behind and to the right, the pneumogastric in front and to the right, the left vena innominata crossing in front, while the pleura is directly behind. The case of Halsted, of Baltimore, is the first suc- cessful case on record. The vertebral and other branches of the left subclavian are in such proximity to the thoracic duct that it will be dangerous to attempt to tie them at this point. Ligation of the Subclavian Arteries in their Second and Third Sur- gical Divisions—Operation.—The procedure is essentially the same on the two sides. Place the shoulders upon a cushion, pull downward on the arm of the side to be operated upon, and turn the patient's face to the opposite side. Find the location of the scalenus anticus, as in the pre- ceding operation. Slide the skin well down upon the clavicle, and along this bone make an incision three or four inches in length, commencing one inch to the inner side of the scalenus muscle and terminating near the anterior edge of the trapezius. Allowing the skin to resume its nor- mal relations, the incision will be carried above the clavicle. Upon a director divide the outermost of the clavicular fibers of the mastoid muscle. The internal jugular vein, seen in the anterior portion of the wound, will be carefully drawn to the inner side, the operator keeping well above the junction of this with the subclavian, and thus avoiding the lymphatic duct A prominent plexus or group of veins, viz., the external jugular, transversalis colli, and suprascapular, will be seen traversing the wound, coming from their respective origins, toward the subclavian, near the jugular. These should be secured with a double ligature, and divided, or held aside. Dissecting carefully, the suprascapular and transversalis colli arteries will be observed running, in general, in the direction of the first incision. The posterior belly of the omo-hyoid may be found in the upper margin of the wound, crossing the scalenus at about a right angle. The transversalis colli and the suprascapular may be secured or held to one side, the finger passed along the scalenus until the tubercle on the first rib is felt, immediately behind which the artery will be found. If it shall have been determined to tie the artery in its second portion, the scalenus anticus muscle will be cut upon a direc- tor, the operator being careful to avoid the phrenic nerve, which crosses the muscle in front, coming from above downward and inward. (It is between the layers of the sheath of this muscle.) The ligature is next passed around the artery from before backward, care being taken not to wound the pleura. If the third division of the artery is to be secured, the part of the above operation relating to the division of the scalenus will be omit- ted. The nearest cord of the brachial plexus must be carefully ex- cluded, posteriorly to the artery; the subclavian vein in front and be- low (Fig. 328). LIGATION OF ARTERIES. 399 The subclavian arteries have been tied behind the scalenus anticus thirteen times, with four recoveries. All of the fatal cases were on the right side. In one of the "Prize Essays" of the American Medical Association I published the histories of two hundred and fifty-one ligations of the sub- clavian artery in its third surgical division, of which one hundred and thirty-four ended fatally. As far as these histories relate to aneurism they have been given. A study of the remaining cases led me to con- clude that in all lesions causing dangerous haemorrhage in the upper brachial or axillary regions an effort should be made to control the bleed- ing at the seat of injury. Failing in this, deligation of the subclavian, in its third division, is demanded. Ligation of the Vertebral Artery—Operation.—Locate by pressure the carotid tubercle (the transverse process of the sixth cervical vertebra). The point at which the artery is to be secured is one inch directly below this bony prominence, which must be the center of a perpendicular in- cision, four inches in length. Commence the incision at the outer bor- der of the sterno-mastoid muscle, where the external jugular vein crosses. The internal jugular is seen and drawn inward. The transverse cervical artery, and one or two smaller veins, are met wdth next, and drawn to the outer side of the wound. The scalenus anticus muscle is now brought into view, and to the inner side of this a depression be- tween this muscle and the longus colli. In this sulcus the artery lies, the vein being in front of it. In my case I had to tie the vein with a double ligature, divide, and turn the ends aside in order to secure the artery. Ligation of the Internal Mammary—Operation.—This vessel may be secured, as has been described, close to the parent trunk, or ir may be tied in one of the intercostal spaces. In the third or fourth space make an incision, about two inches in length, obliquely from without inward and downward, the center of which should be about half an inch external to the edge of the sternum. Divide the fibers of the pectoralis major and the intercostal muscle, and clear away the tissues with a blunt-pointed instrument. The artery, with its venae comites, will be seen in front of the fibers of the triangularis sterni, which sepa- rates it from the pleura on the right and the mediastinum on the left side. In separating the veins from the artery, care should be taken not to break through the thin structure between the vessel and the cavity. The other branches of the subclavian artery do not require especial consideration. The inferior thyroid is often tied in the removal of goitre. I have, in six operations, found and deligated it prior to ab- lation of a bronchocele. It will usually be seen on the tracheal side of the common carotid, just below the anterior belly of the omo- hyoid. Ligation of the Axillary Artery—Anatomy.—-This artery may be tied at any part of its course. On account, however, of the difficulty of approach of that portion beneath the pectoralis minor, it is usually 330 A TEXT-BOOK OX SURGERY. secured in the axilla, below this point, or between the upper margin of this muscle and the lower border of the first rib. Operation.—With the head thrown back and the shoulders elevated, allow the arm to remain by the side of the body. About two inches from the sternal end of the clavicle, and half an inch below its inferior border, carry an incision outward, parallel with this bone, a distance of from three to four inches. This incision may divide a superficial vein which passes from the cephalic over the clavicle. The clavicular fibers of the pectoralis major and the costo-coracoid membrane are divided upon the director. The axillary vein will then be seen in the anterior por- tion of the wound, lying in front of the artery, which may be felt to pulsate, or seen just external to it. More external still may be seen the anterior cord of the brachial plexus, while in the lower portion of the wound the cephalic vein crosses over to empty into the axillary, below the clavicle. Beneath the clavicle the subclavius muscle may be seen. The needle should be passed from before backward. If necessary, a second incision may be made, beginning in the center of the first and carried in the direction of the axilla, as recommended by Cham- berlain. This operation is somewhat more difficult than ligation of the sub- clavian in its third division, but it is preferable, on account of being farther removed from the heart. Delpech advised an incision beginning at the junction of the middle and outer third of the clavicle, and sepa- rating the deltoid and pectoralis muscles. Operation below the Pectoralis Minor.—Shave and cleanse the axilla, and extend the arm at a right angle to the body. Divide the dis- tance between the two folds of the axilla into thirds, and the junction of the anterior and middle thirds will indicate the position of the artery. On this line make an incision in the axis of the arm, well up into the ax- illa. Cutting through the skin and fasciae, the contents of this space will 0150737367�0845435 LIGATION OF ARTERIES. 331 be seen. The vein lies internal to the artery, often overlapping it, and should be drawn carefully backward. The median nerve overlies the artery, or is on its anterior aspect, and should be drawn forward when the needle is passed from behind forward (Fig. 333). Ligation of the Brachial Artery —Anatomy.—-This artery lies in the furrow along the inner border of the coraco-brachialis and biceps muscles, tending more and more to the front as it nears the elbow-joint. In the lower half or three fourths of its course it has its venae comites on either side, with occasional commu- nications across the track of the ar- tery. The median nerve crosses it by the front, from the outer side, on its way to the forearm, while the basilic vein is well to the in- ner side. As this vein passes up toward the axilla it pierces the deep fascia, and lies on the inner side and close to the artery, joining with the venae comites to form a single large trunk. Operation.—A line drawn from the junction of the middle and ante- rior thirds of the axillary space (as above given) to the middle of the elbow-joint, in front, will pass over the brachial artery in its entire length, The place of election is the middle of the arm. At this point make an in- cision, three inches in length, over the artery and in its axis. Divid- ing the skin and deep fascia, the white cord of the median nerve will be first seen, on the outer side of the brachial, overlapping the companion vein on this side. Just internal to this is the artery, with the other ac- companying vein and the basilic in close relation (Fig. 334). The liga- ture should be passed from the in- ner toward the outer side. The op- Fig. 334.—Ligation of the brachial near the middle and the lower third. 382 A TEXT-BOOK ON SURGERY. eration above this point is essentially the same. In the lower third of the arm proceed as follows: On a level with the condyles of the humerus, and between the median basilic vein and the tendon of the biceps, commence an incision, which is carried upward three inches in the brachial line. Cutting through the deep fascia, the artery is readily found to the radial side of the median nerve, and surround- ed by its veins (Fig. 336). The needle is passed from the inner side. Occasionally the brachial artery is double, while more frequently it bifurcates into the radial and ulnar, at a varying distance above the elbow. Ligation of the Ulnar and Badlal Arteries.—The radial artery may be tied immediately above the wrist, or in the upper third of the arm. Operation at the Wrist—A vertical incision, one inch and a half long, is made in the center of the depression, between the outer bor- der of the radius and the radial border of the extensor carpi radialis muscle. Immediately beneath the deep fascia the artery will be ob- served, with its vena3 comites, from which it is separated and tied (Fig. 335). To find the artery in the upper third, draw a line from the middle of the elbow-joint, in front, to the styloid process of the radius. Along this line make an incision, about three inches in length, avoiding the superficial veins, if possible. Cutting directly down, the artery will be found between the supinator longus externally and the pronator radii teres on the ulnar side. The radial nerve is well to the radial side, and the venae comites on either side (Fig. 336). The ulnar artery may be tied at the bend of the elbow, and near the wrist. As it passes beneath the pronator radii teres and flexor muscles, it is so deeply situated that an attempt to deligate it here is not justifi- able. Above this point it may be secured by a downward extension of the incision given for ligature of the brachial at the bend of the elbow (Fig. 336). Near the wrist-joint an incision should be made about a quarter of an inch to the radial side of the tendon of the flexor carpi ulnaris muscle. This incision should commence one inch above the level of the pisiform bone, and extend upward one inch. The ulnar nerve will be seen partly concealed by the tendon, while the artery and its accompanying veins are immediately on its radial side (Fig. 335). Ligation of the Intercostal Arteries—Anatomy.—The artery lies be- hind and near the lower border of the rib, the vein above, and the nerve below it. From near the angle of the rib to the vertebral column it is separated from the thoracic cavity by the pleura alone, but in front of this it runs between the two layers of intercostal muscles. Operation.—An incision should be made just along the lower bor- der of the rib. After passing through the outer plane of intercostal muscles the artery may be seen and secured. Or, failing in this, take a long, curved aneurism-needle, and through a puncture near the lower border of the rib pass it behind the artery and around the LIGATION OE ARTERIES. 333 Fio. 335—Ligation of the ulnar and radial arteries of the wrist Fio. 336.—Ligation of the radial in the middle of the forearm and of the brachial at the bend of the elbow. 384 A TEXT-BOOK ON SURGERY. rib, taking care not to puncture the pleura. When the point of the needle is felt at the upper margin of the bone, another puncture is made to allow its escape. The needle is now- armed with a strong cat- gut and withdrawn. A pellet of sublimate gauze is laid over the skin, between the points of exit and entrance, around which the ligature is tied. In exceptional cases it may be necessary to remove a portion of the rib. Ligation of the Abdominal Aorta—Anatomy.—-The aorta usually bifurcates upon the body of the fourth lumbar vertebra, a little to the left of the median line. This point is on a level with the high- est point of the iliac crests, and is a little to the left of and below the umbilicus. The point of election is one inch above the bifurca- tion. Operation, Median—-In the tinea alba make an incision, six inches long, the center of which corresponds to the umbilicus. When within an inch of the navel, curve to the left three fourths of an inch, and one inch farther on regain the middle line. Divide all the tissues down to the parietal peritonaeum, and then arrest all bleeding before opening this. After opening? into the cavity, the transverse colon should be displaced upward, and the small intestines brought out through the wound and secured in a soft cloth, kept warm with sterile towels. With the finger- nail or a blunt director scratch through the peritonaeum and expose the aorta, around which a large animal ligature should be passed from the right side. Lateral Incision.—From the free end of the left eleventh rib com- mence an incision, which carry downward to within three fourths of an inch of the anterior superior iliac spine, thence parallel with Poupart's ligament to its middle. Divide the three abdominal muscles down to the parietal peritonaeum. When this is reached, use the fingers, the nails of which have been closely pared, and lift the peritonaeum from the posterior abdominal wall. Passing over the posterior iliac crests and into the iliac fossa, the ridge formed by the psoae muscles is reached and must be crossed. The lumbar nerves and ureter should be avoided, and, by a free dilatation of the wound and concentration of light, the aorta may be seen and tied, about three inches above the lumbo-sacral junc- tion. Of these two procedures the former is anatomically and surgically preferable. * Ligation of the Common Iliac Artery—Anatomy.—The common iliac arteries extend from the left side of the body of the fourth lum- bar to the sacro-lumbar junction. It is crossed by the ureter in front, near its bifurcation, and by some filaments of the sympathetic nerve higher up. The left common iliac vein lies wholly internal, and is on a plane somewhat deeper than the artery. The inferior mesen- teric vein crosses the left artery, but is within the peritoneal folds. The right iliac artery crosses in front of both the iliac veins, passing at a right angle to the left vein and obliquely over the right, until * The abdominal aorta has been tied ten times, all fatal. LIGATION OF ARTERIES. 335 near its termination the artery is in front of and external to the vein (Fig. 337). Operation—Anterior Incision.—Make an incision in the linea alba ex tending from about one inch above to about five inches below the umbili- cus. Avoid the umbilicus as directed in the ligation of the aorta. Arrest all bleeding before the parietal peritonaeum is opened. When this is done draw the small intestines out through the wound and protect them in a «ip ns. 33T. Dissection showing the relation of the right common external and internal iliac arteries and veins, The ureter is seen crossing the iliac near the bifurcation. soft, clean cloth, kept warm by sterile towels. The posterior wall of the peritonaeum is scratched through by means of two dissecting-forceps and the aneurism-needle passed from within out. 336 A TEXT-BOOK ON SURGERY. Lateral Incision.—Same as for the aorta.* The anterior incision is preferable. Ligation of the Internal and External Iliac Arteries—Anatomy.— The internal iliac artery, less than two inches in length, has the ureter in front, its accompanying vein and the lumbo-saeral nerve behind. Operation.—Through the Peritonaeum.— Proceed as in the same operation for the primitive iliac. If necessary, a transverse incision may be added to that in the linea alba. Behind the Peritonaeum.—One inch and a half internal to the anterior superior spine of the ilium begin an incision, which travels downward and inward across the track of the external iliac. Be careful not to carry the deep incision far enough internally to divide the epigastric artery. Cut down to the parietal peritonaeum, and separate this from its attach- Fig. 338.—Ligation of the gluteal, internal pudic, and sciatic arteries. * This artery has been tied about seventy times. For aneurism about 33 per cent recovered. while for haemorrhage almost every case ended fatally. LIGATION OE ARTERIES. 33' ment to the abdominal wall and iliac fossa, along the iliac artery. AVhen the bifurcation is reached, draw firmly with a retractor upon the upper lip of the wound and pass the needle from the inner side.* This opera- tion may be demanded in sciatic or gluteal aneurism, or haemorrhage from these vessels. The former method is preferable. The Gluteal Artery.—Make a five-inch incision, on a line extending from the spine of the last lumbar vertebra to the trochanter major. The center of this line will indicate the point at which the artery emerges. Separate with a dull instrument the fibers of the gluteus maximus, dis- place anteriorly the gluteus medius, and find the groove between the minimus and the pyriformis. Follow this groove upward to the bony edge of the notch, and the artery and veins will be found (Fig. 338, upper incision). Fiii. 339.—Ligation of the internal pudic in the perinseum. The Sciatic.—Make an incision, five inches long, on a line from the middle of the sacral spines to the trochanter major. Separate the fibers of the gluteus maximus and find the lower border of the pyriformis. The * The internal iliac has been tied about thirty times, with a death-rate of 66 per cent. 24 * 338 A TEXT-BOOK ON SUROERY. great cord of the sciatic nerve will now be seen emerging from beneath the muscle, and immediately in front of this the small sciatic nerve and the sciatic artery. The Internal pudlc artery is just anterior to this, upon the spine of the ischium (Fig. 338, middle incision). The sciatic artery may also be secured opposite the tuber Ischll, along the outer bor- der of which it runs (Fig. 338, lower incision). The Internal Pudic in the Perinmum.—With the patient supine and the thigh abducted, - -~ • - - - . - - """ make an incision in a line with the symphysis pubis and tuber ischii. The artery will be found as it runs along the inner margin of the ramus of the pubis (Fig. 339). Ligation of the Ex- ternal Iliac in its Lower Portion. —The external lilac has in relation to it the accompanying vein internally. The spermat- ic vessels cross it, and in the male the vas deferens is internal to it at the in- guinal ring. Operation.—One inch to the inner side of the anterior superior spine of the ilium commence an incision, which is car- ried in the direction of the middle of Poupart's ligament, and terminates one inch above this point, without entering the in- ternal ring. Divide the three muscles down to the transversalis fascia, arrest all bleeding, divide the fascia carefully, re- tract the upper lip of the wound, and lift the peri- tonaeum from the iliac fossa and artery (Fig. 340). Displace any overlying lymphatics and in- troduce the needle from the inner side.* Fig. 340.—Ligation of the external iliac in its lower portion, and of the femoral in Hunter's canal. * Ligation of the external iliac has proved fatal in almost every instance in winch it was tied for haemorrhage. For aneurism about 67 per cent recover. LIGATION OF ARTERIES. 339 The deep circumflex and the epigastric branches, which arise about half an inch above the ligament, may also be tied by this incision. In its upper portion this vessel may be secured by the same operation as for the common iliac. Ligation of the Femoral Artery—Anatomy.—-At Poupart's ligament the vein is on the same plane as the artery, and immediately internal to it. One quarter of an inch to the outer side, and deeper than the artery, lies the anterior crural nerve. One inch and a half from the ligament the profunda femoris arises from the outer aspect of the common trunk. and from one to two inches lower passes behind the superficial femoraL Four inches from Poupart's ligament the relations have changed to such Fig. 341—Ligation ot the superficial femoral in Scarpa's space. an extent that the femoral vein is deeper and slightly behind the artery. The long saphenous nerve lies upon the sheath of the artery, in its middle third, and occasionally sends a branch through Hunter's canal. The sartorms muscle covers the femoral artery in all of its course except the first four inches, where it is superficial. Operation.—A line from a point half way between the symphysis pubis and the anterior superior spine of the ilium to the internal condyle 340 A TEXT-BOOK ON SURGERY. of the femur will run over and parallel with the femoral. It may be secured in any part of its course. In Scarpa's Space.—The point of election for tying the superficial femoral is from four to five inches below Poupart's ligament. With this as the center, make an incision three-inches long on the line already indi- cated. Beneath the skin and fascia some superficial and unimportant vessels may be divided; the fibers of the sartorius will be seen in the lower portion of the wound, and should be drawn downward with a re- tractor. The saphenous nerve will next be seen on the outer side of the common sheath of the vessels. The sheath should next be incised, and the artery carefully isolated by inserting a dull director beneath and around it from the inner side. The ligature is passed the same way. Fig. 342.—Ligation of the deep and superficial femoral near the bifurcation of the common femoral, and in the apex of Scarpa's triangle. In this same plane an incision may be made to expose the artery lower down, where it is completely hidden by the sartorius. This mus- cle may be drawn to the side most convenient to the operator (Figs. 341, 342). In Hunter's Canal.— Find the junction of the middle and lower thirds of the thigh. In the femoral line, with this point as the center, make an incision, about four inches in length, directly down to the sheath of the LIGATION OF ARTERIES. 341 sartorius, which is incised and the muscle displaced outward. Imme- diately upon opening the posterior layer of the sheath of the muscle, the oblique aponeurotic fibers which pass from the adductor magnus to the vastus internus—forming the anterior wall of Hunter's canal—are seen. These may be divided on a director, or the sheath opened half an inch above this point. The saphenous nerve is on the sheath, and the vein is behind and to the outer side (Fig. 343). The Common Femoral above the Profunda.—Make an incision in the femoral line, from three fourths of an inch above Poupart's ligament downward for three inches and a half. Do not divide the ligament, but approach the artery one half inch below. The superficial epigastric vein and artery may be wounded. Divide the fascia lata, and pass the ligature from within out. (Dissec- tion shown in Figs. 341, 342.) The Profunda Femoris. — Make an incision in the femoral line, three inches and a half long, the center opposite a point one inch and a half to twro inches below Poupart's ligament. As above, approach the common trunk and search along its outer border for the origin of the profunda* (Fig. 342). Pass the ligature from with- in out, one inch from its origin. Avoid the branches of the ante- rior crural nerve. In wounds of the posterior fem- oral region it may be necessary to tie this vessel as well as for aneurism. Ligation of the com- mon femoral is rarely called for, and should only be done in ex- treme cases. In modern surgical practice, deligation of the super- ficial femoral is comparatively free from danger. Ligation of the Popliteal— Operation.—Place the patient on his belly, with the popliteal space looking upward. Make an incision, four inches long, beginning two inches and a half above the level of the joint, at the outer edge of the semi-membranosus tendon, and extending down through the middle of the space. Dividing the dense, deep fascia, the areolar tissue wdiich sur- Fig. 343.—Ligation of the popliteal artery. Relations of contents in the left lower extremity. * In a large majority of subjects I have found this branch given off one inch and a half be- low the ligament. 342 A TEXT-BOOK OX SURGERY. rounds the vessels and nerves of the space will be seen, and at the same time, and superficially, the popliteal nerve. Draw this and the vein which is immediately below outward, and the artery will be seen deeply situated, and in the upper part of the space internal to the vein. Lower down the relations change, the nerve crossing superficial to the vein, and this overlying the artery (Fig. 343). Ligation of the Posterior Tibial Artery at the Middle of the Leg.— Make an incision, half an inch from and parallel with the inner margin of the tibia, three inches and a half long. Avoid the internal saphenous vein. After passing the deep fascia, look for the lower tibial fibers of the soleus, which pass ob- liquely from this border of the tibia backward and slightly downward. Divide these on a director, and with the finger separate the sural from the flexor muscles. Retracting the edges of the wound, the artery will be seen, with a vein on either side and the posterior tibial nerve lying just behind. The vessels are held down by the common sheath of the deep muscles (Fig. 344). Opposite the Ankle-joint.— Half way from the tip of the internal malleolus to the ante- rior edge of the tendo Achillis commence an incision, which extends directly upward for one inch and a half. Dividing the skin and fascia upon a director, cut the dense internal annular ligament. The artery, with its two veins, will be found with the posterior tibial nerve and Fig. 344.—Ligation of the posterior tibial above the malleolus. tendon of the flexor longus pollicis behind, and the flexor longus digito- rum and tibialis posticus in front. As the artery curves around the mal- LIGATION OF ARTERIES. 343 leolus it wall be found one third the distance from the tip of the mal- leolus to the convexity of the heel. The Anterior Tibial at the Middle of the Leg. —A line from a point half way between the anterior tuberosity of the tibia and the head of the fibula to a like point between the twTo malleoli, in front of the ankle, will indicate the position of this artery. At the middle of the leg make a four-inch incision in this line, di- viding everything dowm to the dense fascia im- mediately over the mus- cles. Split this on a di- rector and dissect it up carefully, searching for the interspace between the tibialis anticus in- ternally and the exten- sor proprius pollicis ex- ternally. Finding this, discard the knife, and with the finger separate the muscles, and the ar- tery, veins, and nerve will be found deep down upon the interosseous membrane, the nerve be- ing external and slight- ly in front, and the veins wound about the artery. In order to re- lax the muscles and ad- mit the light, flex the tarsus on the leg (Fig. 345). At the Lower Por- tion.—One inch above the tip of the internal Fig. 345.—Ligation of the anterior tibial in the middle and lower third of the leg, and of the dorsalis pedis artery. 344 A TEXT-BOOK ON SURGERY. malleolus begin an incision, and carry it two inches upward, in the tibial line above given. This incision is along the fibular border of the exten- sor pollicis, between which and the tendon of the extensor communis digitorum the artery will be found, with the nerve on the fibular side, and its companion veins on either side. The Dorsalis Pedis.—One fourth of an inch to the fibular side of and parallel wdth the tendon of the extensor pollicis make an incision, one inch long, over the tarsus. The artery and veins will be seen on a plane slightly deeper than the tendon, with the nerve on the tibial side of the vessels. This line is a continuation upward of the first metacarpal inter- space (Fig. 345). CHAPTER XVI. THE SURGICAL DISEASES AND SURGERY OF THE BONES. Ostitis.—Inflammation in bone may be acute or chronic, general or circumscribed, traumatic or idiopathic. It may involve the periosteum (periostitis), the compact and cancellous substance (ostitis), and me- dulla (endostitis or osteo-myelitls). Endostitis and periostitis may occur independently, yet ostitis, more or less severe, must of necessity be a part of a pronounced inflammation of either the periosteum or the endosteum and medulla. The termination of inflammation in bone is in resolution or local death. In resolution the inflammatory embryonic tissue undergoes granular metamorphosis and is absorbed, or it may be in part converted into new bone. If the bone dies it may be cast off as a sequestrum, or remain imprisoned in a shell of new-made osseous tissue, the invo- lucrum. When the inflammatory process is severe, or the arrest of nutrition sudden and complete, necrosis, or death in mass, occurs ; under other and milder conditions of death in bone, the process of dissolution is known as caries. In necrosis, which is aptly compared to gangrene of the soft tissues, the cast-off portion retains something of its original form and character ; in caries, which is the molecular death, or ulceration of bone, the cell elements disappear by granular degeneration, leaving no trace of the original structure. Pathology.—Simple, traumettic, non-infectious ostitis has been de- scribed in the chapter on Surgical Pathology and Repair of the Tissues. Periostitis and ostititis (when not traumatic) are infectious diseases, due to the presence in the periosteum or bone of certain micro-organ- isms or their ptomaines. There have been recognized in these acute lesions the staphylococcus and the streptococcus pyogenes aureus, the pneumococcus, the bacillus of typhoid, of tuberculosis, and the bacillus t-oli communis. These organisms are all pyogenic except the bacillus tuberculosis, which, in all probability, will not produce a septic pyo- genic ostitis unless by mixed infection with one of the pyogenic cocci. In periostitis not only the periosteal covering but the superficial hyer of bone is always involved, resulting in practically a superficial ostitis or osteo-myelitis with periostitis. It is usually a local disease, involving a limited surface of the periosteum, although at times the entire covering of any bone may be affected. It is of more frequent oc- 25 345 346 A TEXT-BOOK ON SURGERY. currence upon exposed surfaces, as the spine of the tibia, the phalanges (bone felon), and the skull. It is always accompanied with great pain and febrile movement, requiring at times immediate relief by incision and evacuation of pus. In incising the soft parts and superficial cover- ing of the bone, it is well at the same time to use the chisel, penetratino- a considerable distance into the substance of the bone in order to deter- mine how much of the bone or the Haversian canals are involved. In a rarer form of the disease, called periostitis albumlnosa by Oilier (Roswell Park), pus formation does not occur, there being a gelatinoid or mucoid liquid instead of pus. Park suggests that it is the bacillus tuberculosis which is the cause of this lesion. Evidently it is not a pyogenic or- ganism. Acute osteo-myelitis is an infectious disease, due generally to the staphylococcus and streptococcus pyogenes aureus, although the bacillus coli communis, bacillus tuberculosis, or bacillus typhoidii have been found in the pus discharged from the infected foci. It consists of a rapid infectious inflammation of the medulla of the central canal or the can- cellous tissue of the bone, and involves the Haversian canals and the medullary threads which are found in these channels. It is usually painful in the extreme, and the destruction of bone is rapid from the fact that this tissue is non-expansile, and does not yield, as do the softer tissues, in the presence of pus, resisting liquefaction and delaying the discharge of pus and broken-down septic material. It is characterized by high febrile movement and by intense pain, which is exaggerated by motion of the extremity or striking the bone which is involved. It de- mands immediate interference and evacuation of the purulent contents. Simple incision and trephining of the canal of the bone affected is not sufficient; an extended incision should be made, or several incisions, and the bone completely troughed, so that it may be thoroughly drained. The after-treatment consists in packing the cavity thus made with iodo- formized or sterile gauze and treating the wound by the open method. The most frequent form of ostitis or osteo-myelitis and periostitis is due to the presence of the bacillus tuberculosis. The vertebrse, ribs, and sternum are more frequently involved, and next in order are the tibia, the bones of the tarsus and metatarsus and femur. In the long bones the initial focus is usually at the epiphysis, the joint becoming infected by direct invasion through the articular surfaces. In the soft bones (vertebrae, ribs, sternum, etc.) the soft cancellous tissue is the seat of tuberculous deposit. Tuberculous inflammation of bone is a subacute process, not as rapidly destructive as acute osteo-myelitis, oftentimes going on without exacerbations of temperature and without pain sufficient to attract the attention of the patient or surgeon. The presence of a rich granulation tissue, which is part of the tubercular process, produces molecular dis- integration of the substance of the bone (caries), at times causing death en masse of more or less of the bony tissue (necrosis). When the granu- lation tissue is exuberant, the name of ostitis interna fungosa has been applied. When caseous, it is called ostitis interna caseosa, and THE SURGICAL DISEASES. 347 in rarer instances, where the granulation tissue is scant, the bone may break down in practically a dry molecular disintegration, known as caries sicca. Tuberculous ostitis, or osteo-myelitis, is not infrequently converted into an acute infectious process by mixed infection, the pyogenic organ- isms finding in the tuberculous granulation tissue a suitable medium for their proliferation and development. Whether it be an acute or chronic myelitis, operative interference is demanded. In tubercular disease of the vertebral column direct interference is not possible, and this form of tubercular disease of bone will be considered in the treat- ment of Pott's disease. In all accessible locations the indications are ex- posure of the part affected by incision as free as possible, and a thor- ough removal by the chisel or spoon of all diseased bone. It is better in all cases to treat such wounds by the open method, changing the dressing every two to four days as indicated. Osteomalacia—Rachitis.—Osteomalacia (mollities ossium) is a dis- ease of adult life, and is especially apt to occur in child-bearing women. The chief pathological change is the disappearance of the earthy con- stituents from the bones, and their presence in the blood and excretions in abnormal proportion. Softening is often present to such an extent that marked distortions occur from muscular contraction and superin- cumbent weight. The medulla of the bones is the seat of congestion, often resulting in extravasation of blood. In the later stages the bony lamellae disappear by absorption, the process commencing from within. The treatment consists in the prevention of fracture and deformity by proper precaution, and the restoration of the osseous system to its normal condition by generous diet, studied hygiene, tonics, and the ad- ministration of the hypophosphites of lime and soda, with cod-liver oil and iron. Rachitis, or "rickets," is strictly a disease of childhood and youth. Although it attacks the entire osseous system, its disastrous effects are chiefly observed in the bones of the skull and the long bones of the lower extremities. The bones of the skull become thickened and promi- nent, the sternum is advanced and angular ("pigeon-breast"), and the bones of the lower extremities are curved antero-posteriorly or laterally. While the diameter of a rachitic bone is usually increased at all points, the enlargement is more marked near the extremities. Rickets is a dis- ease of malnutrition. Its chief pathological feature is the formation of an embryonic tissue, which in normal condition is converted into bone, but in the rachitic diathesis only partially (if at all) undergoes ossi- fication. The cells of the periosteum are unusually active in this pro- liferation, as are the cartilage bone-making cells ; yet this new tissue remains in great part embryonic, without the formation of the osseous lamella?. The treatment of rickets is, first, to prevent deformity, and, secondly, to relieve the dyscrasia. Rachitic children should be kept in the recum- wnt posture, or, if allowed to stand or walk, artificial support should be given to the lower extremities and spine. The medical indications are 348 A TEXT-BOOK OX SURGERY. nutritious diet, out-of-door life, and the administration of the hypophos- phites of lime and soda, with cod-liver oil and tonics. The correction of the deformities which may result from rickets will be considered in the chapter on Orthopaedic Surgery. Acromegaly.—This term is applied to a condition of hypertrophy of certain bones of the body, as well as an increase of the soft structures. The hands and feet in many instances become enormously enlarged and out of proportion to the rest of the body, while in others the bones of the head and face, especially of the lower jaw, are affected. The central viscera are, as a rule, not involved. It is usually a symmetrical disease, the corresponding bones of the two sides of the body being alike af- fected. It gives to the individual a peculiar and unnatural appearance. Actinomycosis of bone is a rare affection, but should be borne in mind, as it is occasionally met with, especially in the lower jaw, infec- tion taking place through the alveolar process from a decayed tooth. Hydatid cysts have also occasionally been met with in the bones. Syphilitic ostitis and periostitis are given in the chapter on Syphilis. Periosteal gumma is met with most frequently upon the bones of the skull and upon the tibia, this painful affection being more marked when the patient retires at night. The deeper gumma of bone, also due to the presence of the lymphoid tissue of the syphilitic process, in com- mon with periosteal gumma, does not suppurate unless mixed infection occurs. Ostitis deformans (Paget's disease) may occur in any of the bones. In some cases this affection resembles osteomalacia, in which, from pressure or superincumbent weight, the bones give way, producing all kinds of deformities. It is a general disease and symmetrical, the bones of the two sides being alike involved. After the deformities have occurred, a supernatural hardening (sclerosis) takes place, leaving the bones harder than normal. Fractures. A fracture is a sudden solution of continuity in bone or cartilage. The term is commonly applied to lesions of bone. A fracture may be partial or complete ; transverse, oblique, or longitudinal; single, double, or multiple ; simple, comminuted, compound, and complicated. A par- tial fracture occurs when a bone breaks or splinters on one side (its convex surface) and bends on the opposite (green-stick fracture). In a complete fracture there is a total solution of continuity. A transverse fracture, or one in which the line of cleavage is, in general, at a right angle with the axis of the bone, is rare as compared with the oblique. A longitudinal fracture is a split in the long axis of a bone. It is frequently caused by penetrating wounds (gunshot), or may result from a fall with great violence upon the hands or feet, when the cleavage commences in the articular surface. In this way the astragalus may be driven between the fragments of a longitudinal fracture of the tibia, or a like accident occur at the knee or wrist. A single fracture is one break in one bone ; a double fracture is a FRACTURES. 340 solution of normal continuity in two bones of one member, as the ulna and radius, the tibia and fibula ; multiple fracture is a term applied to two or more separate breaks in one or several bones. When a bone is broken in one direction, and at one point, without injury of any sur- rounding organ or perforation of the skin, it is termed a simple frac- ture ; if there are more than two fragments it is a comminuted fracture ; if any part of the fractured surface communicates with the atmosphere it is a compound; and if it communicates with a joint, or involves in the fracture the wound of any important organ, as a large artery or vein, or, as in fracture of a rib, occasionally the pleura or lung is wounded, it is a complicated fracture. An impacted fracture is one in which the fragments are splintered and interlocked with more or less complete immobility. A fracture may be caused by external violence, directly or indirectly applied, or by muscular action, or both forces may unite in the pro- duction of the lesion. As an example of direct violence, in the effort to ward off a blow from the head the ulna may be broken directly beneath the contusion of the soft parts. A blow on the vertex which fractures the base of the skull, or a fall on the foot which breaks the femur, are common examples of fracture from indirect violence. Contraction of the quadriceps extensor may fracture the patella, or the same lesion may result from a fall on the knee, in which the direct violence and the action of this powerful muscle unite to cause the fracture. In addition to these direct agencies, certain conditions of the tissues predispose to fracture. The bones of the aged break more readily and are slower in repair than the young and middle-aged. There is a not infrequent condition of fra- gility in the bones of the insane which, either alone or together with excessive and uncontrollable muscular action, renders them liable to break. I have seen one specimen of this nature in which every rib was broken, and some of these in two or more places. As heretofore stated, fracture is common in the disease known as osteomalacia, and may occur, though less likely, in rachitis. Sex, vocation, and manual pref- erence also predispose to fracture. Men suffer much more frequently than women, and any vocation which exposes to violence increases the proportion of fractures. The bones of the right, the preferred side, are more frequently broken than the left. Symptoms and Diagnosis.—The symptoms of fracture are : Loss of function ; absence of normal contour; pireternatured mobility; crepi- tus ; pain. A broken bone which is not impacted no longer acts as a support, or sustains muscular contraction. The natural shape or outline is more or less distorted by displacement of the fragments. Careful manipulation will determine the overriding, measurement will show shortening, while comparison with the uninjured side will determine the degree of asymmetry. Crepitus, which is not always necessary to correct diagnosis, is the sensation imparted to the touch, and occasionally recognized by the ear, when the rough fragments are moved so as to grate upon each other. The diagnosis of an impacted, fracture is more difficult, since crepitus and 350 A TEXT-BOOK ON SURGERY. mobility are absent. Shortening must of necessity exist, which, with partial loss of function and more or less pain and thickening at the point of fracture, will lead to the recognition of the lesion. A longitudinal Fk;. 346.—Fracture of radius and ulna near the wrist. fracture or fissure is often with difficulty recognized, and may escape de- tection. The Roentgen ray photograph and the fluoroscope are most valuable adjuncts in the exact diagnosis of fractures (Figs. 346, 347). Fig. 347.—Overlapping fracture of radius and ulna and interosseous union. (Case of Mrs. J. K. B.) Process of Repair.—The first and immediate result of a fracture is haemorrhage, which occurs from the arteries, arterioles, capillaries, ven- FRACTURES. 351 ules, and veins of the medulla, compact substance, periosteum, and any surrounding soft parts which may be involved in the injury. As a re- sult of the irritation determined by the accident and haemorrhage, in- flammation is precipitated. Hyperaemia of the bone and contiguous soft tissues ensues. As in ostitis, absorption of the bony walls of the Haver- sian canals occurs with the dilatation of the vessels, and general cell proliferation follows. In the medullary cavity proper, in the medullary spaces of the Haversian systems, in the periosteum, and the inflamed surrounding tissues, this process is common. As in all inflammatory processes, the leucocytes are present in great numbers. The medullo- cells, myeloplaxes, osteoblasts, periosteal cells, and connective-tissue corpuscles, undergo rapid proliferation, resulting in the formation of a mass of embryonic cells, which infiltrate the clot between and around the fragment. New-formed capillaries are projected into and through this granulation tissue in the same manner as in the process of repair in wounds of the soft parts. If the broken ends do not come in contact with the air—that is, if the fracture is not compound—the process of repair in bone after an injury is similar to the physiological process of development of this tissue— namely, the embryonic tissue is developed into cartilage cells, and these, undergoing proliferation, develop into a secondary embryonic tissue, which is formed into bone. If, however, air is admitted to a wound in bone, the process of ossification in the embryonic tissue is more rapid and direct, since the intermediate stage of cartilage-cell formation does not occur. A portion of this new-formed tissue, which results from the irritation following a fracture, undergoes a process of calcification by the absorp- tion of inorganic material from the blood, and is known as callus. That portion which lies around and on the outer side is the ensheathing callus ; between the fragments, the intermediate; and within the medullary canal, the central or "pin " callus. In an adult or middle-aged person, commencing within the first few hours succeeding a fracture, the embryonic tissue, which is formed in varying quantity, remains soft and yielding until about the tenth day, when the cells begin to be infiltrated with calcareous matter. The pro- cess of solidification in the callus is complete at a period varying usually from fifteen to thirty days. It is more rapid in children, and slower in the old. ^Vhen complete displacement with overlapping occurs, or when an aponeurosis or tendon, or other dense tissue, separates the broken ends, the process of callus-building is interfered with, and failure of ossifica- tion may result—ununited fracture. Usually a greater portion of the callus becomes absorbed within from thirty to sixty days after the frac- ture. This is especially true of the ensheathing layer and the central callus. That portion which intervened between the opposing surfaces becomes organized into permanent bone. The pin callus remains for a while, and may completely occlude the medullary canal, but usually at a later period undergoes absorption. In some cases the medullary canal ;^o A TEXT-BOOK OX SURGERY. is not re-established. Fig. 348 shows a section af a broken femur in which, after a considerable lapse of time, the canal was still occluded. The peculiar stalactite (exostosis) occurred at the seat of fracture. The permanency of the external callus and its development into exostoses de- pends chiefly upon the disturbed nutrition of the part. It has been Fio. 318.—Longitudinal section of a fractured femur, show- Fig. 349.—Permanent thickening from insr permanent occlusion of the medullary canal. The new-formed bone in a fractured stalactite exostosis is well shown in the right-hand humerus. (From a specimen of the figure. (From a specimen of the author's.) author's in the Wood .Museum.) noticed that when a fracture occurs near the insertion of a group of mus- cles (as at or near the trochanter), exostosis is the rule, and may be very extensive. Prognosis and Treatment in General.—The prognosis of a simple fracture in a healthy child or adult is always favorable. The danger is increased with the multiplicity and complications of the accident. A compound fracture is sufficiently grave to demand the greatest attention. Death may result from sepsis or very infrequently from fatty embo- lism. A longitudinal fracture is a more serious injury, especially grave, as far as the integrity of the member is concerned, when a joint is im- plicated. In all forms of fracture the prognosis increases in gravity with each decade beyond the third. AVhen the fracture is complete, and displace- ment has occurred, exact reposition is impossible, and shortening almost inevitable. The exceptions are extremely rare, especially in the single bones, as the femur, humerus, and clavicle. The great end to be achieved in the treatment of fractures is a reduc- FRACTURES. 353 tion of the displacement to as near the normal as possible, and the abso- lute retention of the parts as replaced. Reduction may usually be accomplished without an ^ansesthetic, but where the overlapping is con- siderable, and muscular contraction and rigidity marked, narcosis should be secured. A compound fracture de- mands, with fixation, perfect asepsis, and when this is doubtful, free drain- age. The fragments should be reduced, even when it is necessary to remove projecting ends with the forceps or saw to effect this. Once placed in po^ sition, they should be kept at rest, with openings and counter-openings. The various methods of treatment will be described with each fracture. Special Fractures—Cranium.—The bones of the skull may be fractured by direct or indirect violence. Direct, when the bones give way immediately beneath the point which is struck; indirect, as when, by falling from a height and striking on the feet or but- tocks, the base of the skull is fractured by the force transmitted through the vertebral column. A rarer form of in- direct fracture of the skull is that known as fracture by contre-coup, in which the bones give way at a point opposite to that at which the injury is received. Fractures of the skull may occur with or without compression of the brain or meninges. The outer table may be depressed by crushing into the diploe without fracture of the inner or vitreous table, and, strange as it may appear, in rare instances the inner table is broken, while the outer plate is not depressed. More frequently both tables are involved. Fractures of the skull may be simple, compound, comminuted, compli- cated, single, or multiple. They are chiefly divisible into those of the vertex and those of the base. Fractures of the base are usually due to indirect, those of the vault to direct violence. A blow on the top of the head may produce a frac- ture only at the base, or at both the apex and base. Usually the break occurs at a point directly in the line of the force which causes the lesion. Aran demonstrated, by dropping cadavers from a height, that when the frontal region received the blow the fracture usually took place m the anterior fossa, the middle parietal and the occipital region giving Fig. 350.—Case of I. J. Lichtenberg. Showing condition of femur twenty-live years after punshot fracture (at ''the Wilderness," 18(i4). At n, sequestrium projecting from center of shaft. Two small particles of lead may be seen imbedded at the edge of the opening. Numerous exostoses. Amputa- tion done January 8, 1889. 354 A TEXT-BOOK OX SURGERY the key to a fracture respectively in the middle and posterior fossae. A blow on the chin has been known to produce a fracture by driving the inferior maxilla against the temporal bone. A fall on the buttocks may produce a comminuted fracture, the force being transmitted through the vertebral column. Fig. 351 is a copy from a specimen I placed in the Wood Museum of Bellevue Hos- pital. The patient, a heavy man, a sailor, fell through the hatchway to the hold of a ship, a distance of about twenty feet, striking on the buttocks. Death occurred instant- ly. The head was not bruised. The cause of death was a commi- nuted fracture, extending through the temporal, occipital, and sphe- noid bones. Diagnosis.— The diagnosis of fracture of the vertex may be read- ily determined when an open wound exists. In many instances a depres- sion may be determined by palpa- tion, even when the scalp is un- broken. Symptoms of compression of the brain are not reliable aids in the diagnosis of fracture in the first few days after an injury, for the reason that any violence suffi- cient to produce a fracture is also likely to produce symptoms of concussion which might easily be mistaken for compression. The escape of brain substance or ventricular fluid is of course an unmistakable sign. At the base, one of the most reliable symp- toms of fracture, yet not always a positive indication of this lesion, is haem- orrhage, or the escape of a serous fluid from the ears. This only occurs, however, when the line of fracture passes through the petrous portion of the temporal bone. Swelling of the vault of the pharynx is not with- out significance when any violence has been suffered which leads to the suspicion of fracture of the skull. If the basilar process of the occipital bone is involved, extravasation will not unlikely be present in this re- gion. Loss of vision or the sense of smell indicates a lesion of the ante- rior fossa. In many instances the diagnosis must rest wholly upon subjective symptoms. Based upon no objective symptoms, the differentiation between con- cussion and compression of the brain is difficult, and often impossible. In general, it may be said that the symptoms of compression are those of paralysis, usually unilateral and more profound than the symptoms of concussion. In simple concussion the patient may be aroused to partial conscious- ness, the respiratory movements of the muscles of the face will be sym- Fig. 351.—Comminuted fracture at the base of the skull, from a fall on the buttocks. (From a specimen of the author's in the Wood Museum.) FRACTURES. 355 metrical, equality of the pupils is maintained, and vomiting is of frequent occurrence. In compression, stupor is apt to be prolonged and profound, the facial muscles are drawn to one side, and the buccinator of the affected side is apt to puff out with the expiratory effort. There may be inequal- ity of the pupils, and vomiting is absent. In the treatment of concussion of the brain the first indication is rest. The recumbent posture, with the head elevated, should be maintained. If there is marked coldness of the skin, and evidence of great prostra- tion or impending collapse, warmth should be applied locally, and stimulants hypodermically. Stimulants must, however, be given with discretion, since the fever of reaction may be increased by their excessive use. After the shock passes off, cold applications to the head are es- sential. The treatment of fractures at the base is generally expectant. Sur- gical interference may however be called for. In fractures of the vault, with depression, in adults, the trephine should be applied as soon after the injury as is consistent with the patient's safety. If shock is present without serious compression, it will be wise to wTait until reaction is es- tablished. AVhen, however, dangerous depression exists, immediate operation, even without an anaesthetic, is demanded. When the symp- toms of depression are not prominent, an exploratory incision is justifi- able in order to determine with certainty whether there is compression of the brain or meninges. With antiseptic precautions this operation adds little to the gravity of the patient's position. A comminuted fracture always demands the elevation and removal of the fragments. A linear'fracture, with depression, even if this is thought to be confined to the outer plnte, also demands the trephine as far as the diploe, and, if the depression involves the inner table, this should also be raised and the fragments removed. A fracture made by a narrow instrument, or other penetrating substance, as a gunshot missile, etc., demands the trephine at the point of entrance. Localized paralysis, coming on immediately after an injury to the skull, calls for trephining at once. It is always better to operate early than to defer interference until inflammatory symptoms are present. The danger is enhanced by such delay. Operation.—Besides the ordinary cutting and haemostatic apparatus, a trephine and elevator will be found necessary, while a rongeur and sequestrum forceps will be of great service. Of the various trephines, the conical instrument of Gait is preferable. The scalp, within two or three inches of the wound, should be shaved perfectly clean, and it, together with the hair, soaped and scrubbed with a clean brush, then moistened with ether, and washed with a l-to-3,000 sublimate solution. A rubber band or piece of drainage tube carried around the head, dipping beneath the occiput, and passing above the ears and eyebrows, may be used to control bleeding from the scalp. In cutting down to the bone, any wound which may exist should be util- ized, and may be enlarged by a crucial incision, if found necessary. The periosteum should not be lifted. 350 A TEXT-BOOK ON SURGERY. Fig. 352.—Fragments removed by the trephine and ele- vator in a depressed fracture caused by a blow with a hamm°r. The beveling at the expense of the vit- reous table is well shown. When the fracture is well exposed, if there is great comminution, and if the fragments are not tightly impacted, they may be lifted by the elevator without trephining. If this instrument is required, advance the central bit about an eighth of an inch beyond the level of the circular teeth, and fasten it firmly here by turning the screw near the center of the shaft. The point of the bit should be applied upon the solid unfractured bone, about a fourth of an inch from the fissure, and the greater part of the button lifted from the un- injured bone. The instrument is now caused repeatedly to rotate for a half circle and back, and sufficient pressure is made to carry the point and teeth into the calvarium. AVhen the teeth have cut a circle about one sixteenth of an inch in depth, the instru- ment should be removed, and the bit slipped up the shaft to its original position. As the operation proceeds, the trephine should be removed every few turns and the ring cleaned out with a toothpick. A slight bleeding is apt to occur when the diploe is entered. As soon as the inner table is divided the instrument becomes locked and practically immovable. AVounding the dura matter is scarcely probable if the tre- phine is held perpendicular to the plane of the bone which is being cut. If the button does not come up with the instrument, it should be lifted out with the elevator or forceps. The elevator may now be carried care- fully under the edge of the depressed bone, and, using the solid surface for a fulcrum, lifted into position, or, if comminuted, removed. It is always important to look for any fragments, however small, which are apt to be broken off from the vitreous table and driven between the dura mater and the skull. If the dura be torn, the bleeding should be ar- rested by catgut ligatures, and the wound in this membrane closed by sutures of the same material. In passing a needle through the dura it is a wise precaution to employ a grooved director to shield the thin vessels of the pia mater from the needle. The wound should be treated under strict antisepsis, and a twist of sterile catgut inserted for drainage. The trephine should not be applied over the track of the longitudinal or lateral sinuses and the middle meningeal artery. Depressed bone may be lifted from these vessels. Haemorrhage, if it occur, may be controlled by the ligature or by compression. Nasal Bones.—One or both nasal bones may be fractured and de- pressed, and in severe injuries the nasal processes of the superior maxilla and the perpendicular plate of the ethmoid are involved. FRACTURES. 357 Haemorrhage from within the nose is usually severe, and may require the tampon of the anterior and posterior nares. The reposition of the fragments should be effected with great care. A strong, blunt, and nar- row instrument passed along the septum nasi until it is in contact with the inner surface of the fragments, together with lateral pressure from without and at the base of the nose, will best reduce the displaced pieces. In order to hold the fragments in position, the method of treatment in- troduced by Dr. Lewis D. Mason will be found preferable.* After reposi- tion, as above described, a steel drill is passed directly across the nose, being entered through the line of fracture or beneath it. The accom- panying cut (Fig. 353) illustrates the employment of this procedure. This patient received a kick which drove the nasal process of the supe- rior maxilla of the right side and the right nasal bone into the cavity of the nose. The deformity was marked and the voice greatly changed and unusually nasal in tone. The bones could be readily replaced, but would return to their abnormal position as soon as the instrument was withdrawn. Under ether I replaced the fragments, and, while held in proper position, I drove one of my steel fixation drills from side to side, passing it beneath the loosened pieces. A light loop of iodoform gauze was twisted across the nose and over the ends of the drill. The instrument remained in place ten days, was re- moved, and a perfect cure obtained. AVhen the blow is received on the side of the nose, the fracture and de- pression may be unilateral. In such cases, replacement effected after the manner just described will usually suffice, since the fragments are not likely to be displaced when once in position. AAThen the fracture is bilat- eral, the drill should be entered at the level of solid and unbroken bone, on one side, if possible. AA7hen the bones are widely comminuted a second drill may be utilized. In those instances where the perpendicular plates of the ethmoid or vomer are broken, after reposition and fixation with the drills, any lateral deviation of the septum should be corrected. Plugs of gauze may be carried into the nares, if necessary. At times, and especially in children, when the nasal arch is struck from the front, the fracture occurs at the naso-maxillary suture, and the nasal bones are driven in without comminution. In this variety of de- pression considerable force is needed to effect reduction. Such is the rapidity with which repair and union occur here, as in all the bones of the face, that, if the effort at reduction is delayed for more than Fig. -Case of O'Toole. ; Annals of Anatomy and Surgery," vol. ii, pp. 110 and 199. 358 A TEXT-BOOK ON SURGERY. twenty-four or forty-eight hours it will be exceedingly difficult to ac- complish. Fracture of the malar bone occurs rarely, and is the result of violence so great that usually the upper jaw and other bones are broken. Every effort should be made to restore the normal contour to the face by repo- sition of the fragments, none of which should be removed, since the vitality of the bones of the face is so great that necrosis after injury is exceptional. When the fracture is compound, and this is usually the case, the fragments may be lifted into place through the wound, by means of the bullet-screw elevator, or other instruments ; or, as advised by Hamilton, the finger or thumb may be passed underneath the lip to the zygomatic arch, which can be utilized as a point for pressure. At times, however, it may be necessary to enter the antrum maxillare by trephining or drilling through the anterior wall of the antrum. The point of entrance should be immediately above the first (or anterior molar) tooth, at a dis- tance of from one half to three quarters of an inch below the inferior margin of the orbit. Fracture of the zygomatic process, either of the malar or temporal bones, may occur singly or as a complication of the fracture just treated. If the force which produces the lesion does not wound the temporal or maxillary arteries, the treatment is simple. If the depression is sufficient to cause deformity, cut down to the arch, insert a hook elevator, and lift the bone into place, or preferably, as advised by Prof. Rudolph Matas, insert a full-curve (semicircular) Hagedorn needle threaded with silk (followed by silver wire) through the soft tissues near the depressed bone, passing behind and beneath it. Strong traction on the suture will pull the displaced fragment in position. To hold it until union occurs Matas ties the wire over a narrow splint resting on a pad of iodoformized gauze. It is necessary to limit mastication by the application of a bandage, as in fracture of the lower jaw. The superior maxilla may alone be broken, although it is usually complicated with fracture of other bones. A blow received at the roots of the teeth may drive the alveolar and palatal arch downward, or, if the direction of the impinging body is from before backward and upward, the antrum may be opened. The treatment is to cleanse the wound antiseptically and replace all pieces of bone as well as possible. The following case illustrates in a remarkable degree the vitality and reparative power in the bones in the face : In September, 1884. a robust Irishman, about forty years of age, came into my service at Mount Sinai Hospital. He had just been kicked by an unshod horse. The crescentic wound extended from the center of the forehead down by the nasal process, along the facial groove, and out beyond and below the malar bone. The soft tissues were lacerated, and the bones extensively com- minuted. The wound was cleansed of particles of manure, straw, etc. Strict antisepsis was employed, thoroughly cleansing the wound and replacing every piece of bone. The torn edges were pared and closed FRACTURES. 359 by silk sutures. Rapid union ensued, without the exfoliation of any portion of the bone. The great desideratum is the prevention of a scar. Upon the face the greatest care must be taken to avoid deformity. If the soft tissues are torn and contused, the edges of the wound should be smoothly pared and nicely approximated by fine silk sutures. When the destruction of the bone is so extensive that, even after re- position of the pieces, the fragments will not remain in place, it may be necessary to use the lower jaw as a splint, by fixation of the two rows of teeth, with the head and chin figure-of-8 dressing, as for fracture of the lower jaw. The interposition between the teeth of short strips of gutta-percha, thoroughly softened in wTarm water, will firmly fix the broken to the unbroken bones, and admit of the introduction of liquid food between the upper and lower incisors. Fracture of the inferior maxilla may occur in rare instances through the symphysis menti, but much more frequently external to this and near the opening of the mental foramen. The majority of all fractures are of the body, and within the first inch and a half leading backward from the symphysis. Fracture of the angle or ramus is infrequent, and is usually the result of a blow upon the side of the jaw. The coronold process is rarely if ever broken, except by penetrating bodies. The condyle may be broken through its neck by a fall or blow on the chin, or by force applied later- ally at or near the angle. Diagnosis.—Among the symptoms of this lesion are pain at the point of fracture and loss of function. If the break is complete the diagnosis is made evident in the displacement which usually occurs, and by the presence of crepitus. The bone may, however, be broken without dis- placement, and where crepitus is not present. Under such conditions, while a diagnosis may not be positive until the swelling which indicates the formation of callus ensues, the jaw should be kept at rest by one of the methods to be described. AAThen the fracture occurs at or posterior to the mental foramen, the temporary loss of function of the inferior dental nerve, which is not infrequent, points almost unerringly to a recognition of the character of the lesion. AVhen the neck of the condyle is broken, the chief symptom is pain in this region, with partial or com- plete loss of function. Crepitus is with difficulty elicited by the surgeon, although it may be evident to the patient. Treatment and Prognosis.— Immediate reposition of the broken and displaced surfaces, and as perfect a degree of rest as possible, are the first and chief indications for treatment. When the presence of a par- tially displaced tooth offers an obstacle to close adaptation it should be removed. AAThen reduction is effected, one among the following methods may be employed: A simple and ready method, which may be used until a more secure apparatus is constructed, is found in the four-tailed bandage (Fig. 188). The fragments being carefully adjusted, the bandage is applied as already given on page 166. The figure-of-8 chin and head bandage (Fig. 180) is 360 A TEXT-BOOK OX SURGERY. also an excellent emergency dressing for fracture of the lower jaw. If this is intended to be used permanently, a leather or gutta-percha cup should be constructed, to fit over the chin and wrell along the body of the jaw. The material should be cut from, three to three and a half inches wide and about six to seven inches in length, and split from each end in its long axis to within three fourths of an inch of the center. One strip should be about half an inch narrower than the other. If gutta-percha is used, this should be dipped in warm water for a minute or two, until it becomes softened. It is then laid across the chin, the upper and nar- row ends are turned back over and parallel with the body of the jaw, while the lowTer ends are turned upward and made to*cross outside the horizontal ends. The bandage is applied over this cup, which soon hardens into an unyielding dressing. Leather may be prepared in the same way, but requires to be soaked longer than the rubber. Inter-dental splints, made of gutta-percha strips, cut about one inch and a half in length, from one fourth to one half an inch in width, and about one fourth of an inch in thickness, are sometimes employed to fix the molar teeth immovably, and at the same time to separate the anterior teeth enough to permit the introduction of liquid food. These strips should also be softened, and, when placed between the teeth, the crowns of the molars are pressed into the rubber by the bandage. AAThen the fracture is through the molar region, the strip on the broken side is placed on either side of the fracture. The most suitable apparatus is that of Prof. Hamilton, seen in Fig. 354. It consists of a chin-and-head strap, made of strong, soft leather. This piece, where it passes under the chin, is shaped so that while it may not cause uncomfortable pressure at the base of the tongue, it is wide enough, as it passes up on to the side of the face, to in- clude the angle of the jaw in its support. From this point it is gradually narrowed, until at the temple it is an inch in width, and the same where it is buckled at the fronto-parietal suture. A piece of cloth, fashioned so as to fit like a cup over the chin, is sewed on to this. A second strip is buckled around the head, across the fore- head and beneath the occiput, and from this point an antero-posterior strap passes forward to the maxillary piece, to which it Fig. 354.—(After Hamilton.) i* attached at the fronto-parietal junction. Hy shortening or elongating this strap the direction of the pressure on the jaw can be changed, while it prevents the maxillary strip from pulling forward. Apiece of soft lint or cotton should be placed under each buckle. If, after the apparatus is applied, the teeth fit so closely together that it is impossible to introduce liquid nourishment, inter-dental splints of gutta-percha should be employed. In some instances it will be necessary to unite the fragments by silver- FRACTURES. 361 wire sutures. The sutures usually require to be removed after union is secured. A patient with a fractured jaw should not be allowed to talk, and, when in bed, should be required to rest in the dorsal decubitus, so as not to press laterally upon the injured bone. The prognosis is usually favorable. Fixation by ossification occurs in from two to five weeks. In some cases later, while in a small number, in which proper treatment has been delayed, or the character of the injury severe, or the condition of repair in the patient unfavorable, union is delayed or fails utterly. In instances of delayed union fixation should be faithfully tried. If this fails, and the function of the jaw is seriously impaired, the point of fracture should be exposed by incision, the broken edges scraped, one or two holes drilled through each frag- ment, one fourth of an inch from the edges, and fixation secured by means of silver wires. Fracture of the cartilages of the larynx is of rare occurrence. Sim- ple fracture heals without retentive apparatus, quiet being the chief indi- cation. The prognosis is grave in proportion to the danger of asphyxia from inflammatory swelling or emphysema. When the force has been great, and the comminution extensive, death may occur from shock or other complication before asphyxia from occlusion of the trachea super- venes. AVhen this last danger is threatened, tracheotomy should be per- formed early. AVhen the os hyoides is broken, the fragment, if displaced or driven through the soft tissues, may be brought into position by introducing one finger into the mouth and pressing with the other hand from without. It is scarcely possible to retain the ends in apposition, and fibrous union is apt to occur. The ac- cident is rare, is not dangerous, and the prognosis consequently favorable. Clavicle.—The clavicle is, next to the radius, more frequently the seat of fracture than any other bone. In children the frac- ture is rarely complete, and consequently overlapping is not met with, as is the rule in adults. The break occurs, in a large majority of instances, in the middle third, i. e., in that portion of the bone between the attachments of the trapezius and sterno- mastoid muscles. This fracture may be caused by direct violence, or by indirect force, as a fall upon the shoulder or the extended arm. Flo. 355.-(From Gray.) The character of the displacement is shown in Fig. 355. The inner fragment is held in position by the mas- toideus muscle, and is prevented from being carried upward by the costo- clavicular ligament. The weight of the arm and shoulder drags the 26 362 A TEXT-BOOK ON SURGERY. outer fragment downward, while the contractions of the pectoralis major, latissimus dorsi, and subclavius muscles carry it toward the middle line of the body, beneath the inner fragment. In rare instances the displace- ment is the reverse. The diagnosis rests upon loss of function, pain at the seat of lesion, possibly crepitus, loss of symmetry, shortening, and recognition of dis- placement by palpation. The prognosis is good as to resto- ration of function, although in com- plete fracture, overlapping and a cer- tain amount of permanent deformity and shortening are almost inevitable. Treatment.—In complete fracture overlapping of the fragments may be corrected, and the ends brought into apposition, by first carrying the arm and shoulder backward, and then elevating the shoulder. This is the principle involved in Prof. Sayre's excellent method of treating this lesion, which is as follows: Cut two strips of strong adhesive plaster (moleskin is preferable) about three inches wide and several feet in length. Just above the elbow of the arm on the injured side, one strip, Fig. 357.—Sayre's dressing for fractured clavicle. Fig. 358.—Back view. Front view. with adhesive surface nearest the body, is passed around the arm and secured with a safety pin, so that it will not constrict the member (Fig. 356). The hand is now laid over the middle of the sternum, the shoulder elevated, and the elbow carried well backward by an assistant, while the operator carries the plaster directly around the body by the back, fasten- ing it snugly to the integument. The second strip is split near its mid- FRACTURES. 363 die for about three inches, for the accommodation of the elbow, and is applied along the forearm and over the shoulder of the sound side, and obliquely around the back to the same point (Figs. 357, 358). A wad of absorbent cotton should be placed in the axilla of the affected side, and between the hand and the sternum. The plasters should be stitched or fastened securely with safety pins. A convenient and effective ready method is that of Prof. Moore, of Rochester. A strip of sheeting, eight inches in width and three yards long, is held near its center across the palm of the operator, who, for the left clavicle, grasps the elbow of this side from behind. That end of the strip which is next the patient's body is passed between the arm Fig. 359.—Moore's method. Fig. 360.—Moore's method. and chest, then up in front of and over the clavicle of the injured side, obliquely across the back, under the opposite axilla, thence across the right clavicle, and over this to the back. The opposite end is passed to the front of the arm at the elbow, be- tween the first strip and the arm, and is then carried around the back. An assistant now carries the elbow backward and upward, and, while held in this position, the bandage is tied, sewed, or pinned. A sling to support the forearm is added. This is practically a figure-of-8 bandage around the elbow of the broken side and the shoulder of the sound side. The hand is carried across the chest, slightly elevated, and is held in a sling. Safety pins are inserted at the points of crossing (Pigs. 359, 360). In incomplete fracture, and in children, especially during the summer months, when the plaster tends to produce irritation of the skin, A^el- peau's method is preferable. (See Dislocations.) Any form of apparatus should be wTorn at least four weeks. The scapula is almost always broken by direct violence. It is 364 A TEXT-BOOK ON SURGERY. thought to have been fractured in a few instances by muscular action alone. Acromion Process.—The acromion process is usually broken by a fall on the shoulder or a blow received from above. The fracture may occur anterior to, through, or behind the acromio-clavicular articulation. The diagnosis is evident from crepitus, preternatural mobility, and de- pression of the outer end of the clavicle. The treatment is to bend the forearm at a right angle to the arm, and throw a roller under the forearm, at the elbow, and over the clavicle and shoulder of the affected side, fix- ing the head of the humerus in the upper part of the shoulder joint and lifting the acromion into its place. Coracoid Process.—When this process is broken the tendency to dis- placement is downward, owing to the action of the pectoralis minor, coraco-brachialis, and short head of the biceps. Unless the fracture is anterior to the attachments of the coraco-clavicular ligaments, or unless these have been detached, the displacement can only be limited. Treatment.—Place the hand of the injured side on the opposite shoul- der, and apply Yelpeau's bandage as for fracture of the clavicle. The prognosis-is good, although fibrous union is the rule. Fracture of the glenoid process—that is, through that portion of the scapula between the glenoid fossa and the anterior portion of the base of the coracoid process—has not yet been noted. Several instances are recorded, however, of fracture which, while anterior to the base of the acromion, included the base of the coracoid process. Treatment—Flex the forearm at right angles to the arm, and carry it across the chest, leaving the humerus parallel with the axis of the body. Lift the humerus directly upward against the coraco-acromial ligament, place a pad in the axilla, and carry a roller around and under the forearm, at the elbow, and over the shoulder of the same side. Every other turn should be carried horizontally around the body. By this means the head of the humerus keeps the fragment in position. Fracture of the spine of the scapula is rare, but below this it is of more frequent occurrence. Velpeau's bandage, or any method which will give the minimum of discomfort and the greatest degree of rest, will be most successful. Humerus.— Fracture of the humerus occurs most frequently in its lower third, while the proportion of fractures in the middle and upper thirds is about equal. In the upper third this bone may be broken through the anatomical neck ; just below this line, through the tuberosities ; immediately below the tuberosities (the surgical neck); or through the shaft. It may also be fractured longitudinally, with separation of the tuberosities. Fracture of the anatomical nedx, or intra-capsular fracture, is rare. It is caused by a blow or fall directly on the shoulder. Diagnosis.—There may be crepitus. If the shoulder is fixed and the humerus grasped below and up to the tuberosities, and crepitus is felt by moving the head against the glenoid cavity, the character of the injury is evident. If impaction into the shaft has occurred, crepitus FRACTURES. 365 will be absent, but shortening will be ascertained by careful measure- ment. Bony union after intra-capsular fracture is rare, unless impaction has occurred. Osteo-arthritis may result, rendering exsection of the joint necessary. Fracture through the tuberosities occurs also from direct violence. The symptoms closely resemble those of the variety just described. The prognosis is more favorable, since bony union is the rule. Prognosis as to freedom of motion should be guarded, since exostosis may result to such an extent as to interfere with the usefulness of the arm. Fracture through the surgical neck is of far more frequent occurrence than the intra- or extra-capsular fractures at the anatomical neck. It may result from direct violence, although not infrequently a fall upon the hand or elbow may produce it. The bases of the tuberosities are rarely involved in fracture of the neck in adults —except in the young, when separation at the epiphysis may occur. In the middle aged and old the point of fracture is usually about one inch below the tuberosities. Displacement may occur in any direction, although as a rule it is not extreme. The tend- ency of the lower fragment is to be drawrn up- ward by the deltoid and triceps, inward by the pectoralis major and latissimus dorsi, and up- ward and inward by the short head of the biceps and the coraco-brachialis (Fig. 361). Longitudinal Fracture.—This form of frac- ture, though rare, occurs from direct injury. The split usually runs through the head of the humerus and along the bicipital groove, resulting in a separation of the greater tuberosity from the shaft. The bone wdll be found to be flattened and wider than normal, while a deep groove marks the line of cleavage. The prognosis is unfavorable as to restoration of function. Differential Diagnosis.—In dislocation of the shoulder joint there is always abnormal immobility ; the muscles of the shoulder and arm are rigid ; a measurement over the acromion and around through the axilla will be at least one inch greater than on the non-dislocated side ; the head of the bone will be felt out of its normal position ; if the hand of the affected side is laid upon the opposite shoulder, the elbow can not be made to touch the chest wall. In fracture without impaction, crepitus and shortening ; more or less pain on motion; mobility free ; the circumference not increased ; the head of the bone in position ; with the hand of the affected side upon the opposite shoulder the elbow drops to the chest. AATith impaction, all of these symptoms except crepitus. Treatment.—Reduction, of displacement is usually affected by exten- sion from the flexed forearm, the shoulder being fixed by traction in the Fig. 361.—Showing the mechan- ism of displacement in fracture of the surgical neck of the hu- merus. (After Gray.) 366 A TEXT-BOOK ON SURGERY. opposite arm, or by a sheet carried around the body, just under the axilla. In the first manoeuvre it is usually best to hold the arm at right angles to the body, and, continuing the extension, to bring it down par- allel with the chest, in which position it is to be fixed. To this is added direct manipulation of the fragments. The choice of dressings may be made between plaster of Paris and a cup-shaped splint of gutta-percha, sole leather, or bookbinder's board. Properly adjusted, either of these materials will suffice. In the treatment of fractures in general, with the exception of cer- tain fractures which will be separately considered, plaster-of-Paris immo- bilization gives the greatest satisfaction. After the bones have been placed in apposition, and while extension and counter-extension are being made, a canton-flannel roller, or an ordinary muslin bandage, should be applied over a single layer of cotton batting, which is placed next the skin. Compression of this bandage, and of the plaster-of-Paris bandage which is to follow, should be snug, yet not very tight. The tendency of the tissues under the bandage is to become smaller, and it will be found, within a few days after application of the plaster of Paris, that this will appear loose, even when it has been tightly applied. The danger of swelling as a complication of ordinary fractures does not con- tra-indicate the use of gypsum. It may be applied immediately upon receipt of the injury, and it is not necessary or advisable to wait to see how much swelling is going to occur in the limb. If the proper precau- tions are carried out, no harm will ensue. It has been my practice, almost without exception, in fractures of the humerus or lower portion of the thigh or of the leg and back, to apply the plaster at once. As soon as it sets, I immediately spilt it from one end to the other down to the flannel bandage which envelops the cotton batting and the limb. As the plaster is accurately applied, and is stiff, no displacement of the frag- ments can occur; and should swelling take place in the absence of the surgeon, it is a simple matter for any one to insert a pair of scissors and divide the flannel bandage which alone constricts the limb. In this way no amount of swelling can produce gangrene. The plaster-of- Paris dressing should be one eighth of an inch thick, or more. The limb should be held in perfect apposition by extension and counter-ex- tension until the plaster hardens. This dressing is usually left on from four to six weeks, and longer in old persons. AVhen the limb atro- phies to such an extent that the dressing becomes loosened, a strip, half an inch wide or more, and for the entire length of the dressing, may be removed from the plaster dressing, and the whole more tightly adjusted by an ordinary roller outside. If a shoulder cap is to be applied, a pattern is first made by cutting a piece of paper to fit over the shoulder and down the arm. It should be large enough to spread over a part of the scapular and pectoral region and to embrace two thirds of the circumference of the arm. The paste- board, gutta-percha, or leather is cut to correspond to this, and is im- mersed in hot water until it is soft and pliable, when it is lined with a thin layer of absorbent cotton and molded over the arm and shoulder, FRACTURES. 367 where it is secured by a roller, applied as above. The inner side of the arm is protected by cotton or cloth. The forearm and hand should be bandaged and held in front of the ensiform cartilage by means of a sling. If the dressing becomes loose, an additional roller should be applied. Any dressing for this fracture should be worn continuously for at least four weeks. In order to prevent contraction of the biceps, it will be advisable to fully extend the forearm every two or three days. Fracture of the shaft of the humerus near the head of this bone is, in a certain proportion of cases, complicated with dislocation. It is be- lieved to occur as a result of falling upon the hand or forearm while the arm is in abduction. I have met with two instances in which this oc- curred, and in both cases the patients had fallen with great violence upon the injured side. The fracture usually occurs at the surgical neck. The first case was in the practice of Dr. Charles McBurney, during his tempo- rary absence. The patient, a heavily built man, was thrown from his car- riage. Under an anaesthetic it was discovered that fracture existed at the surgical neck, with dislocation of the head of the humerus beneath the coracoid process. Fourteen days after the accident Dr. McBurney oper- ated upon the patient by an original method, which was eminently suc- cessful. An incision was made on the outer aspect of the upper frag- ment, a good-sized hole drilled in this, and a stout, blunt hook inserted, strong traction being made upon the upper fragment in the proper direc- tion ; the arm and forearm were carried up nearly at a right angle to the body, and with the hook inserted in the bone and the fingers on the humerus vigorous traction was made. The effort required was very con- siderable, but no change of direction was needed, reduction being accom- plished at the first attempt. The fractured surfaces were then brought into apposition, but not wired, an aseptic dressing applied, sterile gauze and plaster of Paris over all. The second case came under my care at the Polyclinic Hospital. The patient was a woman, forty-seven years of age, who stated that she had had a fall two weeks previously, and had been unable to use her arm since the accident. A diagnosis was made of dislocation of the right shoulder, with fracture of the humerus at the surgical neck. I proceeded to carry out the operation suggested by Dr. McBurney, following exactly the same method and using his instrument, but no amount of force I could apply in any direction would carry the displaced head into the glenoid fossa or the capsule. The head of the bone wTas immovably fixed, and I was compelled to exsect the upper fragment. I learned later that this patient had had an accident of a like character one year before, and that the dislocation I was dealing wdth was an ancient one ; the last accident evidently had fractured the bone which had been dislocated in the first. Fractures of the shaft of the humerus, although chiefly caused by direct violence, are not infrequently the result of a fall on the hand or elbow, and may, in rare instances, be caused by muscular action alone. The displacement, which is usually not marked, will in great part be de- termined by the direction of the line of fracture. If the break is above 368 A TEXT-BOOK ON SURGERY. the insertion of the deltoid, while the lower fragment is drawn upward by the deltoid and the long muscles extending from the scapula to the elbow, the upper fragment is apt to be drawn toward the thorax by the pec- toralis major and minor and latissimus dorsi muscles (Fig. 361). If the break is below the deltoid tubercle, the dis- placement and overlapping will, in gen- eral, follow the obliquity of the frac- ture. The lower fragment is apt to be drawn behind the upper longer piece. A not infrequent complication of fractures of the shaft of the humerus is the injury to one or more of the nerves which are in intimate relation to the bone. The musculo-spiral nerve is most frequently involved. A number of instances have come under my obser- vation in which paralysis of the exten- sor muscles (wrist drop) has followed injury to this nerve by fragments of bone at the time of fracture, or by pressure of the callus which is thrown out. If a nerve has been injured at the time of fracture—that is, if paralysis be present—it would be advisable to cut down upon the seat of fracture and determine whether the nerve has been sufficiently in- Fig. 362.—Apparatus for fracture of the hu- merus at any point above the condyles. (After Hamilton.) jured to demand suture. Fig. 363.—Showing mechanism of displacement in fracture above the condyles. (After Gray.) In transverse fracture In two instances I have had to cut down and chisel away the callus around the nerve, in one case making a section of the nerve with resuture. The treatment is practically the same as that just given. If the cup-shaped splint is used it should be made longer, and an extra short, narrow, internal splint may be added (Fig. 362). The plaster-of-Paris dressing is to be preferred. Fracture at the'condyloid extremity of the humerus may be divided into: 1, transverse fracture above the condyles, caused by vio- lence applied to the elbow ; 2, epiphyseal sep- aration (on a plane lower than the above); 3, transverse fracture, with a longitudinal split into the joint (inter-condyloid); 4, fracture of the external condyle ; 5, of the internal con- dyle ; 6, of the external epicondyle; 7, the internal epicondyle. above the condyles the obliquity is usually from behind forward and downward" (Fig. 363), the inferior short frag- FRACTURES. 369 ment being carried up behind the longer. AVhen the lower fragment is split into the joint, the displacement is the same. In epiphyseal separation the displacement is not great, unless the cap- sule is badly torn, as a result of extreme violence. The treatment of these varieties of fractures is the same—reduction by extension and counter-extension, holding the fragments as well in position as possible, placing the forearm in supination at an angle of 90° with the humerus (right angle), and enveloping the member with plaster of Paris from the axilla to the end of the metacarpus. Experience has taught that passive motion should not be attempted during the process of repair, it being better to wait four or six weeks, until union has oc- curred, before allowing motion. The Internal condyle is broken much more frequently than the exter- nal. It is more prominent, and, in the act of falling backward, the arms are thrown out from the body in such a manner that the inner condyle first receives the force of the fall. The fracture may be confined to the tip (extra capsular), or it may include a portion of the internal epicon- dyle, and lead into the joint through the trochlear surface. In treating fracture of the internal condyle, the same angle is ad- visable, with the forearm so placed that the thumb is upward (semi- pronation). Fracture of the external condyle is of rare occurrence. The line of cleavage usually commences about the middle of the external condyloid ridge, and runs obliquely to the articular surface, in the groove between the radial eminence and the trochlear surface, or through the center of this surface. The diagnosis is determined by the crepitus, degree Of mo- bility of the fragment, and by the partial loss of function of the extensor or flexor muscles (as the outer or internal condyle is affected). For the external con- __ dyle, plaster of Paris r 1j» j~ "lbs should be applied, as for / ///;//' j^/ ui^^A fracture of the internal ><^*Hrfll^^ condyle, from the axilla X| JjpS«| ISr to the metacarpus, with ^^^^^^^^ the forearm in Supination. FlG. 365.-Fraeture of eminentia CJo-narci+inn nf fhp piti capitata and external condyle Dig. 364.-Double condyloid or ©epdldUUll ui me epi by force transmitted along T-fracture of the humerus. Condyles is of rare OCCUr- *he rnadmTsT f™m. a fall on the (Helferich.) J , , n hand. (Helfench.) rence, and demands no especial mention. The indications for treatment are similar, and the prognosis more favorable than for fracture of the condyles. In all of these fractures at or near the elbow the surgeon should pro- tect himself always by the most guarded prognosis. On account of the formation of callus, or even the slightest displacement of the fragments, the articular surfaces and the relations which the various bones at the elbow bear to each other are so changed that motion in this complex ]oint is more or less permanently impaired, and a perfect result is prac- tically impossible. I have seen a considerable number of cases in which 370 A TEXT-BOOK ON SURGERY. Fig. 360.—Displacement of the upper fragment in fracture of the olecranon. (After Gray.) the eminentia capltata of the humerus, upon which the head of the radius articulates, has been broken loose, taking with it, as a rule, a part of the external condyle, as the result of a fall upon the outstretched hand, the force applied to the hand being imparted through the radius to the eminentia capltata. The callosities in these fractures are, as a rule, extensive and the deformity well marked. The term "gunstock fracture" has been applied to this injury. Forearm — Ulna. — Fracture of the olecranon process usually occurs as a result of a fall on the elbow, when the forearm is in strong flex- ion. It is occasionally caused by contraction of the triceps. The line of fracture is most frequently at the epiphyseal junction. The displace- ment is upward, in the line of the triceps (Fig. 366). The diagnosis may be determined by loss of function, crepitus, which may be obtained when the forearm is fully extended, or by appreciation of the separation of the two fragments. Treatment— Extend the forearm to the fullest degree consistent with comfort. Make a soft-board splint, two or three inches wide, and long enough to extend from within two inches of the carpus to the same distance from the axilla. Cut a deep notch on either side, three inches below the level of the line of fracture. Pad the splint with bat- ting, making it twice as thick in the bend of the elbow as elsewhere, and wrap it with a roller. Lay the splint on the anterior surface of the arm and forearm, and secure it near the ends by several turns of the roller. Next, take a flannel bandage (on account of its elasticity), and, com- mencing below, cover the forearm and splint by circular turns until the notch is reached, at which moment the roller is carried well above the upper frag- ment, around the pos- terior aspect of the arm, and down again, to be secured in the notch on the opposite side of the splint. This oblique turn is repeated until the fragments are in apposition, wThen the whole is secured by as many circular turns as are needed (Fig. 368). Within a week the fracture should be inspected, by Fig. 367.- -Hamilton's olecranon splint. Hamilton.) (After —Hamilton's dressing: for fracture of the olecranon. (After Hamilton.) FRACTURES. 371 removing a portion of the dressing, and additional turns applied if any separation has occurred. After five or six weeks the splint should be removed, and careful passive motion made, while the fragments are sup- ported by the operator. The union is apt to be ligamentous. Fracture of the coronoid process is exceedingly rare. The diagnosis is difficult—often impossible. If the lesion is strongly suspected, secure quiet by applying a splint in extreme flexion. Fracture of the ulna, in its shaft, occurs in the effort to ward off a blow, or as a result of a fall directly upon the bone. The diagnosis is usually not difficult, even when displacement is slight. In suspected fracture of one of the bones of the forearm, if compression be made by grasping both bones at a point remote from the suspected break, and pain or abnormal mobility be caused at that point, the diag- nosis of fracture is fairly clear. If crepitus is obtained, all doubt is dis- sipated. Displacement of the upper fragment is always slight. The lower may be drawn toward the radius by the pronator quadratus. The obliquity of the cleavage, and the direction of the force which produced the lesion, will almost always determine the displacement. Radius.—Fracture of the radius above the bicipital tuberosity is one of the rarest forms of injury, and, Avhen present, is with great difficulty recognized. The cause is direct violence. Displacement of the upper fragment will be slight, unless the fracture is complicated with a disloca- tion at the radio-humeral joint. The action of the biceps will tend to draw the lower fragment forward. The best position for treatment is to flex the forearm on the arm, wdth the palm turned upward, and to apply an anterior splint, wider than the arm, and provided with an interosse- ous pad. If the displacement forward is extreme, a compress may be employed. Fracture of the radius between the bicipital tuberosity and the in- sertion of the pronator radii teres is also usually from a direct blowT, although it may result from a fall on the hand, or from muscular ac- tion.* AVhile the obliquity of the line of fracture will in great part determine the displacement, the tendency is for the lower fragment to be carried toward the ulna by the conjoined action of the prona- tor aiiadratllS flnrl Tvrrmatnr rnrlii Fig. 369.—Displacement of the fragments in fracture quauidlUS dllU pronator raClll of the radius in its lower third. (After Gray.) teres muscles, while the upper frag- ment is rotated outward by the biceps. AAThen the bone is broken below this point the lower fragment tends toward the ulna. The upper may be held out by the biceps, or carried toward the ulna if the pronator radii teres is contracted (Fig. 369). Treatment—The position wdiich renders the approximation of the fragments most easy is that of supination ; but in this position the two * Packard, in Ashhurst's " Encyclopaedia," vol. iv. William Wood & Co., New York. 372 A TEXT-BOOK ON SURGERY. bones are almost in apposition, and the danger of osseous union between them, with loss of lateral motion, is increased. For this reason it is safer to fix the limb halfway between supination and pronation (with the thumb pointing upward). (The application of the splint is the same as for fracture of both bones.) Fracture at the Carpal End of the Radius.—Fracture through the cancellous expansion of the lower end of the radius is the most frequent of all fractures ; that of the clavicle next in order. The line of fracture is in general transverse, and within one inch of the articular surface, being usually nearer the anterior margin of the articular surface, and running obliquely upward, on to the dorsal aspect of the bone, at a dis- tance varying from one fourth to one inch above the posterior lip. In very exceptional instances the posterior lip or rim is split off, the line of fracture leading from the articular surface upward, on to the dorsal aspect of the bone (Barton's fracture). The styloid process is also occa- sionally broken off, or, when the violence of the fall is great, the bone may be split in its long axis by the first impact of the carpus, and after- ward transversely fractured by the forced extension and strain on the anterior ligaments. Though a fall on the back of the hand has been known to produce a transverse fracture of the cancellous expansion of the carpal end of the radius in a few7 instances, in the vast majority of cases the force is first received upon the palmar aspects of the fingers and the palm, with the hand in forced extension. The mechanism of this lesion is this: In the act of falling, the hand is thrown out, and the force of the fall is received first upon the palm, and chiefly upon the anterior extremity of the metacarpus, whence it is transmitted backward to the carpus, and to the anterior radio-carpal ligaments. As the extension is continued, the strain on this ligament is increased, until the bone begins to yield on its anterior aspect, close to Fig. 370.—Displacement of fragments in Colles's fracture. (After Gray.) and parallel with the radial attachment of the ligament, and, as the force is continued, the line of fracture travels upward and backward. The same force which produced the fracture by forced extension and impact of the body will, if continued, produce the usual displacement, causing the lower fragment to ride backward upon the upper, and frequently causing impaction of the compact posterior rim of the upper, into the spongy substance of the lower fragment (Fig. 370). AVith the upward FRACTURES. 373 Fig. 371.—Colles's fracture, showing the fibrous band which prevents reposition. displacement of the lower fragment, the strong fibrous band spread over the dorsum of the radius at its carpal extremity, the function of wThich is to hold the extensor tendons in position, is torn loose, and frequent- ly raised half an inch or more as it is contin- uous upward with the periosteum of the radius (Fig. 371). 'It is this band of fibrous tissue, together with the par- tial impaction of the fragments, which makes reduction difficult, and in some instances impossible, by direct extension and counter-extension. Treatment— AVhen, after careful examination, there is found any degree of displacement of the lower fragment, upward and backward upon the upper, proceed as follows : With the back of the patient's hand turned upward, the operator with one hand grasps the forearm in such a way that, while the radius is firmly held, the thumb is immediately above the line of fracture. With the other, the hand of the patient is grasped so that his (the sur- geon's) thumb (or index finger, if preferred) presses firmly upon the back of the lower fragment. The hand is now carried strongly back toward the dorsal aspect of the radius (forced and extreme extension), and while in this position the lower fragment becomes unlocked, and may be pushed into place by the thumb, while at the same time the hand, under strong extension, is carried into the straight position. If this manoeuvre fails it should be repeated, and under ether if there is great pain or muscular resistance. Too much stress can not be laid upon this. The cause of so much deformity after this accident is in many cases due to imperfect reposition. If no displacement exists, ex- tension or the employment of any force is contra-indicated. Surgery is indebted to Prof. L. E. Pilcher, of Brooklyn, for his contributions to this important subject. In many instances, however, deformity will inevitably remain. The shortening which may result from the accident, or, in the young, the injury to the epiphysis, which may retard the growth of the bone in its long axis, causes a deflection of the hand to the radial side, and an ab- normal projection of the styloid process of the ulna. AVhen, as in some exceptional instances, the radio-ulnar ligaments are torn, and, as de- scribed by Prof. Moore, of Rochester, the tendon of the extensor carpi ulnaris is displaced, the tendency to deformity is even greater. AVhen proper reduction is obtained, any dressing which keeps the parts at rest will secure a good result. The diagnosis of Colles's fracture is not difficult. The silver-fork de- formity which results from the backward and upward displacement of the lower fragment, the history of the accident, and pain at the seat of injury point to the character of the fracture. Crepitus may not always 374 A TEXT-BOOK ON SURGERY. be elicited ; the hand is directed toward the radial side, and the styloid process of the ulna is unusually prominent. After reduction has been accomplished, a most satisfactory dressing is a snugly fitting gauntlet of plaster of Paris, extending from the metacarpo-phalangeal articulation to six inches above the wrist (Fig. 372). The patient should be advised to move the fingers of the affected side a number of times daily, in order to prevent adhesions of the tendons to their sheaths. If plaster of Paris is not at hand, a padded posterior splint of light board or heavy paste- board may be placed from the end of the metacarpal bones back near to the elbow, with a short anterior splint, extending halfway in the palm of the hand, snugly adjusted with a roller bandage or adhesive plaster. An extra wad of cotton placed between the splint and the dor- sum of the metacarpus fixes the hand in semi-flexion, in which position the extensor tendons are kept tense and aid in preventing redisplacement of the lower fragment. Fig. 3T2.—Plaster-of-Paris dressing for Colles's fracture. Fracture of the styloid process, and longitudinal fracture, should be treated by the gypsum dressing. In fractures of both bones of the forearm proceed as follows : Prepare two splints of thin board, one, the posterior, to extend from within one inch of the olecranon to the ends of the fingers ; the anterior to extend from the elbow to the carpus ; both wider than the forearm at every point. Pad these with some soft material, considerably thicker in the center than elsewhere, to serve as an interosseous pad. AATrap each splint with a bandage to hold the padding in place. An assistant grasps the patient's hand and arm above the elbow, and, with the forearm at a right angle to the humerus, held in a position halfway between supination and pronation, makes steady extension, while the operator makes a care- ful reposition of the fragments. Apply the splints so that the interosse- ous pads will push the muscles down and between the radius and ulna. Then fasten them by a bandage made tight enough to prevent slipping. If, in the course of a few days, the dressing becomes loosened, it can be tightened by applying an additional roller. The forearm is carried in a sling. The treatment should be continued for about four weeks, when passive motion at the elbow, and supination and pronation, should be made, and the dressing readjusted for another week. This simple dress- ing is sufficient for all fractures of one or both bones of the forearm (excepting Colles's or Barton's). FRACTURES. 375 Compound fractures of the bones of the forearm require fixation by this method, and the security of open wounds, free drainage, and strict antisepsis. Carpus—Metacarpus—Phalanges.—Fractures of the carpus occur from great and direct violence, being almost invariably compound. The treatment should be fixation, rest, and drainage under antiseptic precau- tions. The metacarpal bones may be broken by direct violence or by blows or falls on their distal ends. This fracture is not uncommon with boxers. I had under observation three brothers, professional pugilists, each of whom had a metacarpal fracture, and one of whom had also a fracture of the radius, all received while sparring. In the young, in rare instances, separation may occur at the epiphyses, which are at the phalangeal ex- tremities of the metacarpal bones of the fingers, and at the carpal ex- tremity for that of the thumb. The fracture of a metacarpal bone, broken by indirect violence, is usually situated in its middle. The acci- dent is recognized by pain, displacement, or crepitus. The treatment is reduction by extension and counter-extension, with direct manipulation and the application of an anterior splint, padded and arched so as to fill the concavity of the palmar aspect of the bone, and to extend to the end of the finger. A posterior splint is also applied, both fastened by a roller. The danger is from fixation of the extensor tendon as a result of inflammation. Passive motion of the finger every day will prevent this result. In epiphyseal separation the treatment is the same but the prognosis is not so favorable. Fractures of the Phalanges.—In the treatment of fractures of these bones the same principles are involved as for the metacarpus. The chief precaution is to prevent stiffening of the finger from adhesion of the tendons to their sheaths. Passive motion should be made as early as the sixth day. The Sternum—Ribs—Vertebra.—The sternum may be broken by direct or indirect violence. In recent cases reposition may be effected by pressure, or by lifting with an elevator. In the treatment of these cases the most perfect quiet should be enforced. Fracture of the ribs or of their cartilages may result from (1) indirect violence, as a blow upon the sternum; (2) from a direct, injury; or (3) from muscular contraction. The longer ribs are most liable to fracture. AAThen the force is applied to the sternum, the break most frequently occurs at or just anterior to the middle of the bone. The displacement is usually slight. Haemorrhage from division of the intercostal vessels is one of the immediate dangers, while localized inflam- mation of the parietal pleura is inevitable. The diagnosis will depend upon pain, elicited by pressure on the bone at a point remote from the fracture, and occasionally by a peculiar click or crepitus felt by the hand applied over the lesion during a full respiratory act. The respiratory movement is less free upon the affected side. Treatment— Fixation of the chest wall, as far as is possible, is the 376 A TEXT-BOOK ON SURGERY. indication in treatment. To this end, the affected side should be shaved. and adhesive strips, cut one inch and a half in width and long enough to reach from the sternum to the vertebral spines, are tightly applied, ex- tending far enough above and below the broken rib to cover the three or four adjacent bones. The strips should overlap about one half of their width. The body of a vertebra may be broken by indirect violence, as a fall from a height, the patient striking on the head, feet, or buttocks, or the bone may be crushed by extreme flexion or extension (occasionally due to muscular action), or by direct injury, with or without penetration. The character of the injury, the displacement of the spines, pain, and symptoms of pressure upon the cord or nerves will lead to a correct diagnosis. The treatment of fractures of the vertebral column has attracted much attention within recent years. In 1896, before the Surgical Section of the American Medical Association, I gave my personal experience in surgery of the spinal cord, embracing a number of cases of fracture of the vertebra with compression, which had come under my observation. Among them was the case of G. AV. V., male, thirty-one years of age (Fig. 373), who, April 19, 1888, while working at the bottom of an elevator shaft, was struck by the descending car on the head and shoulders and violently doubled over forward, re- sulting in fracture of the eleventh and twelfth dorsal and first lumbar vertebrse. There was immediate par- aplegia, the bladder and rectum be- ing involved in the paralysis. For six months he remained helpless in bed without treatment. At the end of this time I sawT him. He was still suffering from paraplegia from the navel down, and could not control his bladder, which overflowed unless he was catheterized, nor his bowels, which moved involuntarily. I treat- ed him with forced extension, using a plaster-of-Paris apparatus which I devised, and which he wore for more than a year. It consists of a zone or girth of plaster of Paris which, snugly applied, extends from the point of fracture up to the axilla, and of a second zone, the upper margin of which is at the point of fracture and catches on the expansion of the hips below. Into these zones, at three different and equidistant points, are placed iron staples, worked into the plaster dressing. AAThen the plaster hardens, extension bars are placed in the staples, and these by key and ratchet lengthened, thus Fig. 373.—Fracture of the vertebrae. Case of G. W. V. FRACTURES. 377 forcibly lifting the superincumbent weight from the point of fracture. He improved gradually under this treatment, and now, nearly ten years after the accident, is able to walk with the aid of a cane, but has a shambling gait, has not recovered the function of the bladder, and is at times troubled with trophic sores over the sacrum. There were two cases of fracture of the cervical vertebra, in one of which, as a result of a fall upon the back of the head, the fifth cervical vertebra was crushed and the spinal cord divided at this level. Paraly- sis from the level of the nipples down immediately followed, and symp- toms of interference with the phrenic nerves. Four days after the injury I removed the laminae and spines of the fourth, fifth, and sixth cervical vertebrae. The fifth was fractured near the junction of the twTo laminae with the bifurcated spine. One side of the fractured lamina had been driven forcibly into the substance of the cord, crushing it completely, but without penetrating the dura. On opening the latter, the cord was found to be pulpified, but there was no haemorrhage. The patient was not improved by the operation, and died eight days later from respiratory failure, due to ascending degeneration of the cord, which involved the phrenic nerve. Hypostatic pneumonia developed. In the second case the seventh cervical was the seat of fracture. The patient was admitted to Mount Sinai Hospital on October 9, 1895. The arms were slightly involved in the paralysis, which was complete from the lower portion of the scapula down. He was placed in bed on the back, and extension applied to the chin and counter-extension to the legs. He was profoundly disturbed as to temperature, respiration, and pulse—to such ah extent that operation was not deemed safe. The chart for October 12th, the third day after admission, is as follows. The temperature was taken in the rectum : October 12th. Temperature. Respiration. Pulse. 96-0° 95-8° 93-0° 92-(5° 90-8° 92-0° 91-8° 91-8° 91-8° 92-4° 93-6° 95-2° 12 12 14 16 14 9 10 9 9 20 9 10 42 3 '■ .............. ...................... 44 5 " ......... ................ 46 7 "....................................... 98 8 " ............................................. 45 10 " .......... ........... 42 12 noon.................. ................... 36 2p.m............. ............ 30 4 "....... ...... 30 6 "...... 35 8 " ...... 38 12 midnight............... .. ........ 43 In this case the fracture was caused by a fall downstairs, striking on the sacral region. On October 20th, the temperature rose to 103°, respi- ration 20, and pulse 55. The patient was living, seven months after the accident, with complete paraplegia and partial paralysis of both arms; there were at this date large bedsores over the sacrum, due to trophic disturbance. In one case fracture was due to a blow from a heavy stone, striking directly upon the spines of the tenth, eleventh, and twelfth dorsal verte- brae. Eight days after the injury I removed the lamiriae of these ver- 378 A TEXT-BOOK ON SURGERY. tebrae, the fragments of which had been driven upon the dura, crushing the cord without penetrating the dura mater. No haemorrhage outside or inside the dura. The third day after the injury the patient expressed his belief that there was an improvement of motion. This was only temporary, however, and now, nearly a year after the operation, he has complete paraplegia and large trophic bedsores. In a second case, due to direct violence, a pistol ball with fragments of bone were driven into and completely divided the cord at the level of the junction of the third and fourth dorsal vertebrae. Complete paraple- gia followed, and six months after the injury I removed the laminae of the third and fourth dorsal, together with a rim of lead adherent to these at the point of entrance. There was no improvement, and the patient died of general exhaustion eight months later. Included in this list are two cases in which complete paraplegia resulted from a fall, with no evidence of fracture, as determined by careful examination, and later by operative interference and removal of the laminae of the vertebrae at the seat of arrest of function in the cord. In both instances the spinal cord was atrophied, having evidently under- gone degeneration. There was a thickening of the dura in each case (pachymeningitis haemorrhagica externa). Both cases perished ultimately from general exhaustion, and were cases in which, in all probability, haemorrhage occurred outside the dura from slight injury to the bodies of the vertebrae, compression of the cord and its destruction being due to the haemorrhage, the clot having ultimately been absorbed. In one case a young man, twenty-one years of age, was thrown from the cowcatcher of a locomotive ; he was picked up unconscious. AAThen consciousness was restored, it was found that he was paralyzed from the iliac spines down, including the bladder and rectum. For seven months he was treated by rest in bed and a plaster-of-Paris jacket. Motion returned to a very slight degree. Seven months after the injury I re- moved the laminae of the last two dorsal and first lumbar vertebrae. As soon as he recovered from the anaesthetic it was noticed that there was immediate slight improvement in motion in the feet. This continued, and now, six years after the operation, he has fairly good use of the lower extremities, can flex and extend the legs and thighs, and walks about with a crutch and cane. There were several other cases of fracture with complete destruction of the cord, some of which were operated upon, others in which opera- tion was not deemed advisable. Of all the eight cases operated upon, only one died soon enough after the operation to suggest that this was a factor in the fatal result. If properly performed, it may be considered not a dangerous procedure, and, in my opinion, should be done in all cases in which paraplegia, whether partial or complete, has followed the accident immediately or within a few hours, unless the injury has occurred so high up that the profound disturbance of respiration and pulse contra-indicates inter- ference. One of the most encouraging cases is reported by Prof. R. H. FRACTURES. 379 M. Dawbarn, of New York, in which a girl fell from a height and was immediately paralyzed. Removal of the laminae was done within five hours of the accident. The cord was compressed by displaced bone, which was removed, the patient completely recovering within a few months, with no evidence of paralysis. Had this patient not been oper- ated upon, the cord would in all probability have undergone degener- ative changes within a short period of time, and its function been per- manently impaired, even after compression was removed. When complete paraplegia has existed for several months, owing to the hopeless condition of these cases, an exploratory operation is justifiable, in the hope of relieving, if only to a slight extent, the pa- ralysis from compression. The prognosis is, howrever, unfavorable in the vast majority of cases, since the cord is evidently easily destroyed by compression from a frag- ment of bone which does not penetrate the dura. The method of operating I employed in each case is as follows: With the patient in the prone position, reclining somewhat upon one side, in order to interfere as little as possible with the movements of respiration, an incision, the center of which is the seat of lesion, seven or eight inches in length, is made directly over the spines. Retraction should be made by strong hooks, which controls haemorrhage in good measure; the attachments of the muscles should be scraped from the bones in order to avoid wounding any vessels. In this way the laminae are finally exposed, divided with a small rongeur, and removed one after another until the dura is sufficiently exposed. After the wound is entirely dry, the dura is opened by a sharp-pointed knife, cutting down carefully in the middle line until there is an escape of a drop or more of clear cerebro-spinal fluid. Through this primary puncture a dull-pointed, grooved director should be inserted, and the dura divided exactly in the middle line as far as necessary. AA7hen the fluid escapes, the edges of the dura can be held apart by mouse-tooth forceps and the cord inspected. If the latter is touched with the linger, it should be very lightly and carefully done. A light, dull-pointed probe should be passed up and down from the point of opening, to determine whether or not compression of the cord exists above or below. In one instance, following this precaution, I found, as the probe was arrested by the pro- jecting bone, I was an inch below the real point of compression. The dura should be closed by fine interrupted catgut sutures, about three sixteenths of an inch apart, and the muscles of the two sides stitched together with strong catgut sutures. Silkworm-gut sutures are used for the skin wound. It is always wise to leave a twist of catgut projecting from the level of the dura, and out at the inferior angle of the wound, as some oozing is apt to occur which, if not allowed to escape, would exercise compression upon the cord. Most careful asepsis should be practiced. The patient should remain upon the back for the first week or ten days after the operation. I usually dress the wound about the fourth or fifth day. Patients seem to suffer no material inconven- ience from removal of the laminae of two or three vertebrae. 380 A TEXT-BOOK OX SURGERY. AAHien for any reasons operation is not performed, the patient should be put to bed and extension and counter-extension made from the head and legs. Every care should be taken to prevent pressure sores on the back, buttocks, and heels, and strict aseptic care of the urethra and bladder in drawing off the urine is essential. Later the extension bars, as just described, may be applied, or the Sayre jacket or Shaffer brace. Fracture of the articular processes is of less frequent occurrence. This accident results from extreme extension (dorsal), or may occur from direct or indirect violence. AVhen the spinous processes are broken, the lesion may occur near the extremity, but more frequently the laminated expansion is the seat of fracture. The indications in all forms of injury to the vertebral column are to relieve pressure upon the cord and nerves, and insure all possible fixa- tion. AVhile, from the anatomical construction of the spinal column, extension is limited and difficult of accomplishment, yet it may be ob- tained in a sufficent degree to relieve the injured structures from the greater part of the superincumbent weight. AA7hen the bodies are injured, dorsal extension throws, in part, the weight from the spongy bodies on to the compact processes. Fractures of the sacrum are rare, and, when occurring, are due to direct violence by penetrating bodies, or to falls from such heights that other and serious complications render the prognosis grave. No treatment except enforced quiet is called for primarily. AAThen ostitis and necrosis occur as a result of comminution, operative interfer- ence may be required. Fracture of the coccyx, with displacement forward, is not uncommon. The accident occurs from a fall or blow directly upon the tip of the spine. The symptoms are those of pressure upon the rectum, causing difficult defecation, proctitis, and at times fissure or ulcer. Pain is always pres- ent, and is due to inflammation as well as pressure upon the fifth sacral and coccygeal nerves (coccygodynia). The only treatment is removal of this bone, which is almost always followed by relief. The incision is made over the bone, in the posterior median line, the muscular attachment being divided close to the bone. Care must be taken to avoid wounding the posterior plexus of veins, or the rectum. The wound should be thoroughly dried, closed with catgut sutures, and sealed with collodion to prevent infection. Os Innominatum.—Though rarely fractured as compared with other portions of the skeleton, the ilium, ischium, or pubes may be broken singly, or all may be involved in a common lesion at the acetabulum. The force causing the fracture may be directly applied, or, less frequently, by an indirect blow, as a fall on the foot or great trochanter, in which the head of the femur may be driven into the acetabulum with such violence as to cause fracture. AAThen the fracture is confined to the iliac crest the diagnosis will be determined by preternatural mobility, crepitus, and pain, in conjunction ERA ITU RES. 381 with the history of the case. When the bones of the deeper basin are broken, digital exploration by the rectum or vagina will be necessary. The treatment demands reposition and rest. AArhen the acetabulum is involved, extension to the foot and leg (Buck's method), with the foot of the bed elevated, should be practiced. AArhen possible, the bed should be so arranged that defecation may be accomplished without lifting the pelvis. A modification of Crosby's fracture bed would answer this pur- pose well. Fixation of one or both thighs, including the pelvis and lower portion of the abdomen and spine, could be well effected by surround- ing these parts with a plaster-of-Paris dressing. The prognosis will de- pend, in great part, upon the extent of the injury sustained by the pelvic viscera. Rupture of the bladder or deep urethra may complicate frac- ture of the pubic bones. Incision and drainage is essential. Intra-peri- toneal rupture will require suture. Fractures of the femur may be best studied in three groups, viz. : (1) of the upper extremity (including the neck and trochanter); (2) of the shaft; (3) of the lower or condyloid extremity. . Fracture of the neck of the femur may take place wholly within, partly within and partly without, or wholly outside of the capsule. This accident rarely occurs in the young and middle-aged. It is a lesion of old age, and women suffer more than men. The anatomical cause is chiefly a condition of senile rarefaction, which begins usually about the fiftieth year.* It has been demonstrated that the change in the relation of the axis of the neck to that of the shaft in the aged is not enough to account for the greater prevalence of this accident in the old, nor is there a marked diminution of the animal constituents of bone at this time of life. The change is one of senile atrophy. Fracture of the neck of the femur is usually caused by force trans- mitted from below upward, and along the shaft of the femur. In many instances the accident is trivial. The specimen shown in Figs. 374 and 375 was taken from a patient who broke her femur while in the act of kneeling in church, f It has been known to occur even while turning over in bed. The line of fracture may be at any part of the neck, and in exceptional cases is through the epiphysis. AAThen the fracture is near the trochanteric line, or when these tuberosities are involved, it is usually the result of direct violence—that is, a fall or a blow upon the hip. The diagnosis of fracture of the neck of the femur may be determined by the study of the history of the symptoms. If, after a fall upon the foot or knee, or directly upon the trochanter, there results pain in the hip, erersion of the foot, loss of function in the member, shortening, and crepitus, fracture at the neck is probable. These symptoms are, however, not always present. Pain is the most constant, eversion is the * Prof. L. A. Stimson, " Treatise on Fractures," Henry C. Lea's Son & Co. t This patient was treated by Dr. Selden. of Norfolk, Va., and, from the history of the case, together with the appearance of the specimen, I consider it an intracapsular fracture, with osseous union. Prof. F. H. Hamilton, to whom I showed the specimen, considered it rather a condition of senile atrophy. 382 A TEXT-BOOK OX SURGERY. rule, inversion the exception, in about the proportion of eight to one. The turning outward of the leg and foot is probably due to gravity, and when inversion occurs it is due to a peculiarity in the locking or Fig. 374. Fig. 375. overlapping of the fragments. Loss of function is not always entire, for in some instances—and very probably in impacted fractures—the patient has been known to walk a considerable distance upon the limb after the fracture. This is, how- ever, a rare occurrence. Shortening is deter- mined by comparative measurement of the two sides, from the anterior superior spine of the ili- um to the inner malleo- lus. The internal mal- leoli should be made to touch, and should be di- rectly in a line with the symphysis pubis, umbil- icus, and interclavicular notch. The end of the tape should be held on the thumb nail, and pressed well into the notch, just under the anterior superior spine. Fig. 376.—Showing the displacement of the fragments in fracture of T^ . ,-, • -i „-!„„,, the neck of the femur. (After Gray.) It IS then Carried along pyr iroiiwi j GEMELLUS SUPERIOR OBTURATOR INTERNUI GEMELLUS INFERIOR OBTURATOR EXTERN!!! QUADRATUS riHOBII FRACTURES. 383 the inner side of the thigh, knee, and leg, to the under edge of the inner malleolus. The degree of shortening will vary from one fourth of an inch up to two or more inches. The occasional normal inequality in the length of the two lower extremities should not be lost sight of. This varies from one eighth to, in some instances, as much as one inch and over. To determine that the shortening is between the trochanter and the acetabulum, apply Nelaton's test; a line drawn from the tuber- osity of the ischium to the anterior superior spine of the ilium passes over the upper surface of the great trochanter. The distance the tip of the trochanter may be above this line will give the degree of shortening. Bryant's test is, with the patient resting upon the back, the legs parallel and extended, to drop a line from the anterior superior spine and to measure the distance between this line, at its nearest point to the tro- chanter and this tuberosity. If the fracture is above the trochanter the tuberosity will be found nearer the line than on the sound side. Crepitus can not always be obtained. In the case of impaction it is not possible without the employment of force sufficient to unlock the fragments, and in many cases of fracture above .the trochanteric line, without impaction, crepitus is not felt. Any unnecessary manipulation of the hip is contrary to the best rules of practice, and an effort to elicit crepitus should, therefore, not be made. It is difficult, and at times impossible, to determine at what particular portion of the neck the fracture has occurred. Prac- tically it makes little difference, as the treatment is the same. Treatment.—Rest in the dorsal decu- bitus, with fixation of the pelvis and the affected limb, are the immediate indica- tions. In the majority of cases pain is not present, and, since union is scarcely to be expected, the extremity may be held in proper position, and with the least dis- comfort, by sand bags placed on each side and pressed well up to the injured mem- ber. To secure more perfect fixation, ex- tension in a limited degree may be desir- able. To obtain this, place the patient upon a hard mattress. If the bed is too soft and yielding, place wide boards un- derneath the top mattress in order to hold it smooth and firm. Elevate the foot of the bedstead from six to ten inches, by placing the legs at this end upon blocks of wood or bricks. Cut two strips of strong adhesive plaster (Maw's moleskin is preferable) about two inches wide and long enough to extend from the hip to beyond the sole. Lay one of these upon the inner and outer surface of the thigh and leg, exactly opposite each other, and hold them in place by a well-adjusted roller. The strips can be more nicely applied if they are partially divided with the Fig. 377.—Fracture of the neck of the femur, with impaction. (Bigelow.) 384 A TEXT-BOOK ON SURGERY. scissors, in a direction upward and inward, at intervals of about two inches. Six inches below the knee the bandage is interposed between the strips and the integument. In order to prevent pressure upon the malleoli, a stick about six inches in length is placed between the ends of the adhesive strips, and the extension weight is attached to this. It is intended by this method to make the traction from the femur and not from the leg. A piece of board provided with a pulley is next fastened to the foot of the bed, so that the tip of the pulley will be on a level with the malleoli. The weight will vary from two or three up to eighteen pounds. A pound for every year of life up to eighteen is the rule ; but this is too much for fracture above the trochanter. About ten pounds is sufficient for all ordinary cases. Shot in a bag, or smoothing-irons, are usually employed for the extension weight, which is tied to the string (Fig. 378). The pa- tient's body serves as the counter-extending force, the gravitation toward the head of the bed being about counteracted by the weight attached to Fig. 378.—Combination of Buck's extension and Hamilton's long splint. the foot. Additional benefit and comfort may be obtained by laying small, long bags, filled with sand, on either side of the thigh and leg. When the limb tends too strongly to outward rotation (or inversion) this may be corrected by the sand bags, or by Prof. Hamilton's long splint, which is shown in Fig. 378, and which is tied by strips of bandage from the axilla to the ankle. The foregoing is practically Buck's ex- tension, to which may be added Hamilton's long splint. In some instances it may be found advantageous to use Volkmann's sliding foot piece, seen in Fig. 379. This consists of a posterior splint for the leg, to which is attached a foot piece having the angle shown in the cut. This splint should be perforated for the heel, and rest upon two cross-bars of wood, which in turn slide up and down on a rectangular frame. Upon the upper edge of these parallel bars a tongue is cut, and a corresponding notch or groove in the cross-bars. This apparatus is complicated and will rarely be needed. Buck's extension, with Hamil- FRACTURES. 385 Fig. 379.—Volkmann's sliding foot piece ton's long splint, or preferably the sand bags, will meet almost every re- quirement, and give the greatest satisfaction. In order to prevent the bedclothing from coming in contact with the fractured limb, wire screens (Figs. 380, 381) may be em- ployed. The most easily managed and sim- ply constructed ap- paratus for making the necessary exten- sion and counter-ex- tension, in applying the fixed dressing for fractures of the lower extremity, is made as follows: Into each end of a table, about five feet long, two holes are bored, and into these two perpendicular pieces are fitted, two feet long and about two inches in diameter, while a strong horizontal bar con- nects the two upper ends. One of these uprights is smoothed, rounded, and padded, to prevent injury to the perinaeum. The foot of the injured side be- ing nicely bandaged, the patient is placed upon the table, astride the padded upright (Fig. 382), with the perinaeum against it, and is suspend- ed by a strap passed over the hori- zontal bar and underneath the sa- crum, being elevated from the table sufficiently to allow free manipulation of the bandages under the back. The head and shoulders are supported upon pillow\s, the foot of the uninjured limb rests upon a stool, a clove-hitch or double loop is thrown around the ankle, and to this a block and pulley is **►—---*—-—Re- attached, the opposite end of which is fastened to the wall. Extension is then applied until, by measurement from the anterior superior spinous pro- fess of the ilium to the lowest point of the inner malleolus, the two legs are found to be of the same length. The pelvis, thigh, and leg are then Fig. 380.—(After Esmarch.) Fig. 381.—(After Esmarch.) 386 A TEXT-BOOK ON SURGERY. Fig. 382. covered with a dry roller, or a trousers' leg, or piece of soft blanket, and the plaster rollers applied. Accessory splints of zinc, copper, tin, or hoop iron may be worked in with the plaster bandages if desired. The prognosis in this class of cases should always be guarded. Use- ful limbs result in a large majority of cases, but the function of the hip is not often fully re- stored. Fracture of the Trochanter.—Separa- tion of the great tro- chanter is a rare ac- cident. The cause is direct violence. A di- agnosis must rest up- on independent mo- bility of the tube- rosity, with crepitus. The treatment should be fixation, firm com- pression by bandages, and rest. Fracture through the Trochanters.— Fracture through the trochan- ters is also comparatively of rare occurrence. The diagnosis may be determined by shortening, crepitus, pain, and loss of symmetry and function. A strong diagnostic feature is, that a portion of the trochan- ter may remain attached to the neck.* Buck's extension with Hamilton's long splints will suffice for treat- ment in the majority of cases of this fracture. The plaster-of-Paris dressing may be used, but for its application anaesthesia is necessary. The prognosis is more favorable as to restoration of function. Occa- sionally enormous exostosis occurs after fracture at this locality. Fractures of the Shaft—The shaft of the femur is usually broken by direct violence, or indirectly by a force transmitted from below upward. In exceptional instances the fracture is caused by muscular contraction alone. The line of fracture is generally oblique, and the displacement is determined chiefly by the direction of this line. In complete fracture overlapping is the rule. When the break is in the upper portion the lower fragment is drawn up by the long muscles extending from the pelvis to the neighborhood of the knee joint, and, as shown in Fig. 383, the upper fragment is usually rotated outward by the external rotators, and tilted up and to the front by the psoas and iliacus. When the frac- ture is near the knee joint the lower fragment is tilted backward by the action of the gastrocnemius, popliteus, and plantaris muscles. The upper fragment is acted upon in a milder degree by the same muscles that caused its displacement in the higher fracture (Fig. 384). Fractures at the condyles may include transverse fracture near the * Prof. L. A. Stimson, op cit. FRACTURES. 387 epiphyseal line, or through the epiphysis proper ; transverse fracture, with a split into the intercondyloid notch ; or one or the other condyles may alone be broken off. The diagnosis of fracture of the shaft of the femur is not difficult, as a rule. Preternatural mo- bility, crepitus, pain, and shortening will usually determine the character of the injury. When the joint is involved, in addition to the usual symp- toms of fracture the knee becomes much swollen. Treatment.—In the treatment of all fractures between the trochanters and the knee joint the choice rests between the method by Buck's exten- sion and the plaster-of-Paris dressing. When the fracture is below the middle of the thigh, the plas- ter-of-Paris dressing is to be preferred and may be applied without anaesthesia, provided that by ex- tension the muscles yield and the fragments come in apposition. The bandages need not extend high- er than the level of the perinaeum, but should take in the foot. When the knee joint is involved, pas- sive motion should be commenced on the sixth or eighth week, and continued at intervals thereafter. Whatever method is employed, immobilization at the seat of fracture should be maintained for five or six weeks. In all fractures of the thigh, be- tween the middle of this bone and the neck, Buck's extension will be found most generally ap- plicable and satisfactory. In fracture of the femur in children, the plaster- of-Paris dressing is to be preferred. The reposition of the fragments should be made under anaesthesia, and the parts immediately immobilized. This class of patients are not easily controlled and kept quiet by the use of the ordinary apparatus.* In one in- stance of fracture at the trochanters in a child just delivered, I placed the extremity in the position assumed in utero, the thigh flexed on the abdomen, the leg flexed on the thigh, enveloped the parts with flannel bandages, and applied plaster-of-Paris rollers from the ankle to the axillae. The dressing was re- moved on the twenty-first day, and the cure was per- fect. There is no shortening or impairment of function, and the child, now ten years old, walks and runs with perfect motion. * In one instance, in the case of a child three and a half years old, with a fracture at the mid- dle of the thigh, chloroform narcosis was obtained during natural sleep, the child not becoming conscious while passing under the influence of the anaesthetic. Fig. 383.—Displacement of fragments in fracture of the thigh in the upper third. (After Gray.) Fio. 384. —Displacement of fragments in fracture of the thigh in the low- er third. (After Grav.) 388 A TEXT-BOOK ON SURGERY. Patella.—Fracture of the patella is usually caused by violent con- traction of the quadriceps extensor muscle, or by a blow or fall upon this bone, or both of these factors may combine to cause this lesion. The line of cleavage is usually transverse, and in the majority of in- stances just below the middle of the patella. It may be broken in an oblique or longitudinal direction, or in several directions at once—" stel- late fracture."' When muscular contraction is the chief or sole factor in this break, the line of cleavage is usually transverse. Longitudinal and stellate fractures are the result of direct violence. Fracture of the patella is usually complete, the separation of the fragments varying from a small fraction of an inch up to two or more inches. The separation is gener- ally more marked on the internal than the external border. In rare in- stances incomplete fracture may occur, the cartilage not giving way. Such cases are scarcely recognizable without exploration, the few re- corded being seen post-mortem. Fracture of the patella is more frequent in men than in women, and occurs mostly in the decades from the twentieth to the fortieth years. The diagnosis may be made from loss of function, pain at the seat of injury, and separation of the frag- ments. Inability to extend the leg, or marked impair- ment of function, is always present. The limb may, however, be used to support the body if it is allowed to fall into the straight position. One of my patients, with a separation of three fourths of an inch, walked, unaided, a quarter of a mile immediately after the acci- dent. Haemorrhage between the fragments occurs in all cases, and therefore communicates with the synovial membranes, which are interposed between the posterior surface of the patella and the general cavity of the joint, and, in cases wdiere the separation is well marked (from half to one inch and over), it is more than prob- able that the reflection of the synovial lining, from the lower anterior portion of the joint below the patella upward and forward to the front of the intercondyloid notch, is torn, and that whatever of extravasation occurs is into the general cavity of the joint. This occurred in the only knee I have opened, immediately after this fracture. More or less effusion into the joint follows in the majority of cases. In longitudinal and stellate fractures the separation is usually slight. Treatment.—A patient with a broken knee-pan should be immediately put to bed, in the dorsal decubitus, the affected limb kept straight, and the foot and leg elevated on pillows. In case of swelling and inflamma- tion at the knee, cold cloths or the ice bag should be applied. The me- chanical treatment should commence at once. Cut a piece of strong adhesive plaster (moleskin is preferable, or, if this can not be obtained, double the ordinary adhesive plaster) about ten inches in length and broad enough to cover the whole front of the Fig. 385. — Displace- ment of fragments in fracture of the pa- tella. (After Gray.) FRACTURES. 380 thigh above, fitting snugly above the upper limit of the patella. To the center of this stitch a strong piece of webbing about an inch in width and several inches in length ; a second piece of plaster, somewhat smaller than the first, is applied from the lower limit of the patella and extend- ing down the leg eight or ten inches. To the center of this, at the mid- dle of the ligamentum patella, a buckle corresponding to the size of the tongue of webbing is stitched with silk thread. With the leg in exten- sion, these strips of adhesive plaster are bandaged snugly to the thigh ; by passing the tongue into the buckle and pulling upon it, the fragments are not only closely applied to each other but the webbing prevents the fragments from tilting. The whole extremity from the perinaeum, in- cluding the foot, is now invested with plaster of Paris, and a window is made over the knee joint in front so that the fracture may be kept under ob- servation during treatment. From day to day the straps may be tight- ened as the condition of the patient may demand (Fig. 38G). Should the cast become loosened by shrinkage of the limb, a strip of sufficient width should be cut out in front for the whole length of the cast, and an or- dinary roller bandage applied to make it fit more snugly. In this way the action of the quadriceps extensor is temporarily paralyzed. In five or six days the patient may move about care- fully on crutches, and after he be- comes accustomed to the use of these he can walk about and attend to busi- ness without danger to the limb. This dressing should remain undisturbed for from eight to ten weeks, at the end of which time it should be re- moved, and while the fragments are held closely in apposition by the hand of the surgeon, passive motion is made flexing the leg, not farther than twenty-five degrees from the anterior plane of the thigh. A lighter plaster dressing is then applied, and the patient can go another month without its removal, when the same passive motion is repeated, and this should be continued for as much as six months from the date of injury. After this time a posterior splint of light and strong shellac board may be applied in the morning and removed upon going to bed, the patient going about with the aid of a cane. The atrophy of the muscles of the thigh and leg should excite no concern. In fact, the security of firm ligamentous union depends in good part upon this muscular atrophy. Fig. 386.—Fracture of the patella. 390 A TEXT-BOOK ON SURGERY. The functions of the muscles and of the joint are fully re-established as soon as the apparatus is left aside and the patient begins to use the limb. The essential point in the treatment of fracture of the patella is to pre- vent stretching of the filaments of the ligament or fibrous tissue which is to hold the pieces together, and if this is properly attended to, a union will be obtained of such character that the functions of the leg will be practically restored. The failures which have occurred in the treatment of these injuries have been due chiefly to lack of appreciation of this fact. I have treated a good number of cases of fracture of the patella, and by this rigorous method have never failed to restore the usefulness of the limb. Instead of the shellac splint I have in a number of instances had prepared a legging made of light steel bars, worked in with strips of bandage soaked in glue. These are fitted to a plaster cast of the limb, then cut down on one side and corset hooks attached, so that it may be laced on by the patient. In an emergency, when this apparatus can not be obtained, the method employed by the late Frank H. Hamilton should be employed. It is as follows: A posterior splint is made to extend ffom near the heel to the gluteal fold. Shellac board is best suited for this purpose, but sole leather, gutta-percha, or a piece of plank will suffice, if these lighter articles can not be obtained. If either of the first three articles is employed, the piece should be cut wide enough to envelop from one half to two thirds of the circumference of the limb. Three inches above and below the center of the knee joint a tongue, one inch wide and two inches long, should be cut, and turned out so that the attached end is nearest the joint. This splint is dipped in warm water until soft enough to be molded to the part, when it is lined with a sheet of absorbent cotton and applied on the posterior aspect of the limb. The cotton or padding material should be consider- ably thicker opposite the popliteal space, in order to prevent complete extension of the leg. Secure the upper and lower ends by turns of the roller thrown around the thigh and leg, and next begin the oblique or approximating turns by carrying a flannel bandage around the leg, so that it catches behind the lower tongue, whence it is carried obliquely upward above the upper fragment, across the quadriceps, and back to the starting point. This is con- Fig. 887.-Hamiiton'8 »Pg^;™ for fracture of the patella. tin lied until the upper frag- ment is brought into appo- sition with the lower. For the lower fragment the bandage is made to catch behind the upper tongue upon the splint. When the fragments are approximated the entire limb is invested by the roller. After the dressing is applied the same position is maintained for two FRACTURES. 391 weeks. The portion of the bandage immediately over the fracture should be opened on the fifth or sixth day, and a careful inspection made, in order to determine whether the roller has slipped and re-separation oc- curred. If the bandage is at all loose it should be tightened, but never drawn so tightly that it produces any discomfort. This inspection should be repeated every five or six days, but the splint is never taken off until the eighth week, when passive motion at the knee joint should be made. The after-treatment is the same as just given. When such satisfactory results can be obtained by the conservative methods just detailed, it does not seem to me advisable to perform the operation of wiring the fragments together, an operation, no matter how skillfully done, not free from danger to the integrity of the joint or limb, and, in rare instances, to the life of the patient. Cases are on record in which amputation was necessary and death followed this operation. I have had under observation at one time three cases in which the ligamentous union was so firm that a refracture of the upper fragment took place before the fibrous union would give way. In certain cases of wide separation and loss of function, and in all cases of open wound in which infection has occurred, the operation of wiring is justifiable. It is performed as follows :- Under strict asepsis, an incision is made across the joint opening between the fragments, and all clots removed, with any soft tissues which may have intervened. The fragments are then drilled for a single or double set of wires, as may be determined upon. The drill holes enter obliquely through the fragments half an inch from the margin and come out upon the broken surface about one eighth of an inch in front of the synovial surface. All fluid is now removed by gauze sponges, the wire is twisted, and the fragments brought together. The drills invented by Prof. William F. Fluhrer, of New York, will be found very useful in this operation. The wound should be closed with catgut sutures and sealed without drainage. It is sometimes necessary, when this opera- tion is done for the relief of old cases with wide separation, to divide the insertion of the quadriceps extensor muscle from above, in order to bring the fragment down. A straight splint or plaster-of-Paris cast is applied to hold the extremity immovable. After eight weeks the patient is allowed to move about, and passive motion should be made. Many cases of wide separation, however, retain the function of the limb in a remarkable degree. In a case occurring in my practice, from which the two accompanying cuts were taken, there is a separation of more than three inches with the leg flexed (Fig. 388), and nearly one inch and a half in extension (Fig. 389); yet this patient has perfect use of the limb. No approximation of the fragments was ever attempted in this patient. He was kept in bed, with the leg elevated, for six weeks, and an ordinary roller applied after this, without any effort of bringing the fragments together. Longitudinal fractures of the patella should be treated by fixation of the muscles of the thigh and leg, and lateral approximation of the frag- A TEXT-BOOK OX SURGERY. ments by fiannel bandages, well applied over a thin layer of absorbent cotton. Stellate fractures, in which the air is not admitted to the joint, should be treated by Hamilton's method. ^_____._^ In compound fractures of the patella in which the joint is laid open, the cavity of the joint should be carefully drained and strict antisepsis employed. If the fragments are widely separated, and can not be kept in approximation, strong catgut or fine wire sutures may be employed to hold them in position. Such instances wull rarely occur. Leg.—Fracture of one or both bones of the leg occurs next in fre- quency to that of the radius, the clavicle, and ulna. The upper end of the tibia is usually broken by direct violence, although a fall from a height upon the foot may produce a longitudinal or oblique fracture communicating with the joint. The separation sometimes takes place through the epiphysis. The most common point of fracture is the junction of the middle and lower third. The fibula may be broken at the same level, or at a point removed from the line of fracture in the tibia, or this last bone alone may be broken. Near the ankle joint, fracture of the tibia (malleolus) and a complete break of the fibula is comparatively frequent. In this (Pott's) fracture (called also railroad or street-car fracture, since it is often caused by jump- ing from a car in motion) the foot is powerfully everted, and the princi- pal strain falls upon the internal lateral ligament of the ankle joint. As the force is continued, either the internal lateral ligament or the inner malleolus must yield, and, as usual in this test between ligament and bone, the latter yields. As a rule, a crescent of bone is torn off with the ligament, or the entire malleolus is wrenched off at a higher point. The pressure upon the inner aspect of the external malleolus forces this out- ward, and the fibula above is bent nrward and usually breaks about two FRACTURES. 393 or three inches above the tip of the malleolus. If great force is exercised in the production of this fracture, the inferior tibio-fibular ligament may be torn away, or, more likely, the outer lip of the articular surface of the tibia broken off. In exceptional instances, inversion of the foot will produce fracture of the inner malleolus by direct pressure of the astrag- alus, and of the external malleolus or fibula by traction on the external lateral ligament. In fracture of the tibia alone the displacement will be determined by the direction of the line of fracture. Marked overlapping or displace- ment is prevented by the unbroken fibula. In the upper portion, with a, transverse fracture, the deformity is slight. At the lower and middle third the obliquity is usually consid- erable, and from below upward and backward (Fig. 390). The upper frag- ment is tilted forward by the action of the quadriceps extensor, and part- ly by the pressure of the upper end of the lower fragment, which is thrown Fig. 390.—Displacement of fragments in fracture Fig. 391.—Displacement of the fragments in Pott's of the tibia, near the junction of the lower fracture. (After Gray.) and middle third. (After Gray.) in the same direction by the contraction of the sural muscles and the consequent lifting of the heel. The deformity in Pott's fracture is shown m Fig. 391. In complete fracture of both bones of the leg, overlapping and displacement are the rule. Pi a gnosis.—Fracture of the fibula alone may exist without detection, although a careful examination, with direct pressure, will usually elicit crepitus or reveal the point of fracture by abnormal mobility and pain. Fracture of the tibia is easily made out by palpation along the spine, crepitus, loss of symmetry, and pain. These symptoms, together with the history of the accident, will leave little room for doubt in any case. 28 394 A TEXT-BOOK ON SURGERY. Pott's fracture is recognized by the peculiar eversion of the foot, the ab- normal prominence of the internal malleolus, pain, and loss of function. Crepitation of the fragments of the malleoli may be elicited, and preter- natural mobility of the fibula, at a point two or three inches above the Fig. 392.—Flaster-of-Paris dressing in fracture of leg. tip of the outer malleolus. In inversion with fracture the outer malleolus is prominent. Fracture of both bones is easily made out by the de- formity, abnormal mobility, and crepitation. Treatment—In most cases of fracture of one or both bones of the leg it is the best practice to reduce the displacement by extension and coun- ter-extension, and apply the plaster-of-Paris dressing at once. This should extend at least halfway up the thigh, in all cases, in order to fix the knee joint. It is applicable to all fractures of one or both bones, from the knee down to and including the malleoli. Extension can usually be made from the heel and ankle by an assistant. A layer of cotton batting is placed next to the skin, a dry muslin or flannel roller, making firm compression, is applied, and the plaster bandages over this (Fig. 392). The plaster cast should be split down the middle line, in front, to guard against even the remote danger of swell- ing. At the end of six or eight weeks all splints should be removed, passive motion made at the knee and ankle, and the apparatus reapplied and worn for at least two weeks more. In applying the plaster in Potts fracture the eversion needs to be overcome and the straight position maintained while the gypsum is hard- Fig. 393.—Fracture box. ening. Where the deformity is extreme the foot should be held in a position of slight overcorrection until the cast hardens. When plaster-of-Paris can not be had, starch is next in order, or splints of felt, leather, bookbinder's board, metal, or wood may be em- ployed. When swelling has occurred the fracture box (Fig. 393) is a most useful apparatus. It consists of a bottom, a foot piece, and two movable FRACTURES. 395 side-pieces. This may be placed upon a pillow or box to give it a slight elevation, or the apparatus may be modified after Petit's box (Fig. 394), since the position of partial flexion is usually more comfortable than full extension. If any extension is needed it may be secured by a bandage around the ankle and foot, which is also passed through the holes in the foot piece. In fixing the leg in this fracture box the sides are turned down, a thick layer of cotton or some soft material arranged for the leg to rest upon, and shaped to fit the natural contour of the calf. The sides are also packed, turned into position, and fastened. As soon as the first swelling subsides, or as soon as it is evident that no marked swelling would occur, the plaster of Paris should be applied. Compound fractures of the leg are treated by immediate reduction of the deformity, by free drainage where infection is evident, and strict antiseptic precautions. For perfect fixation, and at the same time leav- Fig. 394.—Petit's fracture box. (After Stimson.) ing the wound open for irrigation and inspection, the interrupted or the fenestrated plaster-of-Paris dressing is the most generally useful. If the injury is slight and limited, the fenestrated dressing is preferable. Extension is made from the foot, and, after reposition and drainage are secured, the plaster bandages are applied. As soon as the dressing sets, windows large enough to permit of free inspection are cut immediately over the wound and at the points of exit of the drainage tubes below. A good-sized twist of sterile catgut should always be preferred to a rubber drain, unless suppuration is present. A wire loop, worked into the plaster or tied around the leg after hardening has taken place, will serve as a medium for suspending the limb at anv required height (Fig. 3!);-)). The interrupted plaster dressing is less satisfactory and more diffi- cuit of application. The entire leg and foot, and halfway up the thigh, are covered with a dry flannel or muslin roller, which passes over the 396 A TEXT-BOOK ON SURGERY. wound, retaining the sublimate and iodoform gauze in place. A strong piece of bar iron, or two or three thicknesses of hoop iron, or a twist of from four to six ordinary telegraph wires, is now shaped to follow the outline of the foot and leg up to within three inches of the wound and exit of the drainage, at which point it is bent up for several inches, and passes over the wound much like the handle of a valise (see Fig. 396). Fio. 395.—Fenestrated plaster-of-Paris dressing for fixation and through-drainage in infected compound fractures. As soon as a point three inches above the wound is reached it is again made to conform to the shape of the leg and thigh. A separate straight piece of iron, or, if needed, two pieces, about sixteen inches in length, are also prepared. A layer of absorbent cotton is placed around the leg and thigh before the first bandage is applied, and over this the plaster rollers are carried, above and below the fracture, to within three inches of the wound. After several layers of bandage (generally three thicknesses) have been applied, this much is allowed to harden, and upon this the long iron splint is laid, in front, and the short pieces posteriorly and laterally (out of the way of the drainage tubes), and are fixed by additional turns of the plaster bandages and by plaster mortar worked in with the hands. That portion of the bar which is shaped like the handle of a valise should be stiffened by winding around it several thicknesses of the plaster roll- ers, and adding a sufficient quantity of plaster mortar. Suspension is made from the ends and center of the wire. The fracture box may be employed when plaster can not be ob- tained. Fig. 396 FRACTURES. 397 Foot— The bones of the tarsus may be broken by direct or indirect violence. The diagnosis is not always easily made. The best method of treat- ment is fixation with a plaster-of-Paris dressing. When the os calcis is broken, and the tuberosity drawn up by the sural muscles, the leg should be flexed well upon the thigh, and the tarsus extended in order to relax this group of muscles, or the tendo Achillis divided. Fracture of the astragalus is rare. In one instance I removed this bone after a fracture about half an inch from the anterior or scaphoid articulation. The accident resulted from a horse falling upon the foot. The body of the bone was twisted so that the malleolar surface was up- permost. Fracture of the metatarsal bones and phalanges should be treated in the same manner as the corresponding bones ot the upper extremity. Ununited Fractures—Fibrous Union.—In a certain proportion of cases union between the ends of broken bones is delayed beyond the time usually required for ossification, and may remain permanently un- united. The causes of ununited fracture are: (1)Failure to secure immobility ; (2) presence of muscle, tendon, nerve, or other substance between the fragments ; (3) violent and prolonged inflammation of the broken bones and the surrounding soft parts in which granular degeneration occurs with considerable loss of bone substance ; (4) any intercurrent disease which interferes with nutrition ; (5) a too great separation of the frag- ments. If the ends of broken bones are not kept in contact, and at the same time immovable, fibrous union may result, for by motion the pro- visional callus is injured, and may disappear by absorption as a result of continued irritation. If the fragments overlap, so that no portion of the broken surface of one side is in contact with that of the opposite end, no matter how well adapted the dressing may be, muscular contraction may retard or prevent union. The intervention of any of the soft tissues, or any foreign substance, may prevent the formation of callus, and lead to fibrous union. Ostitis after fracture may lead to destruction of the fragments, and of the shafts of bone, to such an extent that union can not occur. Instances are on record where, resulting from fracture, rarefying ostitis has de- stroyed the entire bone. Any general condition of impaired nutrition increases the liability to fibrous union. Rickets, osteomalacia, syphilis, tuberculosis, or any acute febrile disease supervening upon fracture, tends to interfere with or to delay bony union. When by any reason the broken surfaces are separated, osseous union will probably not occur. This accident and result are exemplified in fracture of the patella, where fibrous or ligamentous union is the great rule. The diagnosis of fibrous union is determined from continued preter- natural mobility at the seat of fracture after two months have elapsed. Crepitus is not to be depended upon, as the ends of the fragments may 398 A TEXT-BOOK ON SURGERY. be rounded off by absorption, and covered over with inflammatory new- formed material, or at times with cartilage. Treatment.—Any constitutional disease, especially syphilis, or any impairment of nutrition, must be specially treated. In the administra- tion of tonics, cod-liver oil, with the hypophosphites of lime and soda, should play an important part. It is of importance to fix the broken part immovably by the plaster- of-Paris or other solid dressing. This should not be removed for eight or ten weeks, when passive motion of any articulation near the seat of fracture, and necessarily included in the dressing, should be made. After the first movement of the joint the dressing should be reapplied and the passive motion repeated every second week. Great care should be preserved to prevent motion at the seat of fracture. If, after the lapse of from ten to fourteen weeks, there are no indications of union, a mild inflammation should be induced in the tissues immediately about the fracture. This may be accomplished by forcibly rubbing the ends of the bones together (after an anaesthetic has been administered), and then investing the member with gypsum dressing. In obstinate cases more radical measures may need to be adopted. With the part rendered bloodless and under careful asepsis, the line of non-union is exposed by incision (usually longitudinal), the soft parts lifted from the ends of the bone, and all new tissue scraped or chiseled from the fractured surfaces. If the broken surfaces are sufficiently extensive, as in oblique fracture of the tibia, a steel drill or nail serves an excellent purpose. While the wound is still open, so that the nail may be properly guided, this is inserted obliquely through the skin and soft tissues in such a way that it is made to pass through one fragment and well into the other, pinning them closely together. The wound should then be thoroughly dried with sterile gauze, closed with catgut and sealed with collodion, also sealing around the nail at the point of entrance through the integument; iodoform gauze next to the collodion covering, and a roller to make firm compression to prevent oozing. The Esmarch should not be removed until the gypsum is applied and the extremity elevated. A plaster-of-Paris dressing should be applied over all, which should remain undisturbed for from eight to ten weeks. When it is removed and the nail withdrawn, passive motion should be made in any joint which has been locked up by the plaster, and the gypsum again applied. In other cases wiring may be necessary. The ends of the bones are well exposed, the surfaces freshened as above, and a hole drilled about half an inch above and below the line of fracture. Large, soft silver wire is carried through and the ends twisted, bringing the fragments snugly together. When the fractured surfaces are practically at right angles to the shaft of the bone, a single wire may suffice to keep them in apposition; but when the break is oblique, or when, in reuniting bones, a single wire passed through the drill-holes will not suffice to hold the ends in apposition, a circular loop or belt of wire should be used, including in its grasp both fragments. FRACTURES. 399 In certain cases where absorption has occurred, and the fragments are pointed and narrow, the ends may require to be divided with the chisel in order to secure a greater surface for apposition. In a case of ununited fracture of the tibia, three months after the injury, I suc- ceeded in obtaining osseous union by applying a plaster-of-Paris dress- ing and permitting the patient to bear a certain amount of weight upon the foot, until the fracture gave him a sense of throbbing and pain. The foot was then lifted from the ground by crutches for two or three days, and again used to a slight extent. It was then kept entirely still, and this irritation resulted in bringing about bony union. In wiring the humerus after fracture, the great danger of failure lies in the difficulty of immobilization. In all of these cases plasterof-Paris should be applied from the hand to the shoulder and around the thorax, thoroughly enveloping the upper extremity. CHAPTER XVII. SURGERY OF THE ARTICULATIONS. Dislocations.—A dislocation is the displacement of the articular sur- face of one bone from its normal relation with another. Dislocations are traumatic, pathological, and congenital. They are also partial or com- plete, simple, complicated, and compound. Traumatic dislocations are sudden, and result from violence ; patho- logical when, from disease of the joint, the bones and ligaments are more or less destroyed; congenital when, from failure of development, the normal contiguity of the articular surfaces can not be maintained. A dislocation is said to be partial when any portion of the articular sur- faces are still in contact; complete when one articular surface overlaps the other; simple when there is no other lesion than displacement and injury of the capsule ; complicated when there exists with the disloca- tion a fracture into the joint; compound when, by reason of a wound, the air is in contact with the dislocated surfaces. Again, a dislocation may be recent or ancient, the limit of the former variety being from a few hours to two or three weeks. A primitive luxation is one in which the dislocated surfaces retain the same position as at the time of the acci- dent, secondary when another position is assumed. In a dislocation the capsule is almost invariably ruptured. It may occasionally, as at the shoulder joint, be simply stretched without a solu- tion of its continuity. AVhen great violence is employed in producing it, the muscles, tendons, nerves, vessels, fascia, and skin about the joint may be more or less involved. The changes which follow are practically those of acute synovitis, arthritis, or peri-arthritis. Dislocations occur chiefly in adult life, and are most frequent in those joints which enjoy the greatest freedom of motion, and, at the same time, are subjected to the heaviest strains. The condition of the individual, the tonicity of the muscles, and the strength of the ligaments, have a great deal to do with the frequency of dislocations. All things being equal, patients with poorly developed muscles and relaxed ligaments are more prone to these lesions than the well developed and vigorous. The diagnosis of a dislocation rests chiefly upon abnormal immobil- ity and asymmetry. Pain is usually present. Special Dislocations—Inferior Maxilla.—Displacement of the con- dyles of the lower jaw, from its articulation with the temporal bone, may occur on one or both sides; usually it is bilateral. The condyles slip 400 DISLOCATIONS. 401 forward and are engaged partly beneath the zygoma, in front of the emi- nentia articularis, and partly between the zygoma and the temporal fossa. Muscular action alone may produce this luxation, or it may be caused by external violence. The symptoms are great pain, difficult deglutition, and indistinct articulation (especially of the labial sounds). The lower teeth are un- usually advanced, the mouth is opened, and the saliva trickles over the lips. In unilateral luxation the chin points toward the sound side, and the teeth are less widely separated. In the diagnosis the chief point of differentiation is fracture at or near the condyle. In fracture the condyle may possibly be recognized in its normal position by palpation ; immobility is not marked; the mouth is not opened ; crepitus may be obtained. Reduction.—In bilateral displacement, wrap the thumbs with sev- eral layers of bandage or cloth, to protect them from being bitten wThen reduction is accomplished. Place one thumb along the inferior molars of each side, and the fingers beneath the body of the jawT; press down- ward and backward with the thumbs, while the fingers lift the chin upward. Or place a thick roll of leather, piece of wTood, or firm cork, between the upper and lower posterior molars of each side, and upon these, as a fulcrum, lift the chin upward, and at the same time push backward in the direction of the socket. If both of these methods fail, they should be repeated under anaes- thesia. It may sometimes be advisable to attempt the reduction of one side by either of the above methods, and retain it in position while re- ducing the other. After reduction is completed put on a head and chin figure-of-8 band- age, and allow it to remain for a week (Fig. 180), or apply Hamilton's head-stall for fracture of the lower jaw (Fig. 354). In several instances, where the dislocation has become permanent, the symptoms have gradu- ally subsided, and a fair degree of motion and usefulness acquired through the false joint. Clavicle.— The sternal end may be displaced forward on the manu- brium, upward above the sternum, backward behind the manubrium. The last two varieties are rare. . The cause of the first form is usually force applied to the shoulder with the arm thrown backward. In the case of a boy fifteen years old, treated by myself, the displacement was caused by a comrade catching him by both shoulders, placing his knee in the middle of the back, between the shoulder-blades, and violently pulling the shoulders back. The diagnosis is noj difficult, the reduction easy, but the maintenance of the bone in position difficult. A compress, covered with adhesive plaster to prevent slipping, placed upon the bone after reduction, and firmly held in place by a roller, is a proper method of treatment. The arm should be fixed with Sayre's apparatus for fractured clavicle, in order to prevent a repetition of the luxation. 402 A TEXT-BOOK OX SURGERY The outer end of the clavicle may be displaced above or below the acromion process, and above or in front of the coracoid process. Dis- placements under the acromion and in front of the coracoid are very rare. The symptoms are very distinct, and the reduction not surrounded with great difficulty. When replaced, however, the bone is with diffi- culty maintained in position. By drawing firmly outward upon the shoulder of the affected side, and pressing the clavicle downward into position, reduction will be successfully accomplished. Place a firm com- press over the end of the bone, bend the forearm at right angles to the arm, and carry one or two strong strips of adhesive plaster over the com- press, behind the shoulder, along the arm to the olecranon, and again by the front over the compress. Re-enforce this by a bandage, and place the arm in a sling. If luxation recurs, tighten the adhesive strips, and place the arm in a Velpeau's bandage. To apply this bandage, place the hand of- the affected side almost upon the oppo- site shoulder, fixing a wad of cotton be- neath each axilla. Lay the end of a roller on the shoulder-blade of the sound side, and carry the bandage over the acromial end of the clavicle of the injured side, and the front of the arm for a short distance, passing obliquely to the under surface at the elbow, and around beneath the well ax- illa to the point of starting. Repeat this to secure the roller, and then carry the bandage horizontally around the chest and over the tip of the elbow. The oblique and horizontal turns are alternated until the shoulder and arm are completely enveloped (Fig. 397). Humerus, at the Shoulder.—Disloca- tion at the shoulder-joint is by far the most frequent. It may take place in three direc- tions—backward, under the spine of the scapula (subacromial and subspinous) ; downward, below the glenoid cavity {subglenoid); and forward, be- neath the coracoid or clavicle (subcoracold or subclavicular). The first variety is of rare occurrence. The subacromial dislocation is only a partial displacement, and becomes complete when the head of the bone passes well beneath the spine of the scapula (Fig. 402). The sub- glenoid is more frequent, but not so common as the subcoracoid. Dis- placement forward under the clavicle is rare. On account of the coraco- acromial ligament, and the additional protection afforded to the joint above by the acromion process, dislocation directly upward can scarcely occur. Subcoracold and Subclavicular Dislocation.—In the more frequent variety of luxation—the subcoracoid—the capsule is ruptured along the Fig. 397.— Velpeau's bandage. (After Stimson.) DISLOCATIONS. 403 lower and inner portion, extending to the insertion of the subscapularis muscle. It is caused by violence applied directly to the shoulder from without inward and forward, or to the elbow or hand when the extremity is extended. The head of the humerus rests upon and in front of the inner rim of the glenoid cavity and just underneath and in contact with the coracoid process (Fig. 404). The acromion process is unusually prominent, a depression is felt beneath it, while the head of the bone is seen and felt in an abnormal position beneath the coracoid. The hu- merus stands stiffly away from the chest at an angle varying from twenty to thirty degrees. The circumference of this shoulder, measured over the acromion and through the axilla, is greater by at least one inch than on the opposite side (Callaway). If the hand of the affected side is placed upon the sound shoulder, the elbow can not be carried down to the chest- wall (Dugas). According to Kocher—whose researches are based on anatomical as well as clinical demonstrations, the obstacle to reduction is tension of the capsule, especially of the coraco-humeral ligament, with conse- quent closure of the rent through which the head of the humerus has escaped. If this displacement exists, by carrying the humerus directly down until the arm touches the side of the chest-wall, rotating it out- ward and then carrying the elbow in front of the chest to the middle line, the capsule is relaxed and the rent is opened. It only remains to rotate the humerus slightly towTard the body, when the head slips through the opening back into its normal position. Dr. Charles A. Powers, of New York, has shown that the recumbent posture is preferable to the sitting position which was original with Kocher. The steps of this method are well shown in the accompanying cuts taken from his article.* Fig. 398.—First Movement. The elbow is adducted to the body and drawn downward. (The arm and wrist should be firmly grasped, as shown in the figure.) (After Dr. C A. Powers.} * " Medical Record," March 30, 1889. 404 A TEXT-BOOK ON SURGERY. Method.—Place the patient on the back, upon a hard table or the floor, with an assistant holding the shoulder of the sound side firmly down. The operator grasps the member of the injured side at the wrist Fig. 399.—Second Movement. The arm is rotated out until firm resistance is met. (Practically until the long axis of the forearm points directly outward.) (After Dr. C A. Powers.) and elbow and brings the humerus well against the wall of the chest (Fig. 398). Outward rotation is made until the long axis of the forearm points directly outward (Fig. 399), when the elbow is brought along the front of the chest to the median line (Fig. 400) and the hand of Fig. 400.—Third Movement. With the external rotation of the arm still maintained, the elbow is car- ried forward and upward on the chest. (After Dr. C. A. Powers.) the affected side placed on the sound shoulder (Fig. 401). If this fail, repeat the procedure. An anaesthetic is not usually required, but should be given if, after two or three efforts, reduction is not accom- DISLOCATIONS. 405 plished. The method of using the foot in the axilla, as given for sub- glenoid luxation, may also be tried. Fig. 401.—Fourth Movement. The hand is placed on the sound shoulder. (After Dr. C A. Powers.) The subclavicular variety of this forward dislocation is only an exag- geration of the subcoracoid, in wThich the head of the bone slips under- neath and internal to the coracoid, and rests against the serratus mag- nus and behind the pectoralis minor, below the clavicle (Fig. 401). The causes are the same, and the symptoms differ in little else than the pres- ence of the head of the humerus nearer to the clavicle. The arm stands slightly out from the body, and the elbow is tilted backward. The ten- sion on the posterior scapular muscles is greater, and rupture of their attachments often occurs, while the anterior insertion of the subscapu- laris may be dissected up. Pressure on the axillary vessels and nerves is more marked in this luxation. Reduction may be effected by the means just described. Subglenoid Dislocation.—In the subglenoid luxation the capsule is stretched or torn along its lower surface, and the head of the humerus rests upon the margin of the glenoid cavity in a partial dislocation, or, if Fig. 402. Fig. 403. Fig. 404. Fig. 405. subacromial and sub- Subglenoid. Subcoracoid. Subclavicular. spinous. (Bryant.; (Bryant.) (Bryant.) (Bryant.) 406 A TEXT-BOOK ON SURGERY. the capsule is torn, it (usually) slips in front of the long tendon of the triceps, and is lodged upon the axillary border of the scapula, immedi- ately below the articular surface (Fig. 403). The supra-spinatus muscle is severely stretched, and either suffers rupture of its tendon or sub- stance, or, rather than yield, it may tear off a rim of the upper facet of the greater tuberosity. The long head of the biceps and the coraco- brachialis are also subjected to great strain or rupture, while the tension of the deltoid holds the arm in a position with the elbow slightly tilted from the side of the body. Among the less frequent complications of this lesion may be men- tioned pressure upon the circumflex and axillary nerves, and injury or rupture of the great vessels. The cause of this dislocation is violence applied to the shoulder in a direction from above downward, or indirectly to the hand, forearm, or elbow, with the humerus raised at or beyond an angle of 90° to the axis of the trunk. The diagnosis of a subglenoid luxation will depend upon the follow- ing symptoms: The acromion process is unusually prominent, the head of the bone is not in its normal relation to this process, and may be felt low down in the axillary space. There is a depression in the anterior axillary fold in these subjects. The arm is fixed in such a manner that the elbow is directed outward from the side of the body (Fig. 406). As in all the shoul- der dislocations, the arm is so held that, if the hand of the injured side be placed on the opposite shoulder, the elbow can not be made to drop down upon the wall of the thorax. This, the test of Dugas, is important in differentiation from fract- ure in which there is such a considerable degree of motion possible that the arm can be brought well down upon the chest. There is always preternatural immobility in a dislocation. excellent method of differentiation is that of Callaway, based upon the fact that the circumference, measured over the acromial end of the clavicle and the acromion, and through the axilla, is in a dislocation much increased over the normal, or over that present in fracture at the neck. Crepitus, when obtained, will determine a fracture. Reduction—First Method.—Place the patient upon a table, bed, or upon the floor. For the left shoulder the operator removes the shoe from the left foot and places it in the axilla, against the thorax. He now seizes the arm and forearm of the patient, carries it out at a right angle to the axis of the patient's spine, and makes powerful traction in the direction of the glenoid cavity. While this is being effected the arm is brought inward, parallel with and against the side of the body (Fig. 407). The foot not only serves to effect counter-extension, but is also used as a fulcrum for lifting the head of the bone over the edge of the Fig. 406.—Subglenoid. (Bryant.) Another DISLOCATIONS. 407 glenoid facet into the articular cavity of this process. If this can not be accomplished without ether, after one or two trials the anaesthetic Fig. 407.—(Erichsen.) should be given. After reduction a shoulder-cap of book-binder's board, leather, or gutta-percha should be applied, and worn for at least one week. Second Method.—Fix the scapula by placing a folded sheet or long cloth around the body, so that the upper margin of the cloth will touch the axillary folds. The ends are intrusted to an assistant, who, standing on the sound side, makes ./>:•>-• counter-extension. The surgeon now takes hold of \ ,\ ) the arm about its middle with one hand, and near M "\. the elbow with the other, and carries it slowly and \'] \ steadily away from the body, and in the direction of ] j least resistance. When it is at a right angle to the axis of the body, strong traction is made, with slight axial rota- tion. If the manoeuvre is still unsuccessful, car- ry the arm higher, until extension is made in the line of the axillary border of the scapula (Fig. 408). Third Method.—Place the patient in a chair, so that, with the foot of the opera- tor on the edge of the seat, his knee will come snugly into the axilla. Place one hand upon the shoulder to steady it, while the other seizes the arm neai the elbow. Fig. 409.-(After Hamilton.)) With the knee as a fulcrum, use the hu- Fig. 408.—(Bryant.) 408 A TEXT-BOOK ON SURGERY. merus as a lever, which, being depressed, carries the head of the bone into position (Fig. 409). Extension from the forearm, and counter-exten- sion through the medium of the opposite arm, may also be employed. The subacromial and subspinous dislocations are reducible by exten- sion and counter-extension in the line of displacement. Counter-exten- sion may be made by an assistant holding the arm of the sound side, or by the folded sheet (already described) applied just in the axilla. The operator makes extension from the arm and forearm, imparting to the humerus a slight axial rotation. General Consideration*.—Recent dislocations at the shoulder may not always be reduced, and some which are readily replaced are with difficulty held in position. Rupture of any muscle, or group of muscles, renders the luxation subject to recurrence, since there is no antagonism to the remaining muscles. Even when reposition is effected and main- tained, the function of the joint maybe permanently impaired on account of injury to the surrounding structures. Injury of the circumflex nerve has been followed by atrophy of the deltoid and teres minor, while trau- matism of the great cords of the axillary plexus and injury of the vessels have led to impairment or loss of function in the extremity. Ligature of the subclavian artery and amputation have been necessitated after dislo- cation of the shoulder-joint. These injuries may occur at the time of the displacement, or they may be produced by a lack of skill or the employment of too great force in the efforts at reduction. After one or two days from the date of a luxation at the shoulder (as elsewhere) the difficulties of reduction increase, and are in general pro- portionate to the length of time which has elapsed since the accident. At the expiration of the first week inflammatory adhesions occur, and the cavity of the joint is in part filled with the products of inflammation. In rare cases reduction has been accomplished at the end of three, six, and twelve months. The propriety of attempting reduction in ancient shoulder luxations will depend upon the individual case. It will frequently occur that, in the new position, attachments are formed, with ligaments, cartilage, and synovial membrane, with fair, yet limited, motion in the false joint, which, together with the free mobility of the scapula upon the thorax, gives a useful degree of motion to the arm. Under such conditions any attempt at reposition is unnecessary. In well-selected cases, where an ancient dislocation can not be reduced by any other means consistent with safety to the tissues about the joint, and where motion is so limited that the usefulness of the arm is seriously impaired, direct incision, under strict antiseptic precautions, may be employed, and reduction thus effected, with or without excision of the head of the humerus. When complicated with fracture of the surgical neck, McBurney's operation of direct incision, drilling the upper frag- ment just outside the capsular attachment, inserting a hook, and by trac- tion reducing the dislocation, is advisable. The fracture should be treated in the same manner as if no dislocation had existed. DISLOCATIONS. 409 Dislocations at the Elbow-Joint—The upper end of the radius may be displaced forward on to the anterior surface of the humerus, near the coronoid fossa, or backward upon the olecranon process. The anterior displacement is met with somewhat more frequently than the posterior. In the displacement forward the orbicular and a portion of the exter- nal lateral and anterior ligaments are ruptured ; in the opposite luxation only the first two are lacerated. The forward displacement is caused by direct violence applied to the posterior aspect of the upper end of the radius, or by falling upon the palm of the hand, the full force of the contraction of the biceps being thus added to the force transmitted along the shaft of the bone. Symptoms.— Careful palpation will reveal the abnormal presence of the head of the radius near the center of the humerus, while pressure along the outer condyle will demonstrate its absence from its natural position. The forearm is semiflexed and slightly pronated. Treatment.—Flex the arm and push the head of the bone forcibly downward in the direction of the articulation. When reduction is ac- complished, place a compress over the upper end of the bone and the external condyle, and bind it firmly in position. The arm should be snugly bandaged, and carried in a sling for several weeks. The backward dislocation is recognized by the presence of the head of the bone in an abnormal position near the olecranon, behind the ex- ternal condyle. Treatment.—While an assistant makes strong extension and counter- extension from the hand and arm, the operator makes direct pressure upon the head of the bone, forcing it in the direction of the articulation. As the displacement is being corrected the assistant should carry the forearm in a position of supination. The after-treatment consists of a compress and bandage, worn for several weeks. The prognosis of this injury is generally not favorable, since it is very apt to recur after reduction, and may become permanent. A fair degree of usefulness is maintained, however, in many cases of chronic luxation of this end of the radius. The production of a rich callus, more or less permanent, resulting from raising the periosteum as the ligaments are torn is a frequent cause of impaired motion after this injury. Complete forward dislocation of the ulna alone, at the elbow, can not occur without fracture of the radius or extensive laceration of the radio- ulnar ligaments. Subluxation of the Head of the Radius.—This lesion is met with usually in children from nine years old and under, and is much more common than complete dislocation at this joint. It is caused by sudden traction on the hand or forearm in lifting a child by a single arm or in saving it in the act of falling. The symptoms are loss of function, the arm often hanging as if it could not be moved. Motion at the wrist may be, however, free. Pres- sure over the head of the radius causes sharp pain. Passive flexion at the elbow is permitted to about 60°, when resistance may be met with. Complete extension is also painful. With the forearm flexed at right 29 410 A TEXT-BOOK ON SURGERY. angles to the arm, pronation is possible, but is slightly resisted, while supination causes great pain. If, however, this movement is carried to the extreme, a distinct click may be heard and felt at the head of the radius, with which the pain suddenly ceases and free motion is re- established (W. W. Van Arsdale).* Reposition is thus effected. With the patient sitting or standing in front of the operator, he grasps the arm just above the elbow with one hand, while with the other the forearm is seized near the wrist. The forearm is now flexed to an angle of ninety degrees with the arm, and steadily rotated into a position of extreme supination. As above stated, the reduction is accompanied by a per- ceptible slip or click. A splint should be applied to hold the arm quiet in the right-angle position for four or five days. The pathological conditions of this lesion are not thoroughly un- derstood. Since it is caused by pulling upon the radius, the cup- shaped articular facet of the head of this bone is evidently abnormally separated from the humerus. One theory is that the soft parts are in- terposed either by muscular action or by atmospheric pressure, while another holds that the edge of *the head of the radius is slightly locked on the humerus, a complete dislocation being prevented by the integrity of the capsule. Dislocation of both radius and ulna at the elbow may take place in all directions. The dislocation backward may be produced by falling upon the hand with the forearm almost extended ; by a blow upon the anterior aspect of the forearm, near the elbow, a blow upon the posterior surface of the humerus, in its lower portion, or force applied at the same time, in oppo- site directions, upon these surfaces. The coronoid process will be found lodged in the olecranon fossa, the upper end of the radius resting on the posterior aspect of the external condyle. The anterior ligament and the anterior fasciculi of the external and in- ternal lateral ligaments are torn loose, and in extreme cases the orbicular ligament may give way, although the yielding of the external ligament usually saves the circular ligament from being torn. The tendon of the brachialis anticus is stretched or is broken loose from the coronoid pro- cess. Pressure upon the brachial artery may be so great that pulsation at the wrist is diminished or absent, while in extreme cases the median, ulnar, or musculo-spiral nerves may be injured. The usual position of the forearm is one of almost complete extension, with pronation. Measurement from the inner condyle to the styloid process of the ulna wdll demonstrate shortening. Muscular rigidity is marked, and motion of the displaced bones difficult and painful. From these symptoms the diagnosis can be readily made. If swelling has ensued, and the tumefaction is great, it is not always easy or possible to recognize the character of the injury. It is best under such conditions to anaesthetize the patient, determine the exact nature of the injury, and treat it at once rather than wait until the swelling is reduced. * " Annals of Surgery," June, 1889. DISLOCATIONS. 411 Treatment—Reduction—Method of Astley Cooler.—With the patient seated in a chair, the operator places his foot on the seat so that the anterior aspect of the patient's forearm will be brought in contact with the anterior sur- face of the surgeon's knee. The forearm should now be grasped near the wrist and forced flexion made, using the knee as a fulcrum, and at the same time as a point of resistance to the extension made by pull- ing upon the forearm (Fig. 410). Flexion unlocks the coronoid process from the olecranon fossa, and extension carries both bones forward into position. Unless the operator is positive that perfect reduction has been accomplished, the joint should be freely flexed and extended to test its working capacity. Care must be taken to hold the muscles in check while this manipulation is going on, for fear the bones may again slip out of place. Band- age the arm and forearm, and apply a Fig. 4io.—(Erichsen.) splint, which should be worn for a week or twTo. When an anaesthetic is used the recumbent posture should be maintained. The bare foot may be utilized instead of the knee. A cloth or sheet folded around the arm, just above the elbow, may be used for counter-extension. Liston advised strong extension from the forearm, and counter-extension from the shoulder, with the arm and forearm held straight. If any considerable difficulty is met with, anaesthesia in the recumbent position should be used. Dislocation of the radius and ulna forward, without fracture of the olecranon, is of rare occurrence, and is always the result of great violence. Rupture of the posterior and lateral ligaments occurs, and the triceps tendon is torn or greatly stretched, while the brachialis anticus and biceps are relaxed. The posterior portion of the olecranon rests upon the ante- rior articular aspect of the humerus, or may slip into the coronoid fossa. The forearm is bent at an angle varying from 90° to 120° to the anterior surface of the humerus, and is well supinated. Motion is painful and limited. The character of the injury may be determined by the absence of the olecranon projection, the smooth, broad, posterior surface of the lower end of the humerus being readily appreciated. Treatment.—An anaesthetic is usually required. With the forearm held at about a right angle to the arm, make extension from the wrist, and counter-extension from the lowrer anterior surface of the humerus, in order to disengage the olecranon process from the coronoid fossa, and, when this is effected, make direct pressure downward upon the anterior aspect of the forearm, near the elbow. After the bones slip seemingly into position, careful examination should be made to see that the radius is in its proper relation to the external condyle, for the ridge between the 412 A TEXT-BOOK ON SURGERY. two sigmoid cavities of the ulna may lodge in the groove between the trochlear surface and the articular surface for the head of the radius. In the outward lateral dislocation the luxation is usually partial. The cause is direct violence applied to the inner aspect of the forearm, near the joint, or to the outer aspect of the humerus, low down, or to force applied simultaneously, in opposite directions, upon these two surfaces. The diagnosis will rest chiefly upon the increased prominence of the inner condyle, and the difficulty of recognizing the outer condyle by pal- pation. The angle at the elbow is about 120°, motion is wanting, and the hand is pronated. Reduction is best effected by strong extension from the forearm, counter-extension from the humerus, and direct lateral pressure in the direction of the displacement. Inward dislocation is always incomplete (Hamilton). The causes are direct violence in the opposite direction to that given for the luxation outward. The internal condyle will be less prominent, the external more prominent, the olecranon will be seen crowded over to the inner aspect of the joint, while the head of the radius rests near the middle of the articular surface of the humerus. The position of the forearm is that of flexion. Reduction is difficult, and should be effected in ether narcosis. Extension and counter-extension should be made in the flexed position, and the arm gradually brought out straight, while at the same time direct pressure is made, in proper and opposite directions, upon the humerus and forearm, near the joint. Dislocation of both bones backward is the most frequent form of dis- placement at the elbow. Incomplete external and incomplete internal luxation are next in order of frequency, while the forward dislocation is most infrequent. In the posterior variety the direction of the force may be such that a deviation to one or the other side may occur. The treatment is practi- cally the same. Direct lateral pressure in the line of the normal position of the bone may be required in addition to the mechanism of reduction above given. Partial anchylosis is not infrequent after these lesions. Passive motion should be begun within two weeks after the injury, and repeated daily if no acute inflammation is produced. Wrist-Joint—Dislocations at the carpo-radial joint are very rare. Only a few instances of complete backward or forward luxation of the carpus are on record. Lateral dislocations are considered impossible without fracture of the styloid process of the radius or ulna. The two principal displacements occur with about equal frequency. In the back- ward variety the anterior aspect of the carpus rests upon the dorsal rim of the cancellous expansion of the radius, the reverse being true in the dislocation forward. The anterior and posterior ligaments are partially or completely ruptured, and the annular ligament, which binds the ten- dons down, may be torn and the tendons displaced. The cause of the backward displacement is a fall on the back of the hand, or a blow upon the dorsum of the radius, just above the wrist, while the hand is in extreme flexion. Violence of a similar DISLOCATIONS. 413 character, applied in the opposite direction, will produce the forward luxation. The diagnosis must be made between Colles's fracture and disloca- tion. In dislocation the deformity from the over-riding carpus is much greater than after fracture. In Colles's fracture the swelling on the dorsum of the wrist is smooth and rounded. When impaction has not occurred crepitus may be obtained. Reduction is effected by extension and counter-extension from the forearm and hand, to which direct pressure in the line of displacement should be added. Dislocation of the metacarpal bones, at their carpal extremities, is rare. Luxation of the metacarpal bone of the thumb is most frequently met with. The carpal end of this bone may be displaced partially or completely, in a forward or backward direction. When the end of the bone rests upon the dorsum of the trapezius it can be easily recognized. Extension and counter-extension, with direct pressure, is usually suffi- cient to accomplish reposition. A clove-hitch or snare may be thrown around the thumb to insure extension. Reduction is at times difficult, and the history of this accident is not without a record of failure both as to replacement and retention when replaced. In the displacement forward, on account of the thickness of the soft parts, the end of the bone can not be easily recognized. An unusual depression may be observed on the radial and dorsal aspects of the wrist, just in front of the os trapezium. Strong extension with counter-extension is necessary, and to this should be added direct pressure, applied near the end of the displaced bone. Luxation of the remaining metacarpal bones occurs rarely, and, wdien met with, the displacement is usually partial, and toward the dorsum of the carpus. The phalanges may be dislocated either backward or forward at the metacarpal articulations, or at the interphalangeal joints. The character Fig. 411.—(After Hamilton.) of the lesion is easily recognized, and the reduction, as a rule, is not diffi- cult. Extension with a clove-hitch, or with the apparatus shown in Fig. 411, will effect reduction. In some instances operative interference is demanded when reposition by extension and pressure can not be effected. Careful asepsis should be observed. On opening into the joint, the resisting ligaments should be snipped with a sharp bistoury, when the displacement may be easily corrected. Hip-Joint—While the head of the femur may be displaced from the cotyloid cavity in any direction, it is customary to consider four distinct 414 A TEXT-BOOK ON SURGERY. / Iliac Pubic \ f 50 T \ \ Ischiatic Obturator j \ 50 u J luxations: (1) Upon the dorsum ilii; (2) into the ischlatlc notch; (3) Into the obturator foramen; (4) upon the os pubis. Practically these lesions occur in each of the quadrants of a circle, the center of which is the center of the acetabulum. As shown in Fig. 412, about 50 per cent of all luxations at the hip occur in the iliac quadrant, 30 per cent in the ischiatic, 11 per cent in the obturator, and 7 per cent in the pubic. Two per cent occur beyond these regions. Cases are on record where the head of the bone was lodged on the tuber ischii, in the perinaeum, and just beneath the anterior-superior spine of the ilium. The capsule is usually torn at its inferior and posterior sur- face. It may be a slit or tear in the long axis of the liga- ment, or frequently a broad rupture occurs along the edge of the cotyloid cavity. The ligamentum teres (when pres- ent) is always torn. The ilio- femoral (or Y) ligament is very rarely completely ruptured. The injury to the muscles and sur- rounding structures is always severe, and varies in proportion to the degree of violence which caused the luxation, together with the particular direction of the displace- ment. In the displacement upon the dorsum ilii the glutei muscles may be lacerated, bruised, or lifted from the ilium by the head of the bone, but not by tension on their tendons, for, with the exception of the lower fibers of the maximus, their axes are slightly shortened in the new posi- tion. The obturator internus, externus, gemelli, and quadratus femoris are greatly stretched, or torn entirely loose. The pyriformis is not so apt to suffer. The pectineus, iliacus, and psoas are carried upward and outward. When the head of the bone is projected into the ischiatic notch, the conditions as to the muscles are practically unchanged. The sciatic nerve and vessels are pressed upon and may be contused or lacer- ated. In the displacement upon the pubes the psoas and iliacus may be injured, while the femoral vessels and anterior crural nerve are more oi less pressed upon. When the head of the bone is lodged in the obturator foramen, the obturator externus muscle and the obturator vessels and nerves are more or less contused, while the glutei and the remaining external rotators are put upon the stretch. Causes.—Dislocations at the hip may be congenital, pathological, or traumatic in cause. Congenital luxations, rare in occurrence, are the result of interference Fig. 412.—Showing the proportion of displacement in the four quadrants of a circle about the acetabulum. DISLOCATIONS. 415 with normal development. Failure to complete the process of ossification in the three bones which compose the acetabulum leaves a soft and fibro- cartilaginous cup or sac, through which, when the weight of the body is sufficient, the head of the femur is more or less completely displaced into the pelvic cavity. Absence of the ligamentum teres is not alone sufficient to account for displacement when the bones, capsule, and muscles are normal, for it is not infrequently absent in cases which have never suf- fered a luxation. Moreover, the majority of cases in which this ligament has been ruptured by one luxation do not suffer a second displacement. An abnormally long, loose, or relaxed capsule will lead to sub-luxation or displacement without rupture of the capsule. Failure of development from the cervical epiphysis is another cause of congenital dislocation at the hip. Pathological dislocations are caused by chronic arthritis. The bones are more or less destroyed, and the capsule breaks down, permitting dis- location of the head of the bone as a result of muscular action or slight violence. Traumatic luxations are direct or indi- rect. The most frequent cause is a fall from a height or from a carriage in mo- tion, the person striking upon the foot or knee, with the thigh carried in such a di- rection that its axis is at a considerable angle to that of the spinal column. Anatomically considered, the most fa- vorable position for the two posterior, and by far the most frequent displacements, is when the thigh is flexed at about an angle of 90° to the axis of the body. If the thigh be adducted, the tendency is to rupt- ure the capsule on its posterior-inferior surface, with escape of the head on to the dorsum ilii, or into the ischiatic notch. When in a position of abduction, the rupt- ure is likely to occur on the lower anterior aspect of the capsule. A fall directly upon the trochanter, with the thigh in adduction or abduction, with extreme outward or inward rotation, is apt to produce rupture of the capsule and lux- ation. Symptoms. — In dislocation upon the dorsum ilii, with the patient standing erect upon the uninjured extremity, the trochan- ter of the displaced femur will be nearer the anterior-superior spine of the ilium than that of the opposite side ; the thigh is slightly flexed upon the abdomen, adducted, and rotated inward. The head of the bone may be appreciated Fig. 413.-Position of extremity in dis- location of the head of the femur upon the dorsum ilii. (After Hamilton.) 416 A TEXT-BOOK ON SURGERY. in the new position. The shortening is from one to two inches, and in the vast majority of cases the great toe of the injured side is directed to or rests upon the instep of the opposite foot, while the knee of the lux- ated side is in front of, and slightly above, its fellow (Fig. 413). Muscu- lar rigidity and fixation are extreme. In very exceptional cases there is eversion of the foot, with slight abduction, which Prof. Bigelow holds to be due to extensive and unusual laceration of the ilio-femoral ligament. When the head of the bone is lodged in the Ischlatlc notcJi, the gen- eral characters of the deformity are the same, yet not so well marked. The degrees of flexion and adduction are less extreme, the trochanter is less prominent, and there is not so much shortening. In the thyroid displacement the Fig. 414.—Position of extremity in dislocation of Fig. 415.—Position of extremity in dislocation of the the head of the femur into the thyroid foramen. head of the femur upon the pubes. (After Ham- (After Hamilton.) ilton.) extremity is increased in length, and the thigh is abducted and slightly flexed upon the abdomen. The toes may be turned slightly in or out, although they usually point to the front. The hip is less prominent than normal. The head of the femur may at times be recognized in the new position, although, on account of the tense condition of the adductor muscles, this is in some instances impossible (Fig. 414). DISLOCATIONS. 417 AVhen the dislocation occurs on the pubes there is abduction, slight flexion, and slight outward rotation. The foot is carried away from that of the sound side, and the toes are pointed outward. The chief diagnostic feature of this displacement is the presence of the head of the bone at Poupart's ligament (Fig. 415). The differential diagnosis is between muscular spasm or rigidity and fracture. Spasm or rigidity of the muscles about the hip may occur as a re- sult of an acute or subacute inflammatory process in the joint, or in the periarticular tissues, or in certain cases of ostitis of the lumbar vertebrae, sacrum, or ilium, in the neighborhood of the psoas and ilia- cus muscles. This condition of partial immobility may be differentiated from that of dislocation by the absence of the shortening, which is present in the displacement on the dorsum ilii and into the ischiatic notch, the lengthening in the thyroid luxation, while the head of the bone on the pubes will determine the character of this lesion. The absence of the characteristic deformity of each of these forms of dislo- cation will determine the diagnosis of muscular spasm or rigidity. The symptoms of fracture near the hip have been given. Shortening, pre- ternatural mobility, and crepitus are to be chiefly relied upon in differ- entiation. Reduction—Dislocation on the Dorsum Ilii—Bigeloufs Method.— In complete ether narcosis, place the patient upon a strong, low table, or upon the floor, in the dorsal decubitus. Grasp the leg of the dislocated side, just above the ankle, with one hand, and near the knee with the other, flex the leg on the thigh, and the thigh on the abdomen, to nearly an angle of 90° with the surface of the floor, ad- duct the thigh until the knee of this side is carried to about the middle of the sound thigh, and then cause the knee to describe a circle outward and downward until the leg is brought to the floor in its normal position (Fig. 416). If the luxation is not reduced the manoeuvre should be careful- ly repeated. This method of reduction by manipulation is based upon the resist- ance to reduction which is made by the ilio-femoral ligament (when this is not torn). The normal position of this ligament is shown in Fig. 417, and its relaxation by flexing the dislocated thigh upon the abdomen is shown in Fig. 418; and it is readily seen that if, with the thigh in this position, abduction, with outward rota- tion, is practiced, the head of the bone will be lifted over the margin of the acetabulum and carried in the direction of the socket. Fig. 416.—Eeduction of dislocation on the dorsum ilii by manipulation. (After '—ilow.) 418 A TEXT-BOOK ON SURGERY. Fig. 417.—The ilio-femoral or Y ligament. (Bigelow.) Fig. 418.—Eelaxation of the ilio-femoral ligament by flexion and adduction of thigh. (Bigelow.) Crosby's Method.*—Place the pa- tient on the floor, in the dorsal decu- bitus. Flex both legs on the thigh, and the thighs on the abdomen, and, with the arms locked underneath the knees, raise the patient from the floor so that the body will rest only on the neck and shoulders. If, after suspension lasting two or three minutes, reduction is not accom- plished, the patient should be swayed from side to side, thus adding alternately slight abduc- tion and adduction to the exten- sion. While the displacement may be overcome without anaesthesia, it is much more easily and surely effected with it. The same result may be accom- plished by employing vertical ex- tension in the manner recommend- ed by Bigelow and shown in Fig. 419. Hamilton's Method.—The pa- tient is in the dorsal decubitus, and the limb is grasped as in Bige- low's method. " Flexing the leg on the thigh, the knee is to be carefully lifted toward the face of the patient, until it meets with some resistance; it must then be Fig. 419.—Seduction of dislocation on the dorsum ilii by vertical extension. (Bigelow.) * This method was introduced by the late Prof. A. B. Crosby. DISLOCATIONS. 419 Fig. 420—Cooper's method of extension and counter-extension in reduction ot dislocation into the ischiatic notch. (Hamilton.) moved outward and slightly rotated in the same direction, until re- sistance is again en- countered, when it must be brought downward again to the bed." The older method of violent extension, by means of blocks and pulleys, should not be employed, unless all other means have failed. Reduction of Dis- locations into the Is- chiatic Notch.—In this luxation the mechan- ism of reduction is prac- tically the same as for the preceding displace- ment. One point must be guarded against — the danger that, when the head of the femur reaches the margin of the acetabulum, it may be deflected below the rent in the capsule, and lodge in the thyroid foramen. If extension and counter-extension after the older method (Astley Cooper's) be necessitated, the pelvis should be fixed by a sheet folded and passed through the peri- naeum and over the groin, and extension made from above the knee, with the thigh flexed al- most to an angle of 90° with the abdomen, and adducted un- til the knee is carried in front of the opposite thigh (Fig. 420). Reduction of Dislocations in the Thyroid Foramen—Method of Bigelow.—-Place the patient upon the floor, in the dorsal de- cubitus, flex the leg on the thigh, and the thigh on the abdomen, making, at the same time, slight abduction. Then rotate the fe- mur inward, adduct, and carry the knee to the floor. The older method involved extension in a lateral direction, ^ means of a sheet folded and FlG' ^-^iSZZL d\1*?gl™ jnt0 the thyroid 420 A TEXT-BOOK ON SURGERY. Fig. 422.—Showing the relation of the iliofemoral ligament in dislocation of the head of the fe- mur into the thyroid foramen. (Bigelow.) pulleys can not be had, the sheet should be tied into a loop and laid over the shoulder of the operator. Reduction of Dislo- cations upon the Pubes —Hamilton's Method. — When the head of the bone is lodged well over the pelvic rim the thigh should be abducted and rotated outward, in order that the head may be thus lifted over the pu- bes, and then flexed upon the body, adducted, and brought down. Rotation outward should cease as soon as the head of the bone has risen above the pubes. When the head has not passed above the Fig. 423.—Showing how flexion of the thigh on the aodomen relaxes the iliofemoral ligament in dislocation into the thyroid foramen. (Bigelow.) passed around the inner surface of the thigh, while the pelvis was fixed by a sheet passed around this part of the body, and upon which traction was employed in an opposite direction (Fig. 424). If which is carried around the thigh rim of the pubes, out- ward rotation is not called for. Fig. 424.—Cooper's method of reducing dislocation Into the thy- roid foramen. (Hamilton.) DISLOCATIONS. 421 If in this manoeuvre the bone slips into the thyroid foramen, the manipulation given for this luxation should be practiced. By Extension and Counter-Extension—Hamilton's Method.—Place the patient upon the edge of a bed or table, so that the injured limb may Fig. 425.—Reduction of dislocation upon the pubes by extension and counter-extension. (Hamilton.) fall slightly over the edge. Extension is made from the thigh, and counter-extension from the perinaeum and groin, in the direction indi- cated in Fig. 425. The tendency of modern surgery is to rely upon ma- nipulation under anaesthesia rather than resort to the forcible methods of extension and counter-extension. The after-treatment of hip-luxation involves fixation of the muscles about the joint for from two to six weeks. A gutta-percha, heavy paste- board, or leather splint, molded to the side of the pelvis, thigh, and down to the ankle, applied upon a thin layer of absorbent cotton, and held in place by a leg-, thigh-, and spica-bandage, should be employed. The prognosis as to rapid restoration of function is not always favor- able. The injury to the capsule, and more especially to the muscles around the joint, may lead to an impairment of the hip, more or less permanent. In permanent luxations, in some instances, a fair degree of mobility may be developed. Reduction has been successfully performed as late as four and six months after the injury. The treatment of congenital dislocations of the hip, and of pathologi- cal luxations, will be given later. Dislocations at the Knee—The Tibia from the Femur.—Displace- ment of the femoral end of the tibia may occur as a result of congenital malformation, disease, or accident. Congenital luxation is rare, and is usually partial. As a rule, the tibia is displaced forward, although the opposite condition may prevail. Absence of the patella has been observed in several of these cases. Pathological dislocations will be given under the head of diseases of this joint. Traumatic luxation at the knee is comparatively rare. The tibia may be completely or partially displaced, and in any direction. Partial dislocation is the rule. Complete luxation is apt to be complicated with a wound. A compound dislocation usually occurs forward or backward. The cause is direct violence. A blow upon the anterior aspect of the tibia, near the joint, or the posterior-inferior portion of the femur, may 422 A TEXT-BOOK ON SURGERY. cause a backward displacement of the tibia, while violence from opposite directions may produce a forward dislocation. The same force applied laterally may also produce the lateral displacements. A favorable condi- Fig. 426.—The author's case of backward dislocation of the tibia at the knee, caused by stepping into a hole while in the act of running. (From a drawing by Dr. Mewborn, fifteen years after the accident.) Fig. 427.—The same, after exsection. tion for luxation is the application of violence when the leg is in extreme flexion. A sudden twisting or wrenching of the femur upon the tibia when the foot is so caught that rotation on the heel is impossible, is favorable to rupture of the ligaments, and lateral or oblique incomplete luxation. The symptoms of dislocation at the knee are usually clear. In the backward variety the antero-posterior diameter of the knee is increased, the tibia projects into the popliteal space, and the condyles of the femur are unusually prominent. In the forward variety the antero-posterior measurements are also increased, the anterior edges of the tibia are easily detected in the advanced position of this bone, while the condyles of the femur are unusually prominent posteriorly. The tibia may be rotated upon its axis. In the lateral displacements the condyle of the femur is recognized as projecting on one side, while the flat end of the tibia is felt on the opposite side. The transverse diameter of the joint is increased in pro- portion to the degree of displacement, which is, however, rarely complete. Treed ment.— Reduction is readily effected by extension and counter- extension, with direct pressure and counter-pressure in the proper direc- DISLOCATIONS. 423 tions. Once reduced, flxation should be secured by Buck's extension, with sand-bags applied to the limb, or an investing splint should be employed. The prognosis after this injury is unfavorable. The function of the joint is rarely fully restored. The question of amputation after disloca- tions of the knee, where there is extensive injury of the surrounding structures, is one of great importance. Shock is more profound in this luxation than in dislocation at any other joint. A primary amputation will rarely be justified except after laceration of the popliteal vessels. All antiseptic measures should be employed, and amputation only advised after every effort consistent with the safety of the patient's life has been made. Exsection is preferable, and offers not only a greater degree of safety but a more useful result. Dislocation of the Patella.—This bone may be displaced by muscular action, without the aid of external violence, or by an injury alone. When the ligamentum patellae is ruptured, it is carried upward for a varying distance by the contraction of the quadriceps. It can only be displaced downioard by a blow received upon its upper margin sufficient to tear it loose from its muscular attachments. Dislocation outward is the more frequent variety, and occurs as a result of muscular contraction and from violence. Displacement inward is the result of a blow received upon the outer margin of the bone. In the lateral dislocations, in rare instances, the patella is turned obliquely on its edge, or it may possibly be completely inverted. The symptoms of these various luxations are unmistakable, and the reduction, by relaxing the quadriceps and pressure, not difficult. The after-treatment is directed to the prevention of recurrence. Dislocations at the Ankle-joint—Dislocations at the tibio-tarsal articulation may occur in four directions, viz., forward, backward, in- ward, and outward. In the last two forms fracture of one or the other malleolus is apt to occur. Dislocation of the tibia inward is caused by a fall upon the foot at a time when it is turned outward, the body-weight being brought to bear upon the inner aspect of the heel and great toe. This form of sprain is frequently caused by leaping from a wagon or car in motion. It may also result from a heavy blow upon the fibular side of the leg, near the ankle, when the foot is solidly fixed against the ground. The displace- ment is usually partial. A complete luxation is apt to be compound. The symptoms of inward dislocation are the great prominence of the inner malleolus and the peculiar twist of the foot, so that the inner side of the heel and the great toe rest on the floor while the sole looks ob- liquely outward and upward. The only displacement it may be mistaken for is that of the astragalus from the os calcis. The treatment is to bring the foot into the normal position by pressure and counter-pressure, and fix it with a splint and bandage. On account of the great swelling which is likely to occur, an immovable dressing should not be applied until the acute symptoms of inflammation have subsided. The symptoms of outward displacement are the reverse of the inward, and can without difficulty be recognized. Displacement of the tendons 424 A TEXT-BOOK ON SURGERY. of the long and short peronei muscles, from their sheaths behind the external malleolus, is likely to occur in this accident. After reduction at the joint these should be pushed into place, and an effort (rarely suc- cessful) made to hold them in position by a compress and bandage, ap- plied before the splint for the luxation is adjusted. Forward dislocation may occur as the result of a blow upon the back of the leg, near the ankle, while the foot is firmly placed upon the ground; by falling forward with great violence, when the momentum of the body is suddenly arrested by the foot striking against the ground ; or by fall- ing backward, with the foot so fixed that great and unusual extension of the tarsus takes place. The symptoms are unnatural prominence of the heel, shortening of the distance between the toes and the front of the tibia, on the displaced side. Reduction.—Place a clove-hitch around the heel and instep for exten- sion, and make counter-extension from the thigh. Flex the leg so as to relax the sural muscles, and make forcible extension from the foot. As soon as the extension is well begun the operator places his foot against the front of the patient's tibia, just above the ankle, and pulls forward on the foot, at the same time flexing it on the tibia. Backward displacement is caused by violence applied in a direction opposite to that which produces the forward luxation, and the symptoms are exactly the reverse. The treatment demands reduction by extension and counter-extension, and direct pressure. Dislocations at the ankle are often complicated with fracture, or may be compound. In any form of injury an effort should be made to save the foot and joint. The ankle is exceedingly tolerant of surgical inter- ference, and, with strict cleanliness and antisepsis, amputation on account of complicated or compound dislocation will be rarely necessary. The fibula may be displaced from its articulation with the tibia at its upper or lower end. At the upper end it is usually luxated forward, as a result of direct violence from behind, although it is possible to have the reverse occur. The bone will be felt in the abnormal and anterior posi- tion, and may be pushed directly back into place. In the backward dis- placement the biceps muscle may produce the luxation, or it may be from violence applied from the front. Strong and continued pressure must be employed to retain the bone in position until adhesions occur. During the treatment the leg should be flexed on the thigh in order to relax the biceps. At the lower end dislocation of the fibula alone, without the tibia, is exceedingly rare. Anatomically, it may occur in both directions. Re- duction may be effected by direct pressure. The fibula may be displaced outward from the tibia by the astragalus being driven upward between these bones. Dislocations of the Bones of the Tarsus.—The astragalus may be partially or completely dislocated forward, backward, outward, or in- ward. The luxation is usually incomplete. On account of the great violence necessary to its production it not infrequently is compound, or DISLOCATIONS. 425 complicated with a fracture. Violence of the same character as that which produces displacement of the tibia will cause dislocation of the astragalus. Treatment—Luxation of the astragalus is a serious accident. The efforts at reduction do not always succeed, and, even when reduction is effected, the injury to the joint may be such that loss of function results. Direct pressure and counter-pressure, while the patient is profoundly anaesthetized, offer the best means of successful reduction. Displace- ments of the metatarsal bones and phalanges of the toes are treated in the same general wTay as described for similar lesions of the hand. The Vertebra.—Dislocation may occur at any articular surface of the vertebral column. The accident is always serious, the gravity being pro- portionate to the degree of displacement and the injury to the cord and nerves. Luxations are more common in the cervical region. One or both articular processes may be displaced forward or backward upon the ver- tebra belowr. In the unilateral displacement the fibro-cartilage between the bodies is only slightly involved, and, while there is pressure upon the nerves passing out of the intervertebral foramen, there is no pressure upon the cord. In the bilateral form the cartilage is torn, the body more or less involved in the luxation, and the cord compressed. The causes are muscular contraction, or violent twisting of the neck by accident. The symptoms of unilateral displacement are pain—which may be referred to the distribution of the nerves passing through the interverte- bral foramen involved—at the seat of luxation and rotation of the head, in a forward dislocation, so that the chin points to the side opposite to that upon which the injury exists. AVhen the luxation is backward, the face is turned toward the seat of injury. In the case of a young lady which came under my observation, the right articular process of the fourth cervical vertebra was displaced for- ward by sudden and violent muscular contraction. Pain wTas acute at the seat of luxation, and numbness down the right arm indicated com- pression of some of the filaments forming the brachial plexus. Reduction was effected as follows: The patient being seated in a chair, the shoul- ders were held immovable and the head further rotated to the left; then strong extension was made by lifting the patient from under the chin and occiput, at the same time carrying the head back to the right. Relief was immediate and permanent. In bilateral luxation careful extension and direct pressure and counter- pressure should be practiced. Dislocation of the condyles of the occipital bone from the atlas is probably always fatal. Luxation at the atlo-axoid joint, with fracture of the odontoid, is also fatal. Ribs.— The ribs may be displaced from their vertebral articulations. nil . *■ ine cause is direct violence, and the displacement usually forward. The true ribs may be dislocated at the junction of these organs with their cartilages, near the sternum. The treatment for these luxations is the same as for fracture. 30 426 A TEXT-BOOK ON SURGERY. Diseases of the Joints in General. Inflammation of a joint may be simple or infective. It may involve the entire anatomical structure of the articulation, or may be limited to a portion of the capsule or its lining membrane. When the lining mem- brane is alone involved it is called synovitis (a similar condition of the tendon sheaths is known as thecltls or tenosynovitis). When the ligaments of a joint are involved it is called syndesmltis. When all of the structures are involved—bone, cartilage, ligaments—it is known as arthritis or osteo-arthritis. A typical simple (non-infective) inflammation of the joint structure occurs after an ordinary sprain. The first symptom is pain and swell- ing proportionate in general to the extent of the traumatism. Hyper- aemia and dilatation of the capillaries in the basement membrane of the synovial membranes and ligaments occur, followed by emigration of leucocytes into the intercapillary spaces as well as into the cavity of the joint, in which there is almost always a transudation of serum. The synovial fluid is increased in quantity, richer in cell elements than nor- mal, and frequently discolored by red blood-corpuscles or free haematin. Not only is the capsule distended, but frequently the communicating bursae are also abnormally filled with fluid. The embryonic cells, which are the product of the inflammatory process, are found not only lining the synovial surface, but there is also a connective-tissue hyperplasia in the substance of the capsule. Simple arthritis or synovo-arthritis as described (pyogenic infection not having occurred) tends to recovery. The inflammatory symptoms subside, repair goes on rapidly, absorp- tion of the exudate takes place, and, when uncomplicated by rupture of the capsule or fracture of bone or cartilage, its function is restored. Should infection occur, the clinical history is entirely different. The symptoms of pain and swelling are exaggerated ; pus forms in the joint; the liquefying action of the toxic products generated by pyogenic organ- isms destroy the synovial surfaces and produce erosions of the cartilagi- nous facings of the bone and the interosseous flbrocartilages, if such exist; softening or thickening of the capsule, increased abnormal hyper- aemia, invasion of the periarticular tissues, and, in the natural course of this form of arthritis, rupture of the capsule and escape of purulent con- tents follow. Neglected cases of pyogenic infection of a joint lead gen- erally to the involvement of the bones connected with the articulation. Osteomyelitis may in this way occur. Treatment—The first essential in the treatment of simple traumatic synovitis, or synovo-arthritis (sprain), is rest. This is best secured by the recumbent posture and elevation of the part involved. The ice bag or cold applications are usually grateful. Immobilization of the part by plaster of Paris or by some fixed dressing, between which and the in- jured member a considerable layer of absorbent cotton is interposed, produces a compression which aids in the absorption of inflammatory products. In sprain at the ankle, as advised by Prof. Y. P. Gibney and others, tight strapping with adhesive plaster from the dorsum of the DISEASES OF THE JOINTS. 427 foot around the ankle and lower leg in figure-of-eight fashion has been used in late years, especially in subjects wiio are unable to give up work. As soon as the injury is received, the strapping is applied ; the shoe is worn as if nothing had happened, and the patient is advised to go about regardless of the sense of discomfort which may be present. A considerable number of successful cases treated in this way have been reported by various surgeons. The treatment of infective arthritis, or synovo-arthritis, demands abso- lute rest from the moment of its inception and the energetic efforts of the surgeon to arrest the invasion of the joint and to build up the nor- mal resistance of the patient. Between the danger of opening into an infected joint and instituting drainage and the threatened destruction of the structures from the presence of a further accumulation of pus in the capsule, the surgeon is frequently at a loss what course to pursue. Since the judicious employment of cocaine renders the procedure practi- cally without pain, especially in children over twelve years of age and in all adults, it would be proper to attempt an evacuation of the puru- lent accumulation in the capsule by careful aspiration and irrigation through a large-sized aspirating needle with a boiled saturated solution of boric acid cooled dowTn to 110° F. Care should be taken to exhaust all of the fluid possible from the joint through the largest aspirating needle, and, of course the needle should be thoroughly aseptic before it is used even in a septic joint. The opening should be at once sealed wdth gauze or collodion and an absorbent compress applied to the joint. It is proper to say that in the author's experience such measures have usually failed, incision and drainage being ultimately necessary. When incision is determined upon, it should be free, and in a large joint, such as the knee ; a single opening upon the outer or inner side of the capsule will usually suffice. Thorough irrigation should follow the incision, and it is well to insert a medium-sized rubber drainage tube which has been taken out of the sterilizer immediately before using. The period for which drainage should be employed will be determined by the symp- toms. When the pus has practically ceased to flow from the tube, it may be removed, and the same careful aseptic dressing applied until recovery is complete. Penetrating Wounds. —Ordinary incision, puncture, or lacerated wounds of a joint are serious only as they cause infection. An'aseptic incision or punctured wound, as in exploration of the joint, is practically without risk. An accidental, punctured wound requires no further treatment than aseptic management and complete rest, unless symptoms of infection occur. It should then be treated according to the directions just given. In laceration of a joint, where the air or any infectious Wit has been carried into the latter, it should at once be made sterile hy irrigation with boric acid solution and the wound closed with or without drainage, as may be demanded. In gunshot wounds of the joint the same treatment should be instituted. These are somewhat mure formidable on account of the destruction of bone which is likely to follow the passage of a ball through a joint. It is advisable to cleanse 42S A TEXT-BOOK OX SURGERY. the wound of entrance and exit, taking the usual antiseptic precautions, keeping the member in complete rest while repair is going on. This method was followed in a recent case of penetration of the knee joint with a ball from a Colt navy pistol, and no sepsis occurred, the joint resuming perfect function wdthin six months after the accident. When infection does occur, the ordinary surgical rules for infected joints should be followed. Dry Synovitis, or Synoco-arthritis, is occasionally met with in sur- gical practice, especially in rheumatic subjects. It is an inflammation of the synovial membrane of the capsule in which there is not only no transudation of fluid into the capsule, but the normal synovial secretion is diminished, and in many cases, even when properly cared for, ending in loss of function or anchylosis. These cases require rest so far as the joint is concerned, and an effort to correct the diathesis which causes the inflammation. Tuberculous Arthritis.—By far the more frequent form of subacute and chronic arthritis which comes under the surgeon's observation is tubercular in character. Tuberculous arthritis may originate in the deposit of the bacilli of tuberculosis directly in the synovial membrane or articular structures proper, and this condition is found as a rule in adults, or indirectly by invasion from foci of this disease in or near the epiphyses contiguous to the joint. This last method of invasion is more frequent in children. The symptoms of tuberculous joint disease vary in some respects owing to the direct or indirect involvement of the cavity. There is also a marked difference between traumatic arthritis and this specific form of infection. Acute arthritis is always a painful affection, and is almost always traumatic in origin. In tuberculous arthritis pain is rarely acute, and is intermittent and mild in character. If pyogenic (mixed) infec- tion occurs, pain and high temperature ensue. AVhen tubercular ostitis precedes the arthritis, pain of a mild charac- ter is more apt to be constant. When the synovial membrane becomes the seat of tuberculous de- posit it becomes softened and thickened, covered with a rich layer of granulation tissue, and relaxed, permitting pathological dislocations, flex- ions, rotations, etc., to take place. The treatment of these cases, both constitutional and local, will be taken up with the special management of the various joints. Diseases of Special Joints. Of the Hip.—Arthritis of the hip, hip-joint disease (morbus com, or morbus coxarius), is a frequent and formidable affection, and one which, in many instances, will baffle the best medical and surgical care through months and years of suffering, ending in destruction of the joint, and frequently in death. It is a disease of childhood, occurring chiefly in the period of rapid growth. It rarely occurs after the twelfth year. It may occur at any time prior to this age, the majority of cases being between the ages of three and six years. DISEASES OF SPECIAL JOINTS. 42 y Fig. 428.—Section of normal femur of a boy eight year? old. (After Gibney.) The pathology of morbus coxa? will vary with the peculiar character of the lesion. The morbid changes which occur in that variety which is most frequently met with are those of tubercular ostitis, followed by destructive arthritis. The initial lesion occurs as an interference with, or arrest of, nutrition, near the diaphyso-epiphyseal cartilage (Fig. 428, a), due to the deposit of tuberculous material at this location. It may begin on the diaphyseal or epiphyseal side. According to Prof. Gibney,* the initial lesion appears in the several centers of ossification about the same time. It is an ostitis rarefaclens. The can- cellous cavities become filled with embryonic cells,. absorp- tion of the lamellae occurs, the inflammatory new products may undergo a slow process of fatty metamorphosis, may become caseous, or with mixed infec- tion the process may terminate in pus formation. The development of the bone is arrested, the ostitis, commencing in the deeper portions, travels in all directions, destruction of the diaphyso-epiphyseal cartilage occurs, with separation of the epiphyses (diastasis). While these changes are going on, the lining membrane of the capsule becomes involved, the process being one of chronic synovitis, which, as has been stated, termi- nates inevitably in inflammatory changes in the tissue proper of the capsule. The joint becomes filled with the products of inflammation, the capsule, overdistended and weakened, ruptures either spontaneously or ;is a result of motion, and dislocation may occur. With separation of the epiphysis and destruction of the neck of the femur shortening ensues. Occasionally the initial ostitis may be situated in the bones which form the cotyloid cavity. It is held that hip-joint disease may, in rare instances, result from a peri-articular inflammation, first a syndesmitis, secondly a synovitis, lastly arthritis. Causes.—The causes of hip disease are chiefly predisposing. Any dyscrasia which impairs nutrition in general favors the lodgment and proliferation of the bacillus tuberculosis and tends to destructive ostitis and arthritis. Traumatism may, and undoubtedly does, precipitate the inflammatory process in many cases, yet the ordinary violence to which this joint is subjected will rarely induce coxitis, except in children affected with some constitutional disease. Excessive use or a blow may produce synovitis, but, in a healthy patient, rapid recovery is almost certain. If diastasis occurs as a result of accident, ostitis ensues, and * " The Hip and its Diseases," Bermingham & Co., Xew York, 1S84. 430 A TEXT-BOOK OX SURGERY. impairment of the joint follows, yet this is an exceedingly rare injury. Rupture of the ligamentum teres, which must occur in a traumatic luxation, could not induce destructive arthritis in an otherwise healthy individual. The symptoms of hip disease are divisible into two stages. The first stage embraces all the phenomena of inflammation, up to a positive and appreciable destruction of the structures which enter into the formation of this joint. The second stage embraces the phenomena of destruction, namely, shortening of the neck, diastasis, rupture of the ligamentum teres and capsular ligament, and luxation. Among the earlier signs of this disease is pain, referred directly to the hip joint, or it may be to the hip and knee joints, of the affected side, and in some instances the pain is felt wholly in the knee of the same side. This symptom is most exaggerated at night and in the early morning hours, and after the child begins to move about may disappear. The distribu- tion of the obturator nerve to both articulations will account for the reflex sensibility in the knee. In a certain number of cases the patients will deny all sense of pain, and even under pressure may not exhibit signs of suffering. In children this effort at concealment (not uncommon) is in- cited by the fear of being subjected to surgical treatment. If, however, a careful examination is made, rigidity of the muscles about the hip will be evident. In standing erect, the weight of the body will be brought upon the sound extremity, the gluteal fold on the affected side is partially obliterated (Fig. 429), and in walking there is almost always a perceptible limp. The iliacus, psoas, and adductor muscles are usually in an abnormal state of tension ; hence the initial flexion of the thigh, and outward rotation or ever- sion of the foot. Rigidity of the psoas and iliacus muscles—one of the more positive early symptoms of hip dis- ease—may be demonstrated in the following man- ner : If the patient be stripped and laid flat on the back, on a hard, level surface, and both legs drawn Fig. 429.—(After Sayre.) Fio. 430.—(After Sayre.) up (Fig. 430), it will be seen that the sacrum, spines of the vertebrae, the scapula?, and occiput rest in contact with the table. If the sound leg be now extended and the popliteal space brought wTell down against the surface of the table, the lumbar spine is only very slightly, if at all, lifted from the table (Fig. 431). If there be rigidity of the muscles DISEASES OF SPECIAL JOINTS. 431 named, as a result of hip disease, on the suspected side, when the effort is made to bring this leg into a position parallel with the sound one, it will be seen that extension of the thigh is limited, and that the motion of the hip joint is transferred to the lumbar vertebra?, so that when the popliteal space touches the table the lumbar spines are lifted from Fig. 431.—(After Sayre.) Fig. 432.—(After Sayre.) one to three inches from the surface (Fig. 432). The duration of the first stage varies from two or three months to as much as one year, and in exceptional cases longer. In the second stage the thigh is further flexed on the abdomen, adduc- tion is more pronounced, and shortening is present in a degree varying with the extent of destructive ostitis in the acetabulum, or head and neck of the femur, and to the character of the luxation. In the usual position of the foot of the affected side, in this stage, the great toe or inner surface of the tarsus rests upon the dorsum of the well foot, or on the spine of the tibia. The shortening —which may be deter- mined by measuring from the anterior-supe- rior spine of the ilium to the inner malleolus —will vary from half an inch to several inches. Nelaton's or Callaway's test—already given in the articles on fractures of the femur—will demon- strate that the shortening has occurred above the trochanter. When suppuration occurs, the capsule gives way, and sooner or later, if surgical interference is delayed, sinuses open through the skin, about the trochanter, or in the groin. Perforation of the acetabulum takes place in a certain proportion of cases. Diagnosis.—Disease of the hip joint may be differentiated from bur- sitis, peri-articular inflammation, rheumatism, neuralgia, sacro-iliac dis- ease, or ostitis of the trochanter or ilium. It is also important to deter- mine whether the initial lesion is a synovitis or an ostitis. Synovitis may be caused by excessive use of the joint, by strain or concussion, by sudden exposure to cold, or it may result as a symptom of gout or rheumatism. It is a painful affection from its incipiency, and the pain increases with the march of the effusion into the joint and the distention of the capsule. Motion increases the pain, which is usually so severe that all movement of the joint is firmly resisted. The cause may usually be traced to an injury. Synovitis due to gout or rheuma- tism occurs usually in adults ; coxitis is practically a disease of child- hood. When ostitis is the initial lesion, the approach of the disease is insidi- ous and much less painful. When present, the pain in ostitis of the head 432 A TEXT-BOOK ON SURGERY. and neck of the femur is deep-seated and dull, and motion is compara- tively free. Rotation and pressure of the head upon the capsule and in the acetabulum do not produce the sharp sense of pain felt in synovitis. Ostitis is the rule in children, synovitis in adults. Bursitis about the hip is rare. The sac between the capsule and the conjoined tendon of the psoas and iliacus muscles, and those situated between the tendons of the gluteus maximus, medius, and minimus and the great trochanter, and that between the quadratus femoris and the lesser trochanter, may one or all be involved. Inflammation in one or more of these bursa? may be recognized by the limited extent, as well as the acuteness of the pain elicited by direct digital pressure immediately over the known position of the sac. Pain in the knee is not present in bursitis at the hip. Rigidity is not general in the muscles about the joint. Peri-articular Inflammation is a painful affection, causing marked lameness from the start; it is accompanied by local swelling and tender- ness if superficial, and usually by exacerbations of temperature, all of which will render it easy of recognition. Muscular rheumatism is rarely confined to the muscles of the hip. It is an expression of a constitutional condition which can not but be elicited by a careful history and study of the case. The pain is more severe and more early recognized than in coxitis. The painful territory may be outlined by fixation of the joint and digital pressure upon the muscles involved. Neuralgia occurs very rarely in children, in the period when hip- disease is most likely to appear. The exacerbations of pain are more sudden in development and acute in character, and occur with greater frequency and regularity than in hip disease. Motion is tolerated better in neuralgia than in coxitis. The symptoms of ostitis which lead to arthritis, if carefully studied, will show a wide difference from neuralgia about the hip. In arthritis or ostitis at the sacro-iliac junction pain is caused by forcibly pressing the ilium against the sacrum. The same symptoms may be elicited by direct pressure posteriorly over the sacro-iliac articu- lation. Motion at the hip is only slightly if at all embarrassed. Prognosis.—In hip-joint disease commencing—as is the rule—in ostitis or epiphysitis, the prognosis is bad as regards restoration of function. Partial or complete anchylosis, with a variable degree of shortening, will result, in the vast majority of cases, no matter how skillfully treated. The proportion of fatal cases can scarcely be de- termined. It is safe to say that at least five per cent of all cases in which the lesion begins as an ostitis end in death in from one to six years. In traumatic synovitis of the hip the prognosis is favorable. A resto- ration of function is the rule. Treatment.— The treatment of hip disease may be divided into me- chanical, operative, and constitutional. In the early stage of coxitis rest to the inflamed articulation, in the DISEASES OF SPECIAL JOINTS. 433 position of least discomfort, is essential. A diseased joint demands protection not only from traumatism in the effort at locomotion, but from reflex and involuntary muscular spasm. Fixation of the mus- cles which act upon and about this joint can be best secured by ex- tension from the lower part of the thigh and counter-extension from the perineum. It has been shown by Bradford and Lovett, of Boston, that in order to gain the full benefit of extension at the hip, the femur should not be brought out entirely straight, but should rest about five degrees short of full extension (175°). If a child with hip disease be seen very early in the history of this affection, flexion of the thigh upon the abdomen will not have occurred to any extent, but, in cases where the inflammatory process has gone on for some time, the iliacus and psoas and adductor muscles will have be- come rigid and shortened to such an extent that the thigh can not be immediately brought out straight. In the former class of cases the apparatus about to be described can be at once adjusted ; in the latter, extension in the recumbent posture is necessary until the shortening in the ilio-psoas muscles is overcome. In fact, since in all cases some time must elapse between the discovery of the lesion and the preparation of the mechanical apparatus, it is a wise practice to put the patient to bed at once, and apply the extension as follows : Cut two strips of moleskin plaster, from one inch and a half to two inches wide, and long enough to extend from six inches above the trochanter to below the sole of the foot. Adjust one to the outer and one to the inner aspect of the thigh, allowing the upper end, which is to be doubled back upon itself and woven in with the roller, to extend four or five inches above the level of the trochanter. Mold them carefully to the contour of the limb, bringing the strips exactly over the inner and outer condyles of the femur, and hold them by a well-adjusted bandage, beginning from above. In order to prevent the plaster from wrinkling, it is necessary to clip it with the scissors, obliquely upward from each edge, at intervals of an inch or two. As the extension is exerted only from the femur, the adhesive strips should not be applied to the skin below this point. The bandage is commenced just at the level of the great trochanter, and that portion of the strips which extends above this is to be turned down and worked in with the roller. That part of the plaster which is exposed from the knee down should be doubled by laying a second strip of equal width on this, the adhesive surfaces coming together. In this way it is not only strengthened, but is prevented from sticking to the dressing. The extension weight—varying from seven to twenty-five pounds— is applied as in Buck's apparatus. The dorsal decubitus should be maintained, for, if the sitting posture is assumed, the iliacus and psoas muscles are not materially affected by the extension. To secure this result the long splint of Hamilton should be applied from the axilla along the thigh and leg. and firmly secured by a bandage carried around the chest, pelvis, and thigh. Or a pillow slip may be pinned to either side of the bed, passing over the chest. 434 A TEXT-BOOK ON SURGERY. As soon as the thigh is fully extended the following mechanism should be adjusted. It is one which is now employed by Dr. Newton M. Shaffer, after many years of trial and a large experience in the management of these cases, in the New York Orthopaedic Hospital and Dis- pensary. It embodies the principle of exten- sion from the pelvis and counter-extension applied to the femur from the trochanter down to the condyles. It can be so arranged as to take advantage of any degree of deformity, correcting flexion, abduction or adduction, and is a modification of an apparatus which was original with Dr. Henry G. Davis, devised by him over forty years ago. It consists, first, of a pelvic band (Fig. 433) so curved behind and in front as to make the shortest possible perineal pads. This band should be made of annealed steel strong enough to bear the weight of the body of the patient. At- tached to this is the cylinder which extends down the leg along the outer side to a point opposite the ankle joint. Accurately fitted into the cylinder is a traction rod with a foot piece, and the connection between the cyl- inder and the traction rod is regulated by an adjust- able rack and pinion. The pelvic band, accurately ad- justed, is fixed by two short perineal pads attached to it in front and behind, and the entire leg is connected with the traction rod by adhesive plasters which envelop it entirely and ex- tend high up on the thigh, making practically all the traction from above the knee. The connection be- tween the adhesive plasters and the foot piece is made by leather straps (Fig. 433). This apparatus may be used in various modifications, not only in the treatment of the deformity, but after the deformity has been modified, in which latter case it is so adjusted that the weight of the body falls en- tirely upon the perineal straps—in other words, forming a double ischiatic crutch. AVhen the deformity is removed or essentially modi- fied, the patient may walk with or without crutches, as the conditions may demand. After a certain length of time has elapsed, the joint Fig. 433.—Shaffer's modification of Taylor's hip splint. iHi Fig. 434.—Four-tailed ad- hesive strip, with buckle ready for application. DISEASES OF SPECIAL JOINTS. 435 reaches a stage of convalescence where simple protection is necessary rather than traction. The modified apparatus then becomes very useful. The modification consists in adjusting the foot piece and cylinder into a well-fitting shoe, which takes the place of the adhesive-plaster traction. The end of the cylinder is inclosed in the shoe worn by the patient Fig. 435.—Showing the manner in which the tails are interwoven. First step. instead of passing on the outer side, and, in addition to the outer bar, an inside bar is added with thigh and calf bands and an automatic knee spring, which enables the patent to bend the knee as occasion may re- quire. It has the same hip-joint and perineal pads, and affords a modi- Fig. 436.—The same, before the bandage-roller is applied. Second step. lied traction support to the hip joint. When strong abduction is neces- sary the instrument shown in Fig. 437 will be found useful. Among many orthopedic specialists the question of preference be- tween this form of apparatus and some modification of H. O. Thomas's method of treating hip-joint disease is not easily decided. Of all the applications of Thomas's idea which have been carried into-effect, the fol- lowing is the most commendable : It consists of a long malleable iron bar, which extends from near the axilla down the back parallel with the spinal column, over the buttocks, and down the posterior aspect of the thigh and leg, curving beneath the heel, and terminating opposite the center of the plantar arch (Fig. 439). At this termination a crossbar from three * 436 A TEXT-BOOK OX SURGERY. to four inches long is welded, from the tips of which the extension straps are adjusted. At the upper end of this perpendicular bar there is a metal bar or belt which encircles the thorax for two thirds of its circum- ference, terminating in straps of strong webbing fastened together with a buckle. At a point opposite the anterior-superior iliac spine a pelvic band, similar in construction to the thoracic band, is adjusted for fasten- ing the instrument around the pelvis at the iliac prominences. To this Fig. 437.—Shaffer's abduction hip apparatus. Fig. 438.—Thomas's hip splint. band buckles are attached behind and in front for double perineal pads. Opposite the gluteal fold a metal band is attached, which encircles the thigh at this point. Farther down, at the junction of the inferior with the middle third of the tibia, another metal band is attached. When adjusted accurately to the contour of the back, buttock, thigh, and leg, it should extend three inches below the extremity, so that when the patient stands, the instrument will rest upon the floor while the foot swings free and clear. The apparatus is applied as follows : The four-tailed adhesive plasters are applied to the leg as above directed ; the splint is then adjusted by fastening, first, the perineal straps snugly, so that the pelvic band will come just below or on a level with the anterior-superior spines; the thoracic and pelvic bands are connected by means of the webbing straps; the leather spraps attached to the foot piece of the brace are then fast- ened into the buckles attached to the plaster on the leg, and firm, steady DISEASES OF SPECIAL JOIXTS. 4;r Fig. 439.—Thomas's hip splint (with American extension). traction made. The entire limb and brace are then incased in a lightly applied muslin bandage so as to prevent any wabbling of the limb. A high shoe is adjusted to the opposite limb, and the patient allowed to walk with this and a pair of crutches. The length of time for which this treatment should be continued will be determined by the result achieved. It is often a necessity for one, two, or three years, and sometimes even longer, and should be wTorn for several months after all active symptoms of coxitis have disappeared. Conditions may arise in which the apparatus just described can not be applied. A fairly good substi- tute, and one which secures fixation, is the plaster- of-Paris dressing, wdiich is applied from the line of the nipple around the abdomen and over the hip, thigh, and leg, including the foot of the affected side. In order to apply it wdiile the leg is in a condition of fairly good extension, the patient may be made to stand on the sound foot upon an elevated stool, allow- ing the lame foot to be pendant. An assistant on either side holds the patient upright, and another makes traction downward as the plaster is applied. The bony prominences should be carefully padded. The child should be allowed to go about after the plaster has hardened, and should wear an elevated shoe, four or five inches high, on the sound foot. This will permit locomotion without danger to the integrity of the affected hip. Vance, of Louisville, Ky., has invented a molded-leather splint, which is applied in the same way. and covers the abdomen, hip, and thigh dowui to and be- low' the knee, and answers the same purpose as the plaster-of-Paris ; but as this latter is so much more readily obtained and more gener- ally applicable, it may be relied upon in the early stages of hip-joint disease and in the later stages after extension and counter-exten- sion in dorsal decubitus has brought the leg- down to the proper plane. When sinuses exist as a result of disease of the hip joint, some slight change in the ap- plication of the apparatus selected will be necessary. It is always essential that the openings of the sinus or sinuses be properly protected by absorbent dressings in such a way that free discharge may be secured without soiling the apparatus. The constitutional treatment of this disease is of great importance. Fig. 440.—Leather splint. 438 A TEXT-BOOK ON SURGERY. Carefully selected diet, out-of-door life, cod-liver oil, the hypophosphites of lime and soda, and tonics are indicated. In the second stage of hip disease operative interference may in rare cases be demanded: (1) To relieve pain on account of suppuration and the retention of pus, or to prevent sepsis from insufficient drainage ; (2) to arrest ostitis in the head and neck of the femur, and in the acetabulum. When riain is so severe that fixa- tion with extension will not afford relief, it is safe to conclude that dis- tention of the capsule exists, or that in the structures which form the joint, or are immediately around it, suppuration has occurred to such a degree that free incision is necessary. The question of performing a rad- ical excision of the hip joint is one upon which a divergence of opinion still prevails. I am convinced, how- ever, that this operation should not be done except as a last resort and when the symptoms of septic absorp- tion are so well marked and severe that radical interference is demanded. Careful conservative treatment by well-adjusted apparatus, incision and drainage of all pus accumula- tions, and careful general treatment of these patients will result not only in securing the recovery of the patient, but will give a more useful joint in the vast majority of cases. In the rare cases in which excision of the hip joint is deemed necessary the wound should be packed with iodoform gauze and treated by the open method, not even partially closed by sutures. The gauze may be changed every few days, the wound irrigated with l-to-3,000 sublimate solution, and again filled. Extension by the weight and pulley, in the dorsal decubitus, is necessary for from three to six weeks after the operation, unless the child is strapped in the wire breeches recommended by Prof. Sayre (Fig. 442) immediately after the exsection. The chief recommendation of this apparatus is that it allows the patient to be carried out of doors or about the house with perfect freedom from motion or pain. The objection is its costliness, which puts it out of the reach of many patients. The extension in bed is very satisfactory in its results, and, with attention to ventilation and the amusement and entertainment of the little patient, the confinement need not be a for- midable objection. When the wire apparatus is used the following directions should be Fig. 441.—Plaster-of-Paris splint for nip disease. DISEASES OF SPECIAL JOIXTS. 439 carried out: Pad the instrument well, so that too great pressure at any one point may not occur. Place the patient in it so that the anus will project well over the crotch. It is well to insert a piece of protective under the sacrum and buttocks to prevent soiling. Fasten the well leg and the body to the instrument by rollers. Lay the extremity of the affected side in its splint, and screw the foot piece up until it touches the sole. Apply two strips of adhesive plaster in the same manner as heretofore given, attach these to the foot piece, and make the necessary extension by turning the screw in the proper direction (Fig. 443). After from four to six weeks, no matter whether the wire apparatus is used or extension in bed employed, the long splint of Shaffer or Thomas or the high shoe and crutches should be adjusted, and the case treated as given for the first stage. Within the last few years the operation of drill- ing into the neck and head of the femur, in certain cases where the initial lesion is an ostitis, has been advocated and performed in a number of instances by Mr. Macnamara.* The object of the operation is to give escape to, and secure drainage of, the products of the inflammatory process, at or near the epiphysis, and thus prevent disintegration of the bone and inva- sion of the joint. To be beneficial it must be done early in the disease. The operation is neither dangerous nor difficult. A longitudinal incision, from two to three inches in ex- tent, is made along the middle of the trochanter, down to the bone. The wound should be deep enough to per- mit the fingers to locate the neck of the femur, on its upper and latteral surfaces, so that the drill may be di- rected along its center. The chief danger to be avoided is entering the cavity of the joint by carrying the drill too far. The small Volkmann spoon is well adapted to this operation. Knee Joint.— Acute synovitis of the knee is frequently of traumatic origin, resulting from the excessive strain to which this joint is subjected, and also on account of its exposed position. It may occur in the history of gout, rheumatism, gonorrhoea, and other diseases. The chief symptoms are pain and swelling. Pain may be elicited by motion, or by direct pressure at any part of the joint, but it is, as a rule, Fig. 442.—(After Sayre.) Fig. 443.—(After Sayre.) "Gibncy on the Hip," Bermingham & Co., Xew York, 1SS4. 440 A TEXT-BOOK OX SURGERY. emphasized over the coronoid ligaments, along the articular margin of the tibia, on either side of the ligamentum patella. The treatment consists of rest by fixation. As a rule, the most agreeable position is that of slight flexion, with the limb elevated and the leg resting over a pillow. Fixation may be best secured by extension from adhesive strips, reaching from just below the knee to beyond the sole. The weight will vary from three to fifteen pounds, according to the age of the patient. It must not be forgotten that the ligaments of the knee joint are susceptible of overstretching from too great and prolonged exten- sion. Permanent relaxation or flail joint may result from overweight employed for too long a time. Cold, applied by means of the ice bag, is a most useful remedy during the acute stage of inflammation. AVhen pain is very severe, and when the capsule is greatly distended, aspi- ration may be indicated. This should be done with all antiseptic precau- tions, and with great care in preventing the entrance of air. The needle may be introduced on either side of the patella, at the point of greatest distention, or where fluctuation is most marked. The diagnosis may be made positive by a small exploring hypodermic needle and aspirator. Or, when the tumefaction is evident above the patella, the needle may be carried from above downward, behind this bone. After the excess of fluid is withdrawn a fair degree of compression should be exercised by enveloping the joint with borated cotton, held firmly down by a roller. Passive motion of the joint may be omitted for as long as six weeks, with or without a fixed dressing as may be required. When an acute synovitis of the knee becomes infected and pus is present, incision and evacuation of the pus, with irrigation, and drainage of the joint are indicated. As a rule, a single Jateral incision made near the posterior level of the joint, as the patient rests in the recumbent posture, will suffice. A sterile rubber drainage tube, about two inches long with a diameter of a quarter of an inch and stiff enough to resist being occluded by contraction of the incision, should be inserted. The joint may be irrigated as often as indicated, probably once a day, with a warm saturated solution of boric acid or a l-to-5,000 mercuric-chloride solution. When pus ceases to flow, the tube may be removed and a small wick of iodoformized gauze inserted for from two to six days. The danger of anchylosis after acute synovitis of the knee joint, last- ing not longer than from one to six weeks, is slight. It is always greater after suppurative synovo-arthritis, or osteo-arthritis. Destructive osteo-arthritis of the knee joint may commence as a syno- vitis, either traumatic or idiopathic, or it may begin as an ostitis (tuber- culous) in or near the epiphysis of the tibia or femur, the joint being secondarily involved. The latter is by far the more frequent source of chronic knee-joint disease. Symptoms.— Pain is not, as a rule, a prominent symptom of ostitis near the knee, and, when the joint has become involved and the carti- lages eroded, in many instances the degree of pain felt is far from being proportionate to the gravity and extent of the destructive process. In exceptional cases pain may be excessive, and may be felt in the ^ DfSEASES OF SPECIAL JOINTS. 441 Fig. 444.—Shaffer's extension knee splint. hip as well as the knee, or may be referred entirely to the acetabulum. As the disease progresses the swelling increases, and is due not only to effusion into the capsule, but also to thickening of the ligaments, and, to a certain ex- tent, to changes in the ends of one or both bones which enter into the formation of this articulation. Later the ligaments give way, and dislocation of the tibia backward, with slight outward rota- tion, occurs (subluxation). In the earlier stages of the ostitis certain constitutional symptoms appear, and remain throughout the course of the disease. Treatment.— When tubercular arthritis of the knee joint is recog- nized in the early stages, the indications are as complete rest as possible for the joint surfaces. This can be obtained in a moderate degree by simple fixation with plaster of Paris, but this does not give the degree of extension which is essential to success. If, however, no extension apparatus can be obtained, the leg should be incased in plaster of Paris, closely applied while extension is being made, from the level of the perinseum down to and including the foot. It is better to leave the knee a little short of full exten- sion—about five degrees of flexion. Shaffer's knee splint or brace (Fig. 444) is capable of meeting the various indications of extension, fixation, and rotation. A simple, less costly, and very efficient apparatus is Thomas's knee splint. It con- sists of a metal ring at the upper or perineal end, joining two parallel bars of iron, the ring having an angle of about forty-five degrees to the inner bar. These bars project below the foot, and the instrument terminates in a ring of iron (Fig, 445). The upper or thigh ring is well padded and fits closely upon its inner as- pect against the perineum and tuberosity of the ischium. It is fastened to the leg by leather straps and corset lacing or by an or- dinary roller bandage. A shoulder strap or suspender, intended to hold the instrument against the perimoum. passes over the shoulder of the side opposite to that of the disease. A high shoe is placed upon the sound foot, and the patient walks at once with and later without the aid of crutches, the 31 Fio. 445.—Thomas's knee and ankle brace. 442 A TEXT-BOOK OX SURGERY. weight of the body falling upon the perinaeum and end of the brace, allowing no concussion in the knee joint. This apparatus, chiefly com- mendable for simplicity and cheapness, does not give as satisfactory extension as the Shaffer splint. In cases of knee joint disease which have not received proper attention in the earlier stages there will very frequently be found a condition of subluxation of the tibia (Fig. 446). Extension in bed in two directions, as shown in the accompanying cut, will have to be made until the ex- tremity is straight enough to wear either the Shaffer or Thomas splint. Operative interference at the knee joint may, in rare instances, be de- manded. Such extreme measures, however, should not be adopted until a thorough trial has been made of a carefully applied and well-attended orthopaedic apparatus. Sometimes it requires three or four years to arrest the disease and effect a cure by these means, but it is often accom- plished with a very fair degree of motion left in the joint. Operative interference, when it becomes necessary, may consist of incision of the capsule and drainage when, as determined by high temperature and great pain and constitutional disturbance, pyogenic infection has taken place, or excision of the joint and removal of the diseased portion of the bone with Volkmann's spoon or gouge may be required. Gouging will suffice in some instances where the destruction of bone is limited, but generally, when forced to a radical step, it will be, found better to make a clean excision at the parts, according to the rule laid down for excision at the knee joint. Diseases of the Ankle Joint.—The pathology, causes, and symptoms of disease at the ankle do not differ from those at the articulation just considered. Synovitis is oftener traumatic than idiopathic. The exposed position of this articulation, which is called upon not only to sustain the entire body weight, but is also frequently subjected to great lateral strain, ren- ders it exceedingly liable to injury. The symptoms of acute traumatic synovitis at the ankle are usually not obscure. Swelling, pain, and heat, following prolonged or violent exertion, a twist, sprain, or other injury, bear strong evidence of inflam- mation within the joint. The injury most difficult to differentiate from intra-articular synovitis, and one which frequently complicates synovitis here, is inflammation of DISEASES OF SPECIAL JOINTS. 443 the sheaths of the tendons which play around the joint. The evidence of thecitis is pain in the track of the tendon, either elicited by direct pressure or by placing the foot slowly in a position which will cause the greatest tension of the tendons, and then requiring the patient to move the foot in various directions which are resisted by the operator. To test the peronei muscles, carry the foot well inward, hold it firmly, and ask the patient to turn the foot out. Thecitis in the track of these tendons will arrest the effort at abduction and outward rotation. The reverse of this manoeuvre will serve to demonstrate a similar condition in the flexors and internal rotators. Tuberculous synovitis of the ankle joint is less painful and comes on slowly. Synovitis from exposure to cold, gout, or rheumatism is fre- quently symmetrical, attacking either both ankles at the same time, or first one and then the other. Traumatic and tuberculous synovitis, on the other hand, are almost always unilateral. The prognosis of simple synovitis of the ankle, when proper, vigor- ous, and prompt treatment is instituted, is in general favorable. Treatment.—Acute synovitis, whether of traumatic or idiopathic ori- gin, demands rest, with an elevated position of the foot. Simple cases will require no more than this, with hot or cold applications, or lead-and- opium wash, applied by soft cloths laid loosely around the ankle, or blotting paper kept wet with vinegar. The employment of compression will depend upon the sense of relief it may give the patient. Absorbent cotton or soft sponges may be used, applied carefully with a flannel or muslin roller. The method of immediate strapping-with adhesive plaster and permitting the patient to walk about, has been employed of late with success, and is recommended by so high an authority as Gibney. It consists in enveloping the foot from near the torso-metatarsal junction, the ankle, and lower fourth of the leg in tight-fitting strips of adhesive plaster, applied in figure-of-8 fashion and partially overlapping each other. Aspiration of the joint to relieve extreme tension from effusion ap- plies here as in other articulations. The needle should be entered in front, between the anterior margin of the external malleolus and the con- tiguous surface of the tibia, away from the vessels and nerves which are opposite the middle of the joint. In subacute or chronic synovitis, or in gonorrhoeal arthritis, compres- sion is indicated, and will often cause absorption of the excessive effusion in the joint. It is especially demanded after aspiration, to give support to the parts, and to prevent a further effusion. Extension is indicated when its employment gives relief from pain, which rest and fixation without extension do not afford. Fixation with liquid glass or plaster of Paris secures rest to the joint in most cases, and permits of locomotion on crutches. Arthritis of the ankle is more often due to tuberculous ostitis of the tibia or the astragalus. The symptoms are those of ostitis, elsewhere given, and the diagnosis and prognosis do not differ materially from similar lesions in other articulations. 444 A TEXT-BOOK OX SURGERY. When osteo-arthritis with pyogenic infection is evident, operative interference is indicated, for the reasons that (1) early incision, by giving discharge to the contents of the capsule, retards or arrests the destructive process; (2) the common experience of surgeons is that the invasion of this joint is practically without danger to the patient's life. Complete exsection of the articular ends of the tibia and fibula, and of the upper half of the astragalus, is rarely called for. An incision upon the side which, from the symptoms present, will give the best access to the diseased bone, and the free use of Volkmann's spoon in re- moving the dead tissues, will'usually suffice. The foot should be kept at rest, and the patient directed to go on crutches until several months after the discharge has ceased and the sinus closed. The operation of gouging is more successful in osteo-arthritis at the ankle than in any other articulation. Complete exsection is only admissible when the de- struction is very extensive. Synovitis and osteo-arthritis of the articulations of the tarsus and metatarsus are treated upon the same general principles as just given for the ankle. The Shoulder Joint— Synovitis of the shoulder is usually general; in rare instances it may be local. It may affect the general synovial surface of the capsule, be reflected into the synovial sheath of the long head of the biceps, the bursa under the tendon of the subscapularis, or that beneath the infra-spiuatus, or in rare instances, especially in the earlier stages, one or more of these bursas may be inflamed, while the joint is not invaded. The bursa between the deltoid and the capsule may also be the seat of bursitis, although this sac does not communicate with the joint. The diagnosis of inflammation in one or more of the bursse about the shoulder may be determined as follows : 1. Direct digi- tal pressure upon any single bursa will indicate the sensibility of the part. 2. Extend the forearm fully, grasp the hand and elbow of the patient, and, while the head of the humerus is pulled away from the glenoid cavity, direct the patient to make strong flexion, wThich the operator firmly resists. If inflammation of the sheath of the long head of the biceps exists, pain will be experienced in the anterior and outer portion of the joint as this tendon is made tense. 3. When the bursa under the infra-spinatus is inflamed, if the arm is rotated inward, and held in this position, pain will be felt when the tendon of this muscle is made to press strongly on the bursa, in any effort at outward ro- tation. An opposite manoeuvre will serve as a test for the bursa beneath the tendon of the subscapularis. In general synovitis each of these move- ments wall be productive of pain, and the differentiation is chiefly between neuralgia and muscular rheumatism. In neuralgia pain is rarely con- stant, the exacerbations appearing at intervals of comparative regularity, and extending in the recognized course of the nerves. Motion is not painful in the degree which characterizes either synovitis or rheumatism, and, if persisted in, the sense of pain may entirely disappear. Swelling is not a featuie of a neurosis. In rheumatism of the muscles about the DISEASES OF SPECIAL JOINTS. 445 joint the pain is superficial, and may be elicited by digital pressure upon the substance of the muscles. The treatment of synovitis is the same at all joints. Artificial exten- sion is indicated when the weight of the extremity is not sufficient. Aspiration is a safe and efficient means of relief from pain, and is indicated when there is marked capsular tension. The needle should be entered through the center of the joint in front. Fixation of the joint by a shoulder cap of felt, cardboard, or leather, should be secured im- mediately after aspiration. AVhen ready for application, lay upon the surface of the board which is to be nearest the skin a layer of absorbent cotton, which shall be wide enough to extend entirely around the arm and over the shoulder, place it in position, and secure snugly by a figure- of-8 bandage around the arm and shoulder. Acute suppurative synovitis demands an immediate evacuation of the purulent contents of the capsule by incision and drainage. The line of in- cision is from the anterior internal tip of the acromion, parallel with the fibers of the deltoid along the anterior margin of the great tuberosity. The capsule is opened external to the long head of the biceps, and, while traction is firmly made upon the edges, the cavity may be thoroughly explored and cleansed. It is of vital importance that in this, as in every cavity which is the seat of purulent inflammation, drainage should, when possible, be established from that portion of the wound which is most dependent. As the patient rests in bed the posterior and outer part of the capsule is lowest. A dull-pointed dressing forceps should be car- ried into the capsule through the anterior incision and bored through the inferior posterior wall and all the tissues to the skin, and when this is pushed ahead of the instrument an incision should be made to allow the escape of the instrument. The wound is stretched by opening the jaws of the instrument, and a rubber tube pulled into place as the in- strument is withdrawn. In tuberculous osteo-arthritis of the shoulder- joint exsection may be called for, after all conservative measures have failed. The Elbow Joint — Synovitis of this articulation need not be sepa- rately considered. The same general principles of diagnosis and treat- ment apply here as in other joints. Tuberculous osteo-arthritis demands gouging or exsection when careful corrective mechanical treatment has failed. The operation will be given hereafter. The Wrist Joint—Inflammation of the synovial membranes of the wrist or in the immediate neighborhood of this joint is of frequent occur- rence. It is often traumatic in origin, and not infrequently tuberculous It may attack the synovial sac between the ulna and radius ; that between the radius and the fibro-cartilage and the first carpal row ; the general synovial sac between the first and second rows and the metacarpus; or that between the base of the first metacarpal bone and die trapezius (Fig. 447). Inflammation of the sheaths of the tendons on the dorsum of the carpus or on the palmar surface may also compli- cate a carpal synovitis, or exist alone. The contiguity of these various structures renders a positive diagnosis of great difficulty. If, when the 446 A TEXT-BOOK ON SURGERY. bones of the forearm are grasped near their center and pressed together, sharp pain is elicited at the wrist, synovitis of the radio-carpal sac is in- dicated. When the swelling is well defined at the edge of the articular end of the radius, extends across the wrist, and is limited to the situation of the first row of the carpus, the radio-carpal sac is probably alone in- volved. When the several capsules are involved the swelling is general. In thecitis the pain is superficial, and usually extends for some distance along the tendons above and below the joint. Contraction of the mus- cles, the tendons of which are in- volved, will point to the location of the inflammation. Differentiation of synovitis from Colles's fracture will depend upon a study of the symp- toms of this lesion already given. Tuberculous osteo-arthritis in its earlier stages is comparatively a painless process, and even after the cap- sule is invaded is rarely as painful as an acute synovitis. Treatment—Synovitis of the wrist does not demand separate con- sideration. Destructive osteo-arthritis requires gouging rather than ex- section. Synovitis of the metacarpal or interphalangeal joints should be treated on general principles of rest and fixation. EXSECTIONS OF THE JOINTS The Hip—Sayre's Operation.—Place the patient on the sound side ; carry the point of a strong scalpel perpendicularly down to the bone exactly halfway between the anterior-superior spine of the ilium and the tip of the trochanter major; * cut along the neck of the femur, keeping the knife firmly in contact with the bone, carrying the in- cision midway between the center and posterior aspect of the trochan- ter, and then curving it slightly forward as it passes about an inch below the tuberosity (Fig. 448). Through this incision, which divides the capsule and thickened periosteum, insert the elevator and lift the periosteal investment from the diseased bone. When the trochanters are involved, the tendons, inserted into these eminences and into the digital fossa just above the great tuberosity, usually require to be detached with the knife, the point of which, in order to avoid wounding any ves- sels, should be kept in close contact with the bone. As soon as the peri- osteum is freely raised, the bone should be divided, with the chain saw or a dull-pointed keyhole or metacarpal saw, and the upper fragment lifted out with the elevator. The sawed surface should be carefully in- spected in order to see if the disease extends farther down the bone, ne- * The extremity should be held parallel with the axis of the spine, with the foot normally ro- tated outward. EXSECTIONS OF THE JOINTS. 447 cessitating a second division. The acetabulum should next be examined, thoroughly scraped with a Volkmann's spoon, and all dead tissue re- moved. Haemorrhage is usually insignificant, and, if occurring, should be arrested as the operation progresses. The wound should be thor- oughly irrigated with l-to-3,000 sublimate, all shreds of tissue and par- ticles of bone removed, and the entire cavity, after being thoroughly dried, filled with sterile gauze, well packed in, and held in place by a thigh and pelvic spica. The patient should now be put to bed with an extension apparatus applied as given for the early treatment of hip dis- ease. Sand bags may be laid along the leg to hold the foot in the proper degree of outward rotation, or a splint may be used. The long splint from the axilla to the heel is often required to prevent a child from sitting upright in bed. The first dressing is changed usually about one week after the operation, and once or twice a week thereafter. After four or five weeks the case should be treated as in the first stage. Prof. Sayre prefers, and frequently employs, the wire breeches for the Fig. 448. psoas and iliacus. (After Braune.) first few weeks after the operation. This apparatus can not always be obtained, and the extension in bed has proved perfectly satisfactory. In a certain proportion of cases the disease is not arrested by the first operation, and a second is required. The outline of the parts involved in this operation is well shown in Fig. 449. 448 A TEXT-BOOK ON SURGERY. Excision of the Knee Joint—Operation.—Under rigid asepsis elevate the foot in order to empty the extremity of blood, and after a minute or two apply the rubber tourniquet above the middle of the thigh. With the leg straightened out, or slightly flexed (Fig. 450), an incision is made across the center of the patella and down on each side until the level of the posterior surface of the. tibia is reached. These points must be low in order to secure drainage. The skin flaps or cuffs are now dissected and rolled up until the upper one is turned back about three inches, the lower two inches. As the flaps are held well away by assistants, the operator cuts down to the femur through the tissues, parallel with the at- tached edge of the reflected upper flap, lifting everything from the anterior aspect of the femur and its condyles to- gether with the pa- tella, the attached fringes, ligamentum patellae, and coronary ligaments—-thus clearing in one mass all the tissues which envelop the anterior three fourths of the joint. By sharply bending the knee the cru- cial ligaments are exposed and divided, the lateral ligaments cut awray, and the disarticulation effected. In stripping the attachments of the ligamentum posticum Winslowii from the tibia and femur, the operator should closely hug the bone and thus avoid wounding the vessels. This dissection posteriorly should extend about three fourths of an inch below the level of the tibia and one and a half inch above the lowest surface of the condyles. De- termining now the amount of bone neces- sary to be removed, a cloth retractor is ap- plied so as to protect the soft parts from bone detritus or injury, and a slice thick enough to freshen the head of the tibia is sawed away, as nearly as possible parallel with the normal plane of the articular sur- faces, or at a right angle to the perpen- Fio. 450.—Incision and exsection of the knee. Fig. 451.—Showing the proper line for sawinsr between the epiphyses of the tibia and lemur and the joint cavity. EXSECTIOXS OF THE JOINTS. 441) dicular axis of this bone. Should the section expose a focus of disease which dips down into the bone, this should be cleared out with a scoop Mr.,- w ' jmM% 9 / Hi J * j'jftUJ'1 rW ■ M lllllll vlililll to. 452.—Longitudinal section through the knee joint. 1, Peroneal nerve. 2, Popliteal vessels. (Afte Braune.) 450 A TEXT-BOOK ON SURGERY or Volkmann's spoon, and finally mopped with a strong bichloride solu- tion (1 to 500). It is important, and especially in children and young adults, that the section should not involve the epiphyseal lines. (Fig. 451.) The section through the end of the femur should now be made (Fig. 452). It follows that if the limb is to be straight in the position of anchylosis, the sawed surfaces of the two bones must be parallel. I have found it of great value to employ this method. By pulling on the foot the limb is fully straightened, and the articular surface of the femur separated from the sawed surface of the tibia. If the operator will now start the saw into the femur, sighting by the flat face of the tibia, the instrument will cut directly parallel with this. If by error the section of the tibia has been slight- ly oblique, that of the femur will have a like ob- liquity, and therefore the bones will fit snugly with the extremity straight. The next step is to dissect away with forceps and curved blunt scissors all the diseased capsule. This should be done thoroughly, and even the bursse that communicate with the joint should be cleaned out. If care is not taken, a portion of the sac which extends up beneath the quadriceps tendon will not be removed. All bleeding points should be tied with catgut and haemorrhage stopped. The bones are now brought in exact apposition, and while so held the steel drills (Fig. 453) are introduced. I usually carry two of these in from below upward, passing them through the skin about two inches below the sawn surface of the tibia and directing them obliquely through the tibia into the femur. When the end of the drill has reached the compact substance of the femur, it is stopped, the handle unshipped, and the drill left in position. Three are used, one on either side from below, and one direct- ly down the median line from above, entering the femur and passing into the tibia. As the leg is now held steady the edges of the wound in the skin are sewed together with catgut, and two short twisted catgut drains inserted at the inferior angles. The united lips of the wound are dusted with iodoform, a narrow strip of aseptic protective, split so as to fit over and not obstruct drainage, lies over the sutures, and over this a light layer of iodoform gauze and then successive layers of sterile gauze, until the whole limb from the ankle to the hip is invested to the thick- ness of about two inches. One thickness of absorbent cotton is now applied, and on the top of this successive layers of veneering or thin Fig. 453.—Wyeth's drills, with adjustable handle, for fixation of the bones in knee-joint exsection. EXSECTIOXS OF THE JOINTS. 451 wooden splints under firm compression of a roller. Over all, a layer of starched crinoline bandage is placed. This dressing is allowed to re- main on for six wTeeks, and when changed the drills are pulled out. Should it for any reason become necessary to remove the dressing about the fourth week, the pins may then be extracted. The roller should be firmly drawn, so that a considerable pressure may be exercised upon the part, to prevent oozing. The elasticity of the cotton distributes the pressure equally, and controls haemorrhage with- out causing discomfort. It is the practice of some surgeons not to apply Fig. 454. Fig. 455. a single ligature in this operation, but to rely wholly upon compression for the control of bleeding. It is better to search for and tie the larger vessels which may have been divided. As in all the antiseptic operations, the indications for a change of dressing are haemorrhage, high tempera- tures, and decomposition of the discharge beyond the zone of asepsis. When the wound is dressed, careful antisepsis should be practiced. Re- covery, with anchylosis in the straight position, is the result desired. This operation has met with remarkable success within late years. The drills are preferable to nails in fixation. They are carried into position by steady pressure on the -handle, with a slight half-rotary movement. When they can not be obtained, the parts may be held in apposition by wiring the bones together. The Ankle Joint.—For the complete exsection of the articular ends of the tibia and fibula and the astragalus, proceed as follows : Commence an incision on the internal sur- face of the tibia, about two inches above the tip of the inner malle- olus, and carry it directly down to this point, and thence forward, from One inch tO Fig. 456.—Volkmann's anterior splint. \ one inch and a half along the tarsus, in the direction of the metatarsal bone of the great toe (Fig. 454). A similar L-shaped incision is made upon the 452 A TEXT-BOOK ON SURGERY. fibular side of the joint (Fig. 455). These incisions divide all the tissues down to the bone. With the Sayre elevator lift the periosteum, with its attachments to the superjacent soft tissues undisturbed, from the diseased portions of bone. Expose the outer malleolus and fibula as high as it is deemed necessary to remove this bone, and divide it with the exsector (or chisel). As soon as the piece is removed the joint is thoroughly ex- posed to view. Now, further lift the periosteum of the tibia and tarsus, and, by forcibly bending the foot inward, dislocate the tibia and inner malleolus outward, through the wound on the fibular side. The diseased surface may be sawn off with an ordinary saw, or with the exsector. The section through the astragalus may be made with a gouge, chisel, or a EXSEOTIOXS OF THE JOINTS. 453 keyhole saw. Usually no vessels of importance are wounded in this dis- section, since, by keeping beneath the periosteum, they are lifted with the tissues. The periosteum should not be elevated over the healthy bone. The sawed surfaces are now brought in apposition, so that the foot will be at an angle of 90° with the axis of the leg. Fixation may be secured by transfixion with small steel drills, carried obliquely from above downward, entering on the internal aspect of the tibia and the external surface of the fibula, and passing into the astragalus (in the same manner as at the knee). The wound should be closed with catgut, leaving a small catgut drain to pass out on each side. An aseptic dress- ing should be applied, and over this plaster of Paris. If the drills are not employed, the parts should be held in apposition while a plaster-of-Paris dressing is applied. Or a Volkmann's splint (Fig. 450) may be applied to the anterior extremity of the foot and leg, and the parts fixed with plaster of Paris, or simple roller. This splint may be made of wood, or sheet or hoop iron, properly padded with sterile gauze. If the bones are not extensively involved, a single L-shaped incision will suffice to expose the joint, and the dead bone can be removed with the gouge or Volkmann's spoon and a counter-opening made for drain- age. This operation is always to be preferred at the ankle. FlG- 458--T1\e. fo.ot aft«[ exsection of the astraiagus 1 # and articular ends ot tibia and fibula. When, in an exsection of the ankle, the astragalus is so much involved that its removal is necessary, the upper surface of the os calcis should be smoothed off with the chisel or keyhole saw, and brought up in apposition with the plane sur- face of the bones of the leg. Fig. 458 represents a foot after recovery upon which I did this operation in 1885. The Shoulder Joint.—Exsection of the head of the humerus is read- ily effected by a single straight incision, about five inches in length, made from the acromion process directly down the arm, parallel with and splitting the fibers of the deltoid (Fig. 459). The periosteum should be carefully lifted as far as the ostitis extends, and the soft tissues abont the capsule raised with the elevator. The edges of the wound should be held wide apart by blunt retractors, and the tendons of insertion of the supra- and infra-spinatus, teres minor, and subscapularis divided close to the tuberosities with the curved blunt scissors. The sheath for the long head of the biceps should be laid open, and this tendon held aside. The bone should now be divided at the limit of the disease. When the sec- tion is completed a strong hook should be fastened into the end of the upper fragment, in order to lift it and facilitate the separation of the soft tissues on the inner and under surface from the bone and capsule. The capsular ligament should be trimmed from the margins of the glenoid cavity and removed with the head of the humerus. All diseased tissues 454 A TEXT-BOOK ON SURGERY. should be dissected out with the curved scissors, and, if the head of the scapula is involved, all disorganized bone should be scraped away with the spoon or rongeur. The capsule should now be divided and the head of the bone dislocated upward through the ^/ wound. The division is then made with a narrow saw, taking the precaution to protect the soft parts from injury. Upon examining the wound left after this operation, it will be seen that the deepest portion is behind and to the outer side of the end of the shaft. Into this depression carry a closed dressing forceps, and bore through to the skin, point- ing the instrument to the inferior and outer aspect of the arm. Divide the skin over the point of the forceps, dilate the opening by separation of the handles, and draw a catgut twist drainage from below upward through the hole. A second shorter twist should make its exit through the anterior and lower angle of the incision, and the wound closed throughout with catgut. The forearm should be held in a sling or fastened across the ab- domen. The application of Esmarch's band- age, and the rubber tubing in the axilla and over the clavicle and scapula, renders this operation practically bloodless. The rate of mortality is exceedingly low. With careful antisepsis it is practically without danger to life. A second operation for the removal of dead bone is occasionally required. The Elbow Joint — Flex the forearm on the arm and make a straight incision, com- mencing in the middle of the posterior aspect of the humer- us, about one inch above the condyles, and extending over the center of the olecranon process, along the ulnar, for from two to three inches (Fig. 461). The tissues should be carefully lifted from the bone and capsule, and held to eitherside by blunt retract- ors. When the trough be- tween the olecranon and internal condyle is approached, extra care should be taken not to wound the ulnar nerve, which passes in this groove. It may be avoided by keeping close to the bones with the knife or elevator. The articular end of the humerus should be exposed, as high as the Fig. 459. Fig. 460.—Longitudinal section through the shoulder joint, showing the relations of the bones, ligaments, and mus- cles immediately about the articulation. 1, The capsu- lar ligament. 2, The acromion. 3, Epiphysis. (After Braune.; EXSECTIOXS OF THE JOINTS. 455 Fig. 461. point of section, by peeling off the soft tissues with the periosteum, after which a retractor is applied and the bone divided at an angle of 90° to the shaft of the humerus. The ends of the ulna and radius may now be readily displaced back- ward, exposed to the point of section, and divided on a line parallel with that through the humerus. As in all the joint exsections, a careful dissection of all the diseased capsule and soft parts must be made. The wound is drained from the most depend- ent portion by means of catgut, and closed with sutures of the same ma- terial. An anterior splint, previously fitted to the arm and forearm, and fashioned so as to hold the forearm halfway between flexion at a right angle and complete extension, is wrapped with gauze and laid on the an- terior aspect of the extremity, and fixed by a roller to the arm and fore- arm, to within a few inches of the incision. A sublimate dressing is next applied to the wound, with cotton and protective, and a bandage over this to effect compression and to hold it in position. When a change of dressing is required, this last bandage only is removed. After the sixth week passive motion should be commenced, and should this not produce Fig. 41)2— Longitudinal section through the elbow joint. 1, Radial nerve. Superficially on the Itexor sur- face the median basilic vein is seen cut across. (After Braune.) a too painful inflammatory reaction it should be repeated once or twice a week for two or three months. Anaesthesia is essential. A very consid- erable degree of mobility may be gained by this practice, although the rule in this exsection is fibrous anchylosis, with limited motion of the joint and function of the extremity. Fxsection of the elbow is not a dangerous procedure, and, although not usually attended with the success which follows some other opera- 456 A TEXT-BOOK OX SURGERY. tions (as those upon the shoulder and ankle), it should be preferred to amputation. The anatomical relations at this joint are shown in Fig. 462. The Wrist Joint—The exsection of this joint is attended with con- siderable difficulty, not only in the performance of the operation, but in the after-treatment. Moreover, it is more apt to be followed by failure resulting in amputation. Of the two procedures—viz., the double lateral and parallel incisions (Fig. 463) and the single longitudinal dorsal incision (Fig. 464)—the latter is preferable when the destructive process is not so extensive, and when the spoon or gouge may be used, while the former will give the freest access to the bones when the saw or exsector is to be employed in the removal of a large portion of the bones which enter into the composition of this joint. In the operation with a single dorsal incision the wrist should be made prominent, by flexing the hand on the forearm, and the integu- ment divided along the tendon of the extensor communis digitorum, which goes to the index finger, the incision extending from the middle of the metacarpus to one inch and a half above the tip of the styloid pro- cesses. The tendon may be retracted to the side most convenient. The posterior segment of the annular ligament is divided, and the tissues lifted from the bones with the elevator. The end of the radius should EXSECTIONS OF THE JOINTS. 457 be removed with the exsector or gouge, when the carpus may be dis- placed backward through the incision, and removed wholly or in pieces. When the section is completed, the surfaces should be brought in appo- sition and fixed upon a well-adjusted anterior splint. Or an interrupted dressing may be applied by incasing the forearm in plaster of Paris to within an inch of the incision, and the fingers and hand in the same ma- terial, back as far as the anterior limit of the wound. A piece of hoop iron (or several pieces of telegraph wire twisted into a single piece) is shaped as shown in Fig. 465, incorporated into the plaster upon the arm, and made to loop over the wrist to the tips of the fingers, where it is turned back underneath the hand, and is fastened to the plaster here by an additional gypsum bandage (Fig. 466). In the other operation one incision is made along the outer and dorsal aspect of the metacarpal bone of the little finger, over the styloid of the ulna, and one inch along this bone. The radial in- cision should commence on the dorsum of the metacarpal bone of the index finger, pass back- ward and slightly toward the radial Surface Of the Fig. 465.—Esmarch's interrupted splint for exsection of the wrist. forearm to a point half an inch above the tip of the styloid process, and thence directly upward along the dorsal aspect of the radius. In extensive operations it may become necessary to divide the tendon of the extensor ossis metacarpi pollicis, which is crossed by the incision. When done, the ends should be reunited by silk sutures when the operation is finished. The tissues are lifted from the bones and capsule as before, and the sections made with the exsector or keyhole saw. Metacarpo-Phalangeal and Inter-Phalangeal Joints.—Excision of the metacarpo-phalangeal, on the inter-phalangeal articulations, may be done when the destruction of bone is limited. The same general rule, viz., that an excision is preferable to amputation, is applicable both to the hand and foot. At the terminal joints, however, the small size of the last phalanges will rarely permit of any operation except amputation. Tendons.—Of the diseases which affect the tendons or their sheaths and which require surgical interference, tuberculosis is by far the most 32 458 A TEXT-BOOK ON SURGERY. important. It may affect any tendon of the body, but is chiefly met with in the sheaths on the dorsum of the wrist. The symptoms are usu- ally those of swelling, which gives a puffy appearance to the entire back of the hand. Pain, at times severe, is not, howrever, a constant symptom. The only operative procedure which promises success, is that which exposes the ten- dons involved by an incision, usually longitudinal, and a thorough dissection of the sheath from the tendon. The use of an Esmarch bandage facilitates the operation. Most careful asepsis should be practiced, the wound closed, and the patient should be directed to move the ringers while the process of repair is going on, in order to prevent adhesions of the tendon to the integument or bone. In rupture or division of tendons it is essential to unite these at once by opera- tion. Two sutures of fine silk are passed entirely through the substance of the tendon, about one eighth of an inch from the end, then tied and left in position. Rupture of the tendon of the quadri- ceps extensor femoris is the most impor- tant injury connected with tendons. The rational treatment, and the only one that appears to offer any hope of success with restored function, is to ex- pose the seat of rupture under the most careful asepsis and reunite the ends by direct suture. Silkworm gut is the best material to employ. When a sufficient fragment of tendon has been left at- tached to the patella, the sutures should be passed through this. When rupture has taken place close to the bone, two holes should be drilled in the upper segment of the bone, as practiced by Buchanan, of Pittsburg, and the tendon of the muscle firmly united to this by a double set of silkworm-gut sutures. The sooner the operation is done after the injury, the better. The limb should be immobilized in full exten- sion after the operation. When the ligamentum patellar is torn, suture should be attempted, as for the quadriceps tendon. The prognosis is even more unfavorable. forearm, wrist, and hand. (After Braune.) EXSECTIOXS OF THE JOINTS. 459 In certain forms of paralysis, especially of the muscles which move the fingers, hands, and feet, it may at times be required to transpose a portion of the tendon of a non-paralyzed muscle and unite it to the tendon of one which has lost its function, the method of Dr. B. F. Parrish ("New York Medical Journal,'' October 8, 1892, (of Kentucky. The tendon, or one half of the tendon, of a live muscle is in this opera- tion sutured to the divided tendon of a dead or paralyzed muscle. Whether the union shall be end to end or lateral (overlapping) must be determined by the conditions to be corrected. Elongation of the tendons of contracted or shortened muscles may also be effected by partial division on opposing surfaces at a given dis- tance, splitting the intervening portion and uniting the half ends by suture. CHAPTER XVIII. REGIONAL SURGERY.—THE HEAD. Tumors of the Scalp.—Tumors of the scalp are congenited and ac- quired. Congenital cysts are deeply situated, being beneath the skin, and not infrequently below the fascia and muscles. Their contents are chiefly white or yellow fluid, and at times hairs (dermoids). Each tumor may consist of a single cyst, or there may be several grouped together (multi- locular), the mass rarely attaining a size greater than an inch in diameter. If left alone they may ulcerate from pressure or injury, or, in rare instances, may cause atrophy and perforation of the calvaria and dura mater. They should be removed in early childhood. The operation con- sists in dissecting out the sac, with its contents. As a rule, small wounds of the scalp, situated where a scar will not be apparent, do not need to be stitched. The edges should be approximated and held thus by a dressing of sublimate gauze and a bandage. Acquired cysts, commonly called "wrens," are of two varieties, one due to retention of sebum in a sebaceous follicle, the duct of which has been obstructed; the other caused by extravasation of blood, where the clot has been absorbed, leaving the serum more or less stained by the decomposition of haematin. They are round, smooth tumors, are super- ficial, and found most frequently upon the upper and posterior portion of the scalp. They are mostly multiple, are unilocular, and contain a granular, cheesy substance. The treatment is removal with the knife. The hair should be shaved from the tumor, and for a slight distance beyond its base. Complete anaesthesia can be obtained by injecting ttl iv to vj of a 4-percent solution of cocaine in the line of incision, and around the base of the tumor. With a sharp bistoury transfix the mass through its base, and lay it open. The integument over the center of the tumor will be found exceedingly thin (not thicker than ordinary writing paper), and may be easily separated from the thickened sac, which should now be seized with a strong pair of forceps and torn out of its bed. If any strong adhesions are found they should be divided with the blunt scissors. Sebaceous cysts occasionally become inflamed and infected, the cap- sule breaks down, the contents escape, and a mass of granulation tissue replaces the original tumor. The new-formed capillaries in this tissue frequently give way, causing repeated haemorrhage. They should be scraped out with a sharp spoon, and the sac removed by dissection. 460 REGIONAL SURGERY.—THE HEAD. 461 Horns, or dense epithelial outgrowths, are occasionally seen upon the scalp and face. Some of these excrescences attain large size. They should be removed by an elliptical incision around the point of attach- ment. The incision should remove the entire thickness of the integu- ment. Lipomata, or fatty tumors, are of infrequent occurrence beneath the scalp, and, on account of the dense integument, they grow very slowly and rarely attain large size. The diagnosis between sebaceous and fatty tumors of this region is not always easy. The treatment is removal by dissection, which is easily effected by lifting the tumor from its cap- sule with the finger or the blunt scissors. The capsule need not be re- moved. Ncevi, port-toine marks, and other vascular tumors, are quite com- mon upon the scalp. They have been treated of in a previous chapter. Papillomata, or warts, occasionally covering a large territory, are found in this region. In one case which came under my care a flat papil- loma, two inches in width, extended from the right temple to the middle line of the scalp. They should be clipped closely with the curved scis- sors, their bases burned wdth the actual cautery or nitric acid, and the operation repeated until a cure is effected. Ulcers from syphilitic gumma of the skull are quite frequently met with in the scalp. Tuberculosis (lupus) of the skin is rare in this region. Elephantiasis, or general thickening of the scalp from connective- tissue new formation, is, fortunately, rarely met with. Ligation of the vessels feeding the diseased area will afford temporary relief, and is a justifiable procedure. Hamatoma has been considered in the chapter on Wounds of the Scalp. Abscess of the scalp requires free incision, irrigation, and drainage. Any doubts as to the character of the swelling may be dissipated by ex- ploration with the hypodermic syringe and a good sized needle. Pneumatocele, or uair tumor," is occasionally met with beneath the scalp. It results from disease or fracture of some of the bones, permit- ting communication with the cavities, as the frontal sinus, or the Eusta- chian tube, etc., and the escape of air beneath the skin. Evacuation of the contents by pressure, with or without puncture, and a compress to prevent recurrence, will produce inflammatory adhesions and effect a cure. Ostitis, or periostitis, is not uncommon in the calvaria. The causes are the same as for ostitis elsewhere. Great care should be observed in the treatment, on account of the proximity of the meninges and brain. Ostitis with exfoliation demands early recognition and immediate opera- tive interference. The rubber tourniquet around the skull may be em- ployed to control bleeding. A free horseshoe or crucial incision should be made, and all the diseased bone removed with the sharp spoon. When the exfoliation is confined to the outer table of the skull the prognosis is favorable. The wound should be kept open, well drained, 462 A TEXT-BOOK ON SURGERY. and allowed to heal by granulation. If pus is found beneath the inner table, enough of the bone should be cut away with the rongeur to per- mit the free escape of all the products of inflammation. The patient should be required to rest in the position which secures most perfect drainage. A loose aseptic dressing should be applied. Abscess of the Frontal Sinuses.—Chronic inflammation of these sinuses demands, as a rule, energetic and thorough operative measures. The accumulation of pus may interfere with the integrity of the eye, often breaking out through the orbit, Headache, great discomfort, and frequent and dangerously high temperatures indicate the sepsis which is occurring. The operation I prefer is the following : Shave the eyebrow of the affected side and make an incision through the middle line of the brow so that w hen the hairs grow out the scar will be concealed. The inci- sion should be free, extending across the root of the nose, if necessary. When the bone is exposed, the sinus is entered by chiseling with a small curved-edged instrument through the anterior lamella of the frontal bone at the inner angle of the supra-orbital arch. A light mallet should be employed and the chisel should be held with the point directed to the nose, so that a slip would not enter either the eye or brain. Continuing into the sinus, an opening one fourth of an inch in diameter should be made and the walls of the cavity thoroughly scraped with the sharp spoon. A strong dressing forceps should now be carried into this opening, against the upper turbinated bones, and made, by boring, to crush through into the nasal cavity. A probe is next carried through this hole and brought out at the nostril of the affected side, and by this a strong silk thread is carried through. A good-sized piece of gauze—so twisted that while the end is as small as a cord the middle portion is as large as the finger—is tied to the string and drawn through the sinus into the nasal cavity and out at the nostril. The entire twist of gauze is now pulled through. This breaks awTay the turbinated bones, does not cause annoying haemorrhage, and leaves perfectly free drainage into the nose and mouth. In several cases which have come under my care this method has been attended with gratifying success. The edges of the wound should be united with fine silk sutures. In cases wrhere the disease is unusually extensive and the discharge pro- fuse, it will be advisable to carry a small soft-rubber drainage tube in through the wound dowm into the nose, leaving one end projecting through the nostril and the other at the inner angle of the incision above. For one or two weeks after the operation irrigation through the tube with warm boric-acid solution (gr. v- § j) should be practiced once a day. When the tube is removed it should be drawn out through the nose. If both sinuses are involved, an incision on one side may succeed in effecting a cure by breaking down the shell of bone which intervenes, and curetting the opposite sinus with the sharp spoon. The effort to cure abscess of the frontal sinus by incision and drain- age at the angle of the orbit is not only apt to fail, but it endangers the REGIONAL SURGERY.—THE HEAD. 463 integrity of the eye from the presence of the drainage tube and the accu- mulation of inflammatory products. Osteoma, or exostosis, occurs quite frequently upon the bones of the skull. When not due to syphilis it should be removed early, by the gouge or chisel, as there is always danger of pressure upon important organs if allowed to remain. Syphilitic hyperostosis requires the specific treatment given for this dyscrasia. Encephalocele, or hernia cerebri, is a protrusion of the brain substance through an opening in the calvaria. This condition usually occurs in children suffering from hydrocephalus, the protrusion taking place through the abnormally enlarged fontanelles. The dura mater sur- rounds and is carried in front of the mass, lying in contact with the peri- cranium. When the meninges alone protrude, the tumor is known as a meningocele. While this variety of tumor may occur at any point in the line of sutures, a favorite seat is in the median line of the skull, below the occipital protuberance. It may be covered with integu- ment, or, as with certain forms of spina bifida, the meninges form the outer covering. Meningocele is often incurable. Careful compression may limit the further development of the tumor, and in rare instances the opening in the skull closes spontaneously and a cure results. When the mass is covered with integument and the pedicle small, a rubber ligature gradu- ally tightened is advisable. Hernia cerebri may occur after perforation of the skull from any cause, as fracture or necrosis. More frequently the mass which pro- trudes is made up of a granulation tissue containing no elements from the brain substance, wThile at times these masses are composed of both brain and granulation tissue (Fig. 468). The character of the tumor will be recognized from its rapid development after perforation of the calvaria. Treatment—When the mass is small, and is just beginning to project, compres- sion should be employed to prevent a fur- ther protrusion. It is not safe to attempt a reduction of the tumor. The hair should be shaved from the scalp near the opening and disinfection accomplished by sublimate irrigation, and a compress of sterile gauze and absorbent cotton applied. If the tumor does not rapidly slough away, it should be removed at the level of the scalp with the elastic ligature or the actual cautery. Sarcoma of the dura mater is a grave condition, fortunately of infrequent occur- rence. In the process of development the tumor is apt to cause absorp- tion of the calvaria, and finally perforation. This usually occurs long after symptoms of pressure from within have been developed. If the Fig. 468 Mass composed of brain substance and sjrauukition tissue, removed by Dr. E. J. Beall from a boy whose skull had been frac- tured. Exact size. 464 A TEXT-BOOK ON SURGERY. patient survive the compression of the brain, the tumor ultimately under- goes necrosis and breaks down into a dirty mass, in which the process of ulceration is accompanied by frequent haemorrhage. Carcinoma of the meninges may occur as a result of metastasis, al- though rarely if ever occurring primarily in this situation. In sarcoma and carcinoma of the dura mater little more can be done than to relieve pain by the employment of narcotics. Hydrocephalus is primarily a tubercular disease of the arachnoid and pia mater in childhood. The gross lesion is a transudation of the serous fluid from the pia and arachnoid into the cavities of the ventricles, the arachnoid, and subarachnoid spaces, Distention of the ventricles, com- pression of the brain substance, separation of the sutures, enlargement and deformity of the head, projection of the eyeballs, downward squint, and loss of cerebral function, are the symptoms, invariably ending in death. Treatment.—Tapping will at times relieve the more urgent symptoms of distention and compression. Careful antisepsis should be practiced, and the aspiration made through one of the lateral angles of the anterior fontanella. A small needle should be introduced, and three or four ounces slowly withdrawn, the operation occupying from fifteen to thirty minutes. This treatment is palliative, and is only justifiable in the effort to relieve the suffering of the patient. A cure is impossible. Wounds of the scalp should be treated as wounds of other parts of the integument. Incised wounds should be rendered aseptic, and may be closed by sutures, or the edges brought into apposition by a sterile- gauze compress and bandage. Sutures are as well tolerated here as else- where. When there is no especial desire to avoid a scar, sutures may be omitted, unless the wound is so extensive and gaping that apposition can not be effected by compression. Silk is preferable in stitching wounds of the scalp. The hair should be trimmed for a fourth or half inch from the edges of the wound. When no large vessels have been divided, the introduction of the sutures will suffice to arrest the bleeding. Lacerated wounds of the scalp are at times very extensive and for- midable. Several instances are reported of complete avulsion of the female scalp from the entanglement of the hair in machinery. In such cases transplantation of integument becomes necessary, in order to pre- vent ostitis from denudation of the calvaria. Ordinary lacerated wounds should be rendered aseptic, and may be treated by a compress of sterile gauze, or sutures employed, after the torn and bruised edges have been trimmed off with the scissors. Contused wounds of the scalp are usually followed by marked swell- ing, due to extravasation of blood (haematoma) beneath the pericranium. The treatment consists in cold applications, by means of the ice bag or cloths taken from ice water. If suppuration occurs, incision should be promptly made. A form of serous cyst sometimes results from hema- toma of the scalp. It should be treated by aspiration, and, if one or two evacuations do not effect a cure, it should be incised and the cyst wall dissected out. REGIONAL SURGERY.—THE HEAD. 465 Gunshot wounds of the scalp which penetrate to the meninges or brain require careful aseptic management and the removal of all pres- sure upon the brain. It has been advised by Horsley and Kramer that artificial respiration should be persisted in after unconsciousness from gunshot wounds of the brain. It is held that the primary effect of the concussion is to paralyze the respiratory center. Punctured wounds of the scalp are not serious, as a rule, when no sepsis is introduced through the wound, and when the bones are not penetrated. Penetrating Wounds of the Skull.—When a foreign body has pene- trated the cranial cavity and passed out, and the patient survives the im- mediate effect of the accident, the wounds of entrance and exit should be cleansed of loose fragments of bone, or any foreign body. To accomplish this it will be not only justifiable, but often imperative, to enlarge both openings, by use of the trephine, and, while employing strict antiseptic precautions, to secure free drainage for the discharge of blood or other fluids from the track of the missile. When severe intra-cranial haemor- rhage occurs, no attempt should be made to arrest it by plugging the wounds through the skull, for fatal compression of the brain might thus result. If the vessels involved can not be reached from the enlarged openings, and secured by haemostatic forceps or the ligature, the head of the patient should be elevated, in order to diminish the pressure at the bleeding point. This may in part be aided by ligation of the ex- tremities, as heretofore described. If there is only a single opening, and the body is lodged within the cranium, a careful inspection should be made about the wound of en- trance, and, if the presence of the missile can be recognized, it should be at once extracted, even if the application of the trephine is required. If the bullet shall have entered the substance of the brain—which can be determined in part by the careful employment of a light Nelaton's probe, provided with a good-sized porcelain tip, introduced through the wound in the skull, sufficiently enlarged by the trephine —the probabilities are that it has passed through the brain in the line of projection of the missile, and is lodged beneath the skull, at or near a point directly in the line of its projection. This condition was found to exist in the remarkable case operated on by Prof. W. F. Fluhrer, in Bellevue Hospital, in 1884. The patient, aged nineteen years, received a pistol-shot wround, en- tering at the forehead and passing through the brain, in the line shown in Fig. 469. The hole of entrance was enlarged by biting off the edges Fig. 469.-Fluhrer'scaseofpen- ,, r> j o o ctrating pistol-shot wound ot of the bone with a rongeur. An alarming haem- the cranium. (After Fluhrer.) orrhage from a vessel of the pia mater was con- trolled by a small artery clamp, or forceps. The patient's head was placed so that the supposed track to be explored was perpendicular to the surface of the table. A good-sized porcelain-pointed Nelaton's probe 466 A TEXT-BOOK ON SURGERY. was carefully introduced, and allowed to find almost its own way in the track left by the bullet. This instrument passed to a depth of six inches, where, a slight resistance being met with, it was allowed to remain. The direction of the probe indicated the point on the opposite side of the skull, at which the missile had most probably struck. Three fourths of an inch below this line the trephine was applied. Upon removing the disk of bone the dura mater appeared dark from blood effused beneath it. An incision was made through this, and the track of the bullet through the pia mater was discovered. It had struck the inner surface of the calvaria, had rebounded with a downward deflection, and was found about half an inch from the hole made by the trephine. A small rub- ber drainage tube was passed entirely through the track made by the bullet, and left projecting at each opening. Irrigation through the tube was not attempted. The wrounds were dressed with iodoformized gauze, loosely laid on, and an antiseptic dressing over this. The patient recov- ered and returned to his occupation, suffering only with a slight impair- ment of memory and occasional muscular spasm. The important lesson to be learned from the case above given is the necessity for great care in attempting to follow the track of a bullet through a substance so soft as the brain. If at any time any force is necessary to carry the probe along, all such interference should be dis- continued, as it is very easy to push «even a blunt, light, porcelain- tipped probe through this soft tissue. The tolerance of the brain to small foreign bodies should not be lost sight of. In many cases it is wiser to trust to encapsulation of the bullet than to search for it when it has passed beyond the dura. In the case of a young lad nine years of age, who came under my care, a twenty-six caliber conical bullet had entered just over the middle line of the right eye, passing directly backward through the brain. There was no paralysis, pain, or inconven- ience from this injury. Under an anaesthetic, twenty-four hours after the accident, I made an incision which exposed the wound of entrance into the skull, enlarged the opening with the rongeur, and removed some pieces of bone that had been driven into the dura and brain. As the bullet had passed out of sight into this organ, the wTound was sterilized and an iodoformized-gauze dressing applied. The patient recovered without accident, and is now, five years after, perfectly well, and at no time has suffered any suggestion of inconvenience from the presence of this foreign body in his brain. Not infrequently compression of the brain occurs from haemorrhage between the skull and the dura mater, or from a collection of pus, exos- tosis, depression of bone, or tumor within the cranium. Within recent years researches in cerebral anatomy and physiology have enabled scien- tists to determine, with accuracy sufficient to justify the application of their conclusions to surgical practice, from the disturbance of function in certain portions of the economy, the region of the brain involved in the zone of compression. That portion of this subject which is most capable of demonstration, and therefore most practical, relates to the interference with motion in certain muscles, or groups of muscles, which REGIONAL SURGERY.—THE HEAD. 467 have their "centers of motion" situated contiguous to the fissure of Rolando, and to certain disturbances of the mind and the senses chiefly located in the cortex of the brain. According to Lucas-Championniere,* who adopts the conclusions of Charcot and Pitres, our knowledge of this subject may be summarized as follows : " In a lesion followed by paraly- sis of the lower extremity the trephine should expose the summit of the ascending parietal convolution, on both sides of the upper end of the fissure of Rolando (Fig. 470). Of the upper extremity, the middle third Fissure of Rolando. Fissure of Sylvius. Fig. 470.—(Modified after Chainpionniere.) of the ascending frontal convolution, also on both sides of the center of the fissure ; upper and lower extremities, both regions just given ; upper extremity alone, with motor aphasia, foot of third frontal and lowrer third of ascending frontal convolutions, in zone marked motor aphasia in Fig. 470. Facial paralysis, lower third of the ascending frontal and foot of second frontal convolutions. Aphasia alone, foot of third frontal:' After a careful analysis of all the cases of cortical lesions of the brain published in America, and a thorough review of the results of foreign investigators, Prof. Starr arrives at the following conclusions : f "1. Various powers of the mind are to be connected with activity in various regions of the brain, the surface of the organ being the seat of conscious mental action. "2. The highest qualities of the mind—intellect, judgment, reason, self-control—require for their normal display integrity of the entire brain, * " La trepanation guidee par les localisations cerebrales." V. A. Delahaye et Cie. Paris, 1878. f " Cortical Lesions of the Brain." 31. Allen Starr, from " American Journal of the Medical Sciences," July, 1884. 468 A TEXT-BOOK ON SURGERY. but especially of the frontal lobes. A change of disposition and charac- ter may be considered as symptomatic of disease of the brain, and, in the absence of other symptoms, of disease of the frontal lobes. "3. The power of sensory perception is distributed over the various regions of the brain with which the various sensory organs are anatomic- ally connected. In these regions objects are not only first consciously perceived, but are also subsequently recognized ; and hence it is in these regions that the memory pictures are stored, by whose aid the act of recognition is accomplished. "(a) Disturbance of sight, whether in the form of actual blindness, or of failure to recognize or to remember familiar objects, or of hallucina- tions of vision, may indicate disease in the occipital lobes. An examina- tion of the field of vision will indicate which lobe is affected, since blind- ness in the right half of both eyes may be due to destruction of the left lobe, and blindness of the left half of both eyes may be due to destruc- tion of the right lobe. u(b) Disturbance of hearing, either actual deafness in one ear or hal- lucinations of sound on one side (voices, music, etc.), may indicate disease in the first temporal convolution of the opposite side. Failure to recog- nize or to remember spoken language is characteristic of disease in the first temporal convolution of the left side in right-handed persons, and of the right side in left-handed persons. Failure to recognize printed or written language has accompanied disease of the angular gyrus at the junction of the temporal and occipital regions of the left side in three foreign and in one American case. "(c) Disturbance of smell, either as an hallucination or as a loss of power to perceive odors, may possibly indicate disease in the temporo- sphenoidal region on the base of the brain. "(d) Disturbance of taste can not, as yet, be connected with disease in any region. This is due to lack of care in testing this sense in cases of brain disease. "(e) Disturbance of general sensation—including the senses of touch, pressure, pain, and temperature, together with the sense of the location of a limb—may occur either in the form of subjective perceptions of such sensations without objective cause, or in the form of impairment of these sensations. In either case it indicates a disease in the central convolutions, and possibly in the adjacent portion of the parietal lobules. "4. The power of voluntary motion of the muscles of the opposite side of the body is located in the two central convolutions which border the fissure of Rolando. Motions of the face and tongue originate in the low^er third of this region ; motions of the arm, in the middle third; motions of the leg, in the upper third. " Spasms in a single group of muscles, or paralysis of a single group of muscles, may indicate disease of its motor area. Extensive spasms or paralysis may indicate a large area of disease in this region; but if more marked in a single group of muscles than in others it may indicate a small focus of disease in the motor area of that group affecting other motor REGIONAL SURGERY.—THE HEAD. 469 areas indirectly and coincidently. Paralysis following spasm in one group of muscles is a characteristic symptom of disease in the central region. "5. Disturbance of the power of speech indicates disease in the con- volutions about the fissure of Sylvius, on the left side in right-handed persons, and on the right side in left-handed persons. If the patient can understand a question and can recall the words needed for a reply, but is unable to initiate the necessary motions involved in speaking, the disease is probably in the third frontal convolution, and in the adja- cent portion of the anterior central convolution. If the patient can not recognize spoken language, but can repeat words after another, or can use exclamations on being irritated, the disease is probably in the first temporal convolution. If the patient can understand and can talk, but replaces a word desired by one that is unexpected, the disease is probably situated deep within the Sylvian fissure, or in the white substance of the brain, and involves the association fibers which join the convolutions just named. " In making a diagnosis of cortical disease care must be taken to dis- tinguish between direct and indirect local symptoms; and also to sepa- rate clearly lesions of the cortex from those of the various white tracts within the substance of the brain.'' As far as the disturbances of motion are concerned, these points of interest bear such close relation to the fissure of Rolando that it is neces- sary to determine approximately its location. Championniere's line is as follows: From the posterior border of the malar process of the frontal bone, at the upper outer angle of the orbit A (Fig. 471) draw a line A B, Fig. 471.—(Modified after Championniere.) directly backward, a distance of two and four fifths inches. From B draw a perpendicular line, one inch and one fifth long, to C. then from C, upward and backward, to D, which shall terminate in the sagittal suture, 470 A TEXT-BOOK ON SURGERY. two and one fifth inches directly behind the junction of the coronal and sagittal sutures E. The point of junction of the sagittal and coronal sutures is not always easily recognized in the adult. If, however, the distance from the root of the nose (the naso-frontal suture) to the poste- rior-inferior border of the occipital protuberance be measured, the point D (Fig. 471) will be found to vary from three quarters of an inch to an inch posterior to the center of this line. The junction of the sagittal and coronal sutures is directly above the external opening of the auditory canal. The researches of Championniere may be particularly applied as follows : In complete and persistent hemiplegia, where the history of the case may exclude extravasation in the deeper ganglia, the center or bit of a large-sized trephine should be placed in the middle of this line, at 2 (Fig. 471), on the side opposite to the paralysis. If there is loss of mo- tion or convulsive movements of the lower extremity alone, the trephine should be applied in the upper third of the line, at 3. When the upper extremity alone is involved (the lesion being probably in the middle third of the ascending frontal convolution), the operation should be performed opposite to the middle and in front of this line. When simple aphasia is present, the trephine is to be applied at the lower end, and well in front of this line, 1. If, when the button of bone is removed, the cause of the compression is not revealed, the opening should be enlarged by the ron- geur, or by reapplying the trephine. In elevating a portion of the cranial vault for exploration, or the relief of compression of the brain, the following rules should be ap- plied : The entire scalp should be closely shaved, thoroughly cleansed, and rendered aseptic. A proper elevation should be given the head, to suit the convenience of the operator and to command the best light. A rubber tube may be carried around the scalp beneath the occiput and just above the ears and eyebrows, thus in part controlling all ex- ternal bleeding. This is, however, not essential. Having determined upon the point of brain surface to be explored, make this the center of a large horseshoe-shaped or trap-door incision. If it has been determined to lift the skull en masse, the horseshoe flap is not raised separately, but the bone being exposed in the line of incision, the soft parts are retracted enough to permit the devision of the cranial vault in this line. In doing this an opening should be made with a small Gait trephine. When the button of bone is removed, a dull- pointed grooved director, slightly curved, should be inserted between the dura and the under surface of the skull, to see that no adhesions exist. A furrow should now be cut from the skull conforming to the horseshoe incision through the "soft parts. Considerable difficulty is experienced in effecting a rapid section of the skull in many cases. Various instruments have been devised, but none of them have given the satisfaction which is to be desired. The cup-shaped rongeur or the fenestrated bone forceps (Figs. 113, 114) are most commonly preferred. Dr. A. De Vilbiss, of Toledo, Ohio, has invented a very useful instrument (Fig. 115). With it great force can be exercised over a limited area of bone to be divided, and the section made with greater rapidity than by REGIONAL SURGERY.—THE HEAD. 471 the older fenestrated forceps. So far the burr drills or saw revolving by a dental or electric motor have not proved satisfactory. The instru- ment becomes overheated from friction, and the operation is delayed. There is also some risk of wounding the vessels of the dura or brain un- less it is well shielded or used with very great cau- tion. The pericranium not having been raised, the bone may be replaced after the operation, without ma- terial impairment of its vitality. The dura mater is next opened by a crescentic or crucial incision and reflect- ed. Any offending mass should be removed. If nothing abnormal appears upon exposure of the cerebral surface, the question of invasion of this organ, or of further surface exposure, must be determined by the gravity and prominence of the symptoms and the condition of the patient. Exploration with a fine probe which will not cut or penetrate the vessels may be carefully done to the depth of one or two inches, and the increased resistance of a neoplasm will at times in Fig. 472.—Appearance of the tumor with dura attached. Natural size. (Keen.) Fio. 47".—Diagram of the skull showing the site of the tumor. £, Fissure of Sylvius. R, Fissure of Eolando. //'. Intraparietal sulcus. V, Vertical or precentral sulcus. T. Temporal ridtre. I, II, III, the first, sec- ond, and third frontal convolutions. The oval dotted line represents the tumor, the cross ( x_) the site Of the sear. (Keen.) this way lead to its recognition and location. In removing a deep-seated tumor considerable brain substance may be divided. In many instances the neoplasm can not be found, or is so deeply situated that the opera- tion has to be abandoned. Haemorrhage should be controlled by fine- 472 A TEXT-BOOK OX SURGERY Fig. 474.—Antero-posterior section of the head half an inch from the median line. R, Fissure of Kolando. /, Inion. A and JB, (solid) lines of puncture, the clotted lines showing their imagi- nary continuation to the fixed points. (After Keen.) catgut ligatures, and by aseptic water at about 110° to 120°. On ac- count of the delicate structure of these vessels, the ligatures should not be drawn too tight or any lateral traction made, for fear of tearing or cutting through. The wround in the dura should be closed with cat- gut sutures. A fine cat- gut drain may at times be indicated. The bone is next turned back into place and the soft parts sutured. If only a mod- erate surface is to be ex- posed, the soft covering should be lifted separate- ly and the large trephine em ployed. The button of bone removed has been replaced in a number of instances successfully by immersing it as soon as cut out in warm sublimate (105° F.) and placing it again in the hole from which it was taken. It would be dangerous to attempt restoration of the bone wThen the underlying dura is destroyed or removed. The success achieved in late years in this department of sur- gery by Horsley,* Keen,f Allis, and others justifies the hope that still great- er progress is probable in the near future. X * " American Journal of the Medical Sciences," April, 1887. f See same, October and No- vember, 1888. % This case of brain surgery (Prof. W. W. Keen, " American Journal of the Medical Sciences," October, 1888) illustrates so well the value of operative interference that an abstract is appended : Tumor of Brain Epilepsy.— A man, aged twenty-six, at the age of three fell and struck his head upon a brick. He remained comatose one hour. At twenty-three years of age he had an attack of severe neuralgic pains. These symptoms increasing, culminated, in February, 1885 (twenty-four years old), in epileptic convulsions, and, in April, paralysis of right face, arm, and leg. Epileptic attacks ceased from November, 1886, to June, 1887. A small scar a quarter of an inch long persisted, located two inches and a quarter to the left of median line and three inches behind the left external angular process. December 8, 1887, it was tender to pressure. Temperature over the scar, 95*5° F.; cor- Fig. 475. REGIONAL SURGERY.—THE HEAD. 473 When laceration of brain has been produced by fragments of bone or other foreign substance, drainage is an essential feature of successful responding point on opposite side, 94-4°. December 15, 1887, operation under ether and incision through the scar down to the bone; no indication of injury to the bone. A nick was made in the skull just at the seat of the scar. Large semi-elliptical flap three inches and a half broad ; con- vexity of incision posterior for drainage was cut and turned forward. Trephine an inch and a half in diameter applied so as to include point under the old scar. Dura adherent to the button in the lower half. Hard mass recognized, and a second button removed. Rongeur used, to fully expose the remainder of the tumor. Dura opened. It was adherent to the tumor, and a portion of it was removed with the neoplasm, which was enucleated with the ringer. Bleeding controlled by fine catgut and hot water, 115° to 120° F. The cavity occupied by tumor was one half filled by the resilient brain tissue before operation was completed. A bundle of horsehairs for drains was carried across the wound and left projecting at each side. Small rubber tube inserted. Patient recovered, improved in mind and body, although mild convulsive movements occurred at rare intervals. In 1896 Dr. Keen writes me this patient " is still doing well after nine years." Keen also proposes the following procedure for the relief of abscess of the lateral ventricles or in hyperdistention by any fluid : ^/ABASELINf Fio. 476.-Diagram to show the relations of the brain to the skull (modified from Eeid). j b, coronal suture, b, bregma ; r, external angular process; h, lambda; h c, lamboid suture; j, pterion ; m, ™af °ldfiP^s» i x, parietal eminence; Sv. a., Sv\ p., anterior and posterior limbs of Sylvian fissures; f. o/k Assure ot Rolando; a. f. c, a. p. c.', ascending frontal and ascending parietal convolutions; s.f. s., i. T^^F™>t and inferior frontal sulci; 1 r. c. 2'r. c, 3 r. c, frontal convolutions; s. t.-s. b superior and ^umtem- poro-sphenoidal sulci; 1 t.-s. c, 2 t.-s. c, 3 t.-s. c, temporo-sphenoidal convolutions , i. p. s i trapai e ai suture; s. p. l., superior parietal lobule; s. m. c, supra-marginal convolutions; a. g., angulai gjms, p. o. f., parieto-occipital fissure; o. l., occipital lobe; g, c, m, a, Keid's base line. I. Trephine halfway from the external occipital protuberance to the upper end of the fissure of Rolando, half to three quarters of an inch to either side of the middle line. Puncture toward the inner end of the supraorbital ridge of the same side (Fig. 474 A). The puncture will pass through the precuneus, and the normal ventricle will be struck at some point in the posterior horn at from two inches and a quarter to two inches and three quarters from the surface of scalp. II. Trephine at one third of the distance from the glabella to the upper end of the fissure of Rolando and half to three quarters of an inch to either side of the middle line. Puncture in the direction of the external occipital protuberance (Fig. 474 B). The puncture will traverse the first frontal convolution well in front of the motor zone, and the normal ventricle will be struck in the anterior horn at about two inches to two inches and a quarter from the scalp. HI. Trephine one and one fourth inch behind the meatus and one and one fourth inch above 33 474 A TEXT-BOOK ON SURGERY. treatment; indeed it is imperative, for drainage is as necessary in the cranial cavity as elsewhere. This point is well illustrated in a brilliant case recently reported by Dr. Oscar H. Allis.* A man received a commi- nuted fracture of the frontal bone, with exten- sive lacerations of brain tissue. The fragments were removed and the wound cleansed. The le- sion extended along the frontal bone to its hori- zontal plate, which was also fissured. In order to secure drainage, with the finger of one hand as a guide, the cribriform plate of the ethmoid was bored through by a drill carried up through the nose (Fig. 477). A probe armed with a ligature was passed through and a rub- ber drainage tube three eighths of an inch in di- ameter pulled through from above downward, the upper end being left on a level with the cerebral surface of the cribriform plate. A second tube was inserted and allowed to project from the nose and wound in the skull (Fig. 478 and Fig. 479). An antiseptic dressing was applied, and the patient recovered without an unfavorable symptom. Reid's base line. (This line extends from the lowest part of the infraorbital margin through the middle of the external meatus to the ear.) Puncture toward a point two and one half inches directly behind the opposite meatus (Fig. 475). The puncture will traverse the second temporo-sphenoidal convolution and enter the normal lateral ventricle at the beginning or in the course of the descending cornu at a depth of about two to two and one fourth inches from the surface. In this route the measurements are for an adult skull. They should be somewhat reduced for children. The depth necessary for puncture will depend somewhat upon the thickness of the skull and variations in the diameter of the skull from youth to old age, as well as upon the distention of the ventricle with effusion. This, the lateral route, has the great disadvantage that it will develop an abscess of the temporo-sphenoidal lobe, as well as dropsy of the ventricle. It is well to state that the center for hearing of the opposite side may be penetrated through this opening, but, as it has been done a number of times without impairment to the hearing, this objection should not prevent the operation. Afr the ventricular end of the puncture the optic thalamus may be injured, but this risk must be taken. Dr. Keen writes me in June, 1896, that further experience recommends this route. As will be seen in the treatment of otitic brain abscess, it is through this part of the skull that the opera- tion is done. * " Annals of Surgery," July, 1889. Fig. 477.—Drilling through the cribriform plate. (Allis.) REGIONAL SURGERY.—THE HEAD. 475 In fracture through the middle fossa, where blood or cerebro-spinal fluid escapes through the ears, natural drainage may be secured through the auditory meatus. In all such cases this canal should be cleansed with sublimate solution, and aseptic-cotton pads applied to absorb the discharge and prevent septic infection. Surgery of the Face. Wounds.—Incised wounds of the face usually bleed profusely. The two essential features in treatment are to arrest haemorrhage and secure repair with the least possible deformity. When the bleeding is only slight, bringing the edges together with fine silk sutures will arrest 476 A TEXT-BOOK ON SURGERY. it. When ligatures are applied, catgut should invariably be employed. Every wound of the face should be treated with the strictest antisepsis. The approximation of the edges should be accomplished with exactness. The finest black iron-dyed silk is the best material, and the interrupted suture should be preferred. If the character of the haemorrhage neces- sitates central deligation, the external carotid (not the common trunk) should be tied. This necessity could scarcely arise in an incised wound, unless the internal maxillary or upper part of the external carotid was involved. Contusions of this region require, as in other parts of the body, local applications, usually of cold water or the ice bag. Ecchymosis is, as a rule, present, and is persistent in the tissues about the eyes. Lacerated wounds of the face are serious, on account of the danger of disfigurement after repair. If the procedure does not involve much loss of tissue, the edges may be pared smoothly and united with silk sutures, under careful asepsis. If there has been extensive contusion, a small catgut-twist drain should be left at each end, to guard against the danger of infiltration of pus in the subcutaneous tissue. In wounds which involve the circular muscles of the eyes and mouth, great care must be taken to guard against contractions and deformities. Punctured wounds require no special consideration. Deligation of the external carotid may be necessitated to arrest bleeding from deep wounds of the spheno-maxillary fossa. Shot wounds of the face are not, as a rule, dangerous to life, even in military practice. Of 3,312 cases, in which fracture of the bones of the face occurred as a result of shot wounds, as given in the "Medical and Surgical History of the Civil War," by Dr. George A. Otis, only 340 died, while of 4,914 flesh wounds only 58 died. In civil practice the rate of mortality is still lower. When the missile has penetrated the spheno-maxillary fossa, or di- vided any deep-seated vessels, the necessity of tying the external carotid may arise. A ball or any foreign body lodged in the bones or tissues of the face should be immediately removed, when this can be accomplished without an operation which may incur the danger of deformity. When, however, the missile is deeply lodged, and is of small size, it should not be molested until there is evidence that it will not remain encapsuled and harmless. Bones or fragments of bone which have been displaced in part, but not entirely stripped of periosteum and vascular attachments, must not be removed, since, if replaced and held in proper position, they usually become reunited to the sound bone. The Eye. Wounds of the eyelids and of the circular muscle of the eye scarcely require special consideration. In incised or lacerated wounds a careful approximation of the edges of such wounds with the finest silk sutures, and the maintenance of the parts in a condition of perfect quiet, are THE EYE. 477 essential. A saturated solution (about grs. xv to 3 j of water) of boric acid is to be preferred for purposes of cleanliness. Contusions about the eye should be treated by cold applications, using a very small and light ice bag, or frequent changes of bits of linen cloth, taken from a block of ice. New Formations.—Vascular growths (naevi or angeiomata), usually of the capillary variety, are not infrequent in the vicinity of the eye. When of small size, not exceeding a half or three fourths of an inch, they may be successfully destroyed by the hypodermic injection of from two to five minims of a 50-per-cent solution of carbolic acid or pure alcohol. The quantity, though small, should be well disseminated in the growth. Great care should be taken not to allow any of the solution to enter the eye. Removal by free excision is not practicable when the tumor is of large size, and when the palpebral margins are involved, or when their shape and situation are such that deformity is apt to follow the excision. A careful application of the rules of plastic surgery to the region of the eye will often obviate deformity, even after extensive dissections with loss of tissue in the vicinity of this organ. What has been said of the excision of vascular growths applies equally to all forms of neoplasms in this region which—themselves a deformity, or malignant in charac- ter—require removal. When this can be done with safety, it is of the utmost importance that the palpebral margin be left intact for at least one eighth of an inch in width. The palpebral branch of the ophthalmic artery, which runs parallel with and about this distance from the free margin of the lid, should not be wounded when it is possible to avoid it. When the dissec- tion is completed, a tongue of skin may be slid from the malar region across the wound, provided the space to be filled does not measure more than one half inch in its transverse diameter. It is at times advisable to Fig. 480. Fig. 481. divide the tension by sliding a shorter flap from the direction of the nose. For larger spaces a flap may be turned from the cheek, hand, or arm, as given hereafter. Fig. 480 represents the space left after the removal of a myxo-sarcoma of the face, and Fig. 481 the method of covering in the 478 A TEXT-BOOK OX SURGERY. deficiency. From the outer angles parallel incisions were continued through the skin toward the ear, as far as was necessary to secure integ- ument enough to slide across the gap. The trans cerse fa- cial artery, which runs about one fourth of an inch below and parallel with the zygoma, should be kept in the flap, which is dissected up until the end nearest the nose can be carried across to the edge of the wound upon the nose and stitched at this point. The lower border is next fastened, and after this the palpebral border is stitched to the up- per margin of the tongue of skin with the finest suture ma- terial. The sutures may be removed in from four to six days. It is necessary to arrest all bleeding from the bottom of the cavity left after a dis- section ; that from the edges will be arrested by the sutures. The tension on the flap should not be so great that the blood supply is seriously interfered with. After the first sutures are inserted, it will be well to wait for a few minutes in order to see that the circu- lation is established. Fig. 482 and Fig. 483 are taken from a patient from whom a large naevus was excised, and the wound filled by free dissection and sliding of the integument of the cheek. Little or no eversion or dragging down of the lid will follow in these operations when carefully per- formed. Epitheliomata may be cured by the application of Marsden's paste even when they involve the free border of the lid. Care- ful attention will prevent the irritation of the conjunctiva by- arsenious acid. Sebaceous tumors (retention fig. 4^3. Fig. 482. THE EYE. 479 cysts) are occasionally met with on the outer surface of the lids, and in the skin about the orbit. They should be removed by thorough dis- section of the sac. When situated upon the lids they rest between the integument and the tarsal cartilage. The line of incision should be par- allel with the free border of the lid, to avoid dividing the horizontal fibers of the orbicularis muscle. Hordeolum, or "stye," is a pyogenic infectious inflammation of the sebaceous gland and hair follicle at the palpebral margin. It is a fu- runcle of the lid. AY arm or emollient applications hasten the suppura- tive process and soften the epidermal covering. The treatment consists in early evacuation of the contents by pressure after pricking the stye with a delicate sharp lance or needle. Professor David Webster recom- mends sulphide of calcium, gr. ss., twice each day as a corrective and preventive of hordeolum. Chalazion.—Obstruction of one or more of the ducts of the Meibomian glands causes a swelling and inflammation of the gland, or tube behind the point of obstruction. These protrusions appear on the conjunctival surface of the tarsal cartilage, and should be treated by puncture through the edge of the lid, with evacuation of their contents by pressure on both surfaces of the lid, directed from the base toward the free bor- der, in the effort to squeeze out the plug and thus restore the normal condition of the excretory duct. A thorough curetting of the walls of the sac by means of a Daviel's cataract spoon introduced through the incision renders a recurrence of the tumor less liable (Webster). Any incision on the under surface of the lids should be made parallel with the ducts of these glands. A rare form of cystic tumor occasionally de- velops in the substance of the tarsal cartilage. It may be cured by inci- sion and destruction of the sac, or by evacuating the contents and inject- ing one minim of 50-per-cent carbolic acid into the cyst. Blepharitis or inflammation of the lids may affect all or a limited portion of these organs. It most frequently involves the ciliary margins, and is known as blepharitis ciliaris. In rare instances the cartilages are involved. Acute blepharitis demands rest and local antiphlogistic ap- plications. Cloths dipped in warm water are in general more agreeable. In chronic blepharitis ciliaris the scaly covering of the inflamed borders of the lids should be removed by the prolonged use of warm boric-acid water and a mop of soft lint, having first trimmed the lashes closely. AVhen this is done the inflamed surface should be lightly touched with a pencil of lunar caustic. At night the lids should be lubricated with a small quantity of cosmoline. Blepharospasm, or spasm of the orbicularis palpebrarum muscle, re- sults usually from irritation of the conjunctiva or cornea. It may, in rare instances, occur without any inflammatory exciting cause (idiopathic blepharospasm). The treatment is rest and the removal of the cause of the spasm. In rare cases division of the muscle through the outer can- thus is demanded to relieve pressure on the conjunctiva, cornea, and globe. Blepharophimosis, or narrowing of the palpebral opening, is due to contraction of the lids at the outer canthus or angle. It may be relieved 480 A TEXT-BOOK ON SURGERY. by an incision commencing in the outer angle and carried directly out through the entire thickness of the commissure for the required dis- tance, extending the cut in the skin a short distance farther than that in the conjunctiva. The edges of the skin and mucous membrane are then united by silk sutures, as shown in Fig. 484. Lagophthalmos.—Inability to close the eyelids may be due to pro- trusion of the globe from tumors of the orbital cavity, or of the globe; it occurs in the disease of which enlargement of the thyroid body and "exophthalmos" are symptoms; in staphyloma and in paralysis of the facial nerve. It is a serious condi- tion, on account of the liability of ulceration of the cornea from pro- longed exposure of the anterior sur- face of the globe. The indications in treatment are first palliative in keeping the lids closed by bandag- ing, or uniting the edges by sutures. When the condition is permanent, the operation of tarsoraphy is to be performed as follows: Introduce a horn spatula between the globe and the lids at the outer canthus; make the tissue tense, and with a sharp knife remove the free borders of the upper and lower lid for a distance sufficient to close the eye to the de- sired extent. The incision should remove the roots of the cilise. The opposing edges are now united with silk sutures. Blepharoptosis.—Ptosis, or inability to lift the upper lid, may be due to partial or complete paralysis of the third nerve, or the filament which supplies the levator palpebral : to adhesions from inflammatory affec- tions of the lid ; to the presence of neoplasms or to acquired or congeni- tal weakness of the levator muscle. Ptosis due to paralysis may be cor- rected by excising an elliptic-shaped piece of the skin of the upper lid, including the areolar tissue and the fibers of the orbicular muscle. The lower incision should run parallel with the margin of the lid and about one quarter inch above it. The edges of the two incisions should be united with silk sutures. Symblepharon is a term applied to adhesions of the lids to the ocu- lar conjunctiva. Limited adhesions may be broken up repeatedly until a cure is effected by the extension of an epithelial covering over the granulating surfaces. A\7hen the adhesions are extensive, Teale's opera- tion may be performed. Supposing the condition shown in Fig. 485 to exist, the symblepharon is cut through at A, in the line of the corneo- sclerotic function, and the lid is dissected up to the normal fold of palpe- bral and ocular conjunctiva (D, Fig. 486). Two flaps (B and C. Fig. 486) are now dissected up from the conjunctiva, and turned down and stitched in position to cover the raw surface left by the dissection of the adhered Fig. 484.—Incision and sutures in operation for blepharophimosis. (De Wecker.) THE EYE. 481 lid. The spaces left by lifting the flaps are closed at once by fine silk sutures (Fig. 487). The island of tissue left on the cornea is allowed to disappear by atrophy. Fig. 485. Symblepharon. A, Incision through the attached con- junctiva at the corneo-scle- rotic junction. Teale's op- eration. (Swanzy.) Fig. 480. The same. D, Adherent con- junctiva dissected down. R, C, Incision for flaps to cover this wound. (Swan- zy.) Fig. 487. The same. A, Tip of sym- blepharon left to disappear by absorption. C, R, Flaps turned and sewed into new position. D, E, Wounds closed by sutures. (Swanzy.) Ectropion, or eversion of the lid, may be partial or complete, and is due first to weakness of the orbicularis palpebrae muscle, especially to the palpebral fibers ; second to cicatricial contractions due to injury or disease of the soft parts above the eye, or of the bones surrounding the orbital cavity. The lower lid is usually involved. The treatment is operative. In mild cases, those in which no cica- tricial adhesions have occurred, the following operation, as given by Swanzy, is advised: Method of A. Robertson.—Thread a long quarter-curved needle with each end of a small Chinese twisted-silk ligature, about fifteen inches long; with one of these perforate the entire thickness of the lid one line from the ciliary margin and one quarter of an inch to the outer side of the center (b, a, Fig. 488). The needle is now passed over the conjunctival surface of the lid, till it meets the fold of conjunc- tiva reflected from the lid on to the globe through which the needle is thrust—the point being direct- ed slightly forward—and pushed slightly downward under the skin of the cheek until a point is reached from one to one and a quarter inches below the edge of the lid, where it is brought out. The other needle is introduced in a corresponding manner at the same distance from the middle line on the inner side (a/, b', d', Fig. 488). A piece of thin sheet - lead, about one inch long and one quarter inch broad, rounded at its ex- tremities and smooth on all surfaces and edges, bent to fit the curva- ture of the eyeball, is now slipped under the loops of the ligature that Fig. 4SS.—Kobertson"s operation for ectropion of the lower lid. (A. Robertson.) 482 A TEXT-BOOK OX SURGERY. pass over the conjunctival surface of the lid; at the same time a short piece of small rubber drainage-tube is passed beneath the loop on the cutaneous surface just below the ciliary margin. Now, as the ends are drawn gradually tight, the edge of the lid is made to revolve inward over the upper edge of the piece of lead, while the tarsal cartilage is molded to the curve of the lead, and the lid assumes its normal position. The threads are tied below over the rubber tube, d, d. The sutures and lead are removed from the fourth to the sixth day. In mild ectropion, due to limited cicatricial adhesions, AYharton Jones's V Y operation may be adopted. As shown in Fig. 490, a V-shaped incision is made so as to include the scar, the flap dissected up, and the underlying cicatricial adhesions cut out. The lid is lifted into its normal position, stitched to its up- Fig. 491.— The same, after the flap is Fig. 492.—Complete ectropion of lower lid, due to dissected up and the suturea tied. cicatricial contractions after ostitis of the orbital (DeWecker.'' margin. THE EYE. 483 In more extensive adhesions (Fig. 492), in which neither of the foregoing methods will meet the indications, a plastic operation is in- evitable. Make one incision, parallel with the free border of the lid, Fig. 493. Showing the cicatricial tissue dissected out, and the flap to be turned from the cheek outlined. which shall extend beyond the cicatricial tissue to be removed. Dis- sect out freely all adhesions and cicatricial material, until, when left to itself, the remaining edge of the lower lid rises into its natural posi- ** Fio. 494. The flap stitched into position, and the wound formed by its removal closed. The lids temporarily sutured. tion. In order to fill the deep oval cavity (Fig. 493) left by such dis- section, a flap may be turned from the cheek, forehead, or arm. The plan of the flap from the cheek is shown in Fig. 494. It should be cut by measurement, so as to fit without tension. As soon as it is 484 A TEXT-BOOK ON SURGERY. turned across to its new position, the eyelids should be stitched to- gether, and the flap accurately and carefully sutured to the margins of the elliptical wound. Before the lower row of sutures is inserted, the edges of the perpendicular wound from which the flap was removed should be approximated by sutures of fine silk, which material should be used throughout. The stitches are to be removed about the fifth day. If any puffing remains at the seat of the pedicle of the flap, it may be relieved, after a few months, by dissecting out a small elliptical piece and bringing the edges together. AAThen the cavity from which the flap has been taken can not be entirely closed by suture, small Thiersch grafts should be employed to prevent a broad cicatrix. Fig. 495.—Knapp's entropion forceps, or clamp. Entropion, inversion of the lid, usually results from chronic inflam- mation of the conjunctiva and tarsal cartilage. It is more frequent in the upper lid. In mild cases relief may be obtained by excising an E G.TIEMANNiCO Fig. 495 a.—Lid scalpels. elliptical strip of the integument of the lid and stitching the edge of the wound together. AArhen, however, the tarsal cartilage is involved, Snellen's method will prove more satisfactory. AA7ith Knapp's clamp applied, make an in- cision through the skin one eighth of an inch from and parallel with the whole length of the margin of the lid. Lift the skin-flap, expose the fibers of the orbicularis muscle, and excise a strip of the muscle about one twelfth of an inch wide for the full length of the incision. The tarsal cartilage is now seen, and from it as far as it is exposed a wedge-shaped piece is excised with a sharp knife (Fig. 496). The apex of the wedge points toward the con- junctiva, but the section should not extend entirely through the cartilage. Three sutures are now inserted, each entering from without Fig. 496. — Perpendicular section showing character of dissection. The muscular strip and a trian- gular strip of the tarsal cartilage are removed. (De Wecker.) THE LACHRYMAL GLAND AND DUCTS. 485 inward, traversing the skin and muscle (Fig. 497) of the strip left at the palpebral margin; then in the same direction it is carried across the wound into the upper bevel of the incision in the cartilage, from which it emerges (without transfixing the integument of the flap), to be again brought out through the tissues it first entered, about one eighth of an inch dis- tant from the point of entrance. Each end of the suture is fastened with a shot, to prevent it cutting through. Eczema of the eyelids is not of very frequent occurrence. Swanzy recom- mends the daily removal of the crusts by FlG. 497.- Front view of the same, with bathing the parts in a warm solution of (^Wecker??^ ready t0 be tied' bicarbonate of potash, drying, and then painting with solution of nitrate of silver (gr. xx to water § j); after this an ointment of boracic acid (gr. xxx to | j) is applied. Eplcanthus.—This term is applied to a congenital defect which con- sists of a fold of skin stretched across the inner canthus and the carun- cula. It may be relieved by excising an elliptical piece of integument in the long axis of the nose just between the eyes. The width of the excised portion must be sufficient to remove the deformity when the edges of the wound are drawn together by sutures. Restoration of the Eyelids.—In destruction of the lids by accident or disease it becomes necessary to restore the covering to the globe. Flaps may be turned from the neighboring healthy integument or borrowed by a plastic operation from the arm. In many cases much damage may be prevented by applying good-sized and numerous grafts to the exposed surfaces while granulation is going on. The Lachrymal Gland and Ducts. Disease of the lachrymal gland is rare. In inflammation of this organ (dacryoadenitis) tenderness and swelling may be observed in the upper outer portion of the orbital cavity. In well marked enlargement from any cause, the eyelid is pushed forward and the globe displaced downward and inward. An abscess here should be opened by puncture through the base of the lid at the most convenient point. AArhen a neo- plasm develops in the gland, extirpation should be done by incision in the fold of the upper lid, just beneath the brow. Epiphora, or continual overflow of tears, is caused by obstruction in the system of canals which normally should conduct the secretion of the lachrymal gland from the margins of the lids into the nasal cavity, or by displacement of the punctum lachrymale, so that the tears can not enter the orifice. On account of its position, the lower canaliculus is of much more importance to the drainage of the eye than the upper. Epiphora due to disturbance of the canaliculus may be present as a symptom of any* displacement of the lower lid, from swelling, paraly- 486 A TEXT-BOOK ON SURGERY. sis, or cicatricial contraction, the direction of the puncture being so changed that neither gravity nor the normal suction-force will carry the secretion into the opening. Occlusion, partial or complete, may occur either from lodgment of foreign substances, products of inflammation, pus, epithelia, etc., and occasionally to calcareous formations (da- cryollths). The most common form of obstruction is, however, met with in the nasal portion of the excretory apparatus. Catarrhal inflammation of the mucous membrane lining the canal or cyst may occlude the duct either by approximation of the walls or by excessive secretion of tenacious mucus. Such condition is met with in patients of all ages, occurring chiefly in the poorly nourished and scrofulous or tuberculous subjects, who suffer from chronic nasal catarrh and ophthalmia, or ostitis of the neighboring bones. As a result of obstruction in the nasal duct, dacryo- cystitis, or inflammation of the lachrymal sac, may ensue with disten- tion, the swelling showing beneath the skin at the inner angle of the eye (muco-cele). The treatment of displaced punctum lachrymale should be directed to the restoration of the lid to its normal position. In partial obstruction, due to catarrhal conditions, relief may be obtained by slitting the canal with the canaliculus knife or scissors, and frequently repeated irrigations Fig. 498.—Agnew's canalicula knife. with the lachrymal syringe. AVhen obstruction occurs, dilatation by means of probes is indicated. Should the stricture be close and resist- ing, the knife should be carefully introduced and a division effected, the dilatation being continued by inserting the probes at intervals of two to six days. The prognosis in many cases, no matter how faithfully and skillfully treated, is not favorable. In slitting up the canaliculus the delicate probe-pointed knife or scis- sors should be introduced at the inferior punctum, and carried toward the canthus for a distance of about one sixth of an inch, the slit extend- ing for this distance. The wound should be kept open by forcibly sepa- rating the edges once or twice a day, until the cut surfaces are covered with epithelium and the trough becomes permanent. Some operators in ch ronic dacryo - cysti- tis prefer to slit the upper canaliculus and pass the probes by this route. The bulb- Fio. 499.—Theobold's lachrymal probes. pointed dilating-probeS should now be careful- ly introduced, beginning with the smaller sizes (Fig. 499). As soon as the bulb enters the sac, it should be gently and slowly directed along the nasal duct until it is arrested by the floor of the nose. The larger sizes maybe introduced as in the treatment of'stricture of the THE CONJUNCTIVA AND CORNEA. 487 urethra. After full dilatation is secured the channel should be washed out daily, for about ten days, with a 1-per-cent boracic-acid solution. For this purpose AneFs syringe (Fig. 500) will be found useful. The probe-pointed nozzle is intro- duced into the sac and the water forced through until it flows freely into the nose. If the obstruction recurs, the probes should be reintroduced at regular intervals, gradually increasing until a permanent opening is effected. Trichiasis, or turning in of the eyelashes, occurs with entropion, but may exist independently. Occurring with inversion of the lid, it does not require any other interference than that given for the cure of entro- pion. AVhen the cilise turn in without inversion of the lid, the proper method of treatment is total excision of the hair-follicles. This should be accomplished by two parallel incisions made Fig. 501.—Gruening's depilating forceps. along the margin of the lid, one on either side of the row of hairs, and extending deep enough to insure the complete removal of the roots of the cilise. AAThen only a few hairs are at fault, the follicles may be destroyed by the galvanic needle. AArhen depilation is de- manded, the instrument shown in Fig. 501 will be found of great service. In distichiasis there is an extra row of cilise; these require removal by the method just given. The Conjunctiva and Cornea. Conjunctivitis may be acute or chronic, and circumscribed or diffuse. Simple conjunctivitis may result from prolonged strain or over-use of the eyes, from the lodgment of foreign particles, or exposure to strong winds. The hyperaemia may be confined to a limited portion of the mucous membrane, or spread over the entire palpebral and ocular con- junctiva. The treatment consists in the instillation of two or three drops of cocaine, two to four per cent solution, at intervals of from one to several hours, the removal of any foreign matter, rest by closure of the lids, or the dark room and the application of soft cloths taken from cold boracic- acid solution (grs. x to 5 j) or from a block of ice. Follicular conjunctivitis may follow an acute simple inflammation, and is characterized by the development of small" red points or elevations scattered over the deeper portions of the palpebral surfaces of the mucous membrane and the contiguous reflection of the ocular conjunctiva. The elevations are swollen and distended lymphatic channels and follicles. The disease is characterized by considerable pain, inability to use the 488 A TEXT-BOOK ON SURGERY. eyes, and a sensation as if a gritty or sandy substance were present. In treatment the condition of the general system should be improved by tonics and nutritious diet; rest to the diseased organs, and the daily application, by means of a camel's-hair brush, into the conjunctival sac of a small mass, about one-eighth-inch diameter, sulphate of copper gr. ss. to ij in 3 j vaseline (Swanzy). Granular Conjunctivitis (Trachoma).—It is not yet positively known whether there is any real pathological difference between follicular and granular disease of the conjunctiva. Trachoma is chiefly met with among the poorly fed, who live in unwholesome surroundings. It is held to be con- tagious at all times, and, when a muco-purulent discharge is plentiful, the contagious nature of the affection is evident. Fig- 502. In the earlier stages there appear upon the low- Granular lower lid. (Eble.) n.-, ., &, ., .^ " er lid round, granular elevations, scattered here and there, or the whole mucous membrane may be thickly studded. As a result of the chronic inflammation the lid is at first thickened. As the process is continued, the usual cicatrization and contraction results, caus- ing, in obstinate cases, deformities of the lids and great and persistent discomfort. The treatment includes the measures just given for follicular conjunc- tivitis. In addition, either the sulphate of copper stick or nitrate of sil- ver in strong solution—grs. x-xx to 3 j—or the mitigeited lunar caustic. Nettleship advises the following strength : "Nitrate of silver, one part; nitrate of potash, two parts, fused together and run into molds to form short pointed sticks; used for granular lids and purulent ophthalmia." Applied daily, or less frequently, as may be demanded. AAThen these measures fail, canthoplasty may be done and the diseased tissue dissected from the lids. In both varieties of trachoma the cure is greatly accelerated by the operation of expression, or squeezing out the contents of the granular elevations by means of Prince's forceps. More can be accomplished by this operation when done thoroughly than by any other method of treatment (Webster). Gonorrhoeal Ophthedmia. —Conjunctivitis caused by the introduction of the virus of gonorrhoea into the eye should be treated with great care and persistency from the first symptom of this painful affection. Usually a single organ is attacked. It is important that, while the effort to cure one eye is being made, the other should be protected from the contagion. To effect this, a watch glass, to the edge of which adhesive plaster is at- tached, is placed over the sound eye and closely fastened to the skin about the orbit by the plaster, so that it is hermetically sealed. This should not be removed until the other eye is well. In the local treatment of the affected eye it is required to remove the purulent discharge by frequent irrigation with warm boracic-acid water or by the pellets of lint or absorbent cotton, and to brush over the everted lids once or twice a day, as the attack is light or severe, a solution of THE CONJUNCTIATA AND CORNEA. 489 nitrate of silver (grs. xx to ^j). The excess should be immediately washed off with tepid water. Cold applications are of great importance, and a very efficient method is to apply frequent changes (every one or two minutes) of pieces of lint about two inches square, which are taken directly from a block of ice and laid over the inflamed organ. In this form of conjunctival inflammation, as in others where the injection is marked and the thickening great, and where painful blepharospasm occurs, or where a free discharge of purulent matter can not be effected by ordinary means, canthoplasty is required. This operation consists in slitting the outer canthus in the direction of the ear, and in this way dividing the fibers of the orbicular muscle. In gonorrhoeal conjunctivitis the impairment of function in the mus- cle is not intended to be of long duration, and the wound is left open. In some cases of spasm of this muscle, and where a chronic inflammation exists, the mucous membrane is stitched to the skin along the edges of the wound, thus preventing a reunion. Reunion may be effected later by paring the edges and bringing the parts together after the lesion for which the canthoplasty was performed is healed. Cocaine should be used to relieve pain, and all adhesion between the ocular and palpebral mucous surfaces should be broken up as soon as discovered. Conjunctivitis in the new-born (ophthalmia neonatorum) is a form of purulent ophthalmia which usually results from the inoculation of the conjunctiva with septic matter present in the genital passages of the mother. It may come from carelessness on the part of the nurse, herself affected with a leucorrhcea, etc., or from the lodgment of any virus in the eye of the child. The treatment is prophylactic as well as curative. The eyes of a child born of a mother known to be suffering from a vaginal discharge of a purulent character should, as soon as possible after birth, be washed or mopped out with clean warm water, or boracic-acid solution, to be followed with one or two drops of a 2-per-cent nitrate-of- silver solution (grs. x—5 j) once or twice a day, for three or four days. Fig. 503.—Drop-glass for the eye. The pus should be gently removed by pellets of absorbent cotton, dipped in warm boracic-acid solution, the lids everted, and nitrate-of- silver solution (grs. v-x to 5 j) applied to the inflamed surfaces by means of a camel's-hair brush. The excess should be immediately washed away by the free use of warm water. This should be repeated every day until the purulent discharge is notably diminished. The eyes should be carefully cleansed with warm solution of boracic acid every half hour day and night, or as often as any secretion appears between the edges of the eyelids. Croupous conjunct'-hitis is a contagious disease met with in children, and characterized by injection of the mucous membrane and the deposit °f a film or membrane upon the conjunctiva. 24 490 A TEXT-BOOK ON SURGERY. The treatment consists chiefly in frequent washing of the eye with warm boracic-acid water in the earlier stages. AAThen suppuration super- venes, the indications are the same as for purulent ophthalmia. Diphtheritic Conjunct i/dtis.—In this disease, which is exceedingly contagious, the inflammatory process is rapid and often hopelessly de- structive. The lids soon become greatly swollen, and the mucous mem- branes are glazed over with a tough, closely adherent diphtheritic mem- brane. The period of infiltration varies from six to ten days, and is fol- lowed by the stage of suppuration. Treatment—The immediate danger is destruction of the cornea, the circulation being more or less interfered with by the false membrane. Since all pressure should be eliminated, in extreme cases it will be advisa- ble to perform canthoplasty. Cold-water dressings should be employed in the early stages. Leeches to the temples are advised. AA7hen suppu- ration ensues, astringents are indicated. Pterygium is the name given to a vascular network which extends from the ocular conjunctiva on to the cornea. It is usually situated on the inner side, less frequently on the outer portion of the globe. It is commonly triangular in shape, the apex encroaching more or less upon the corneal surface. It is caused by constant irritation from dust or sand, or fine particles of matter floating in the air, and is therefore chiefly met with in sandy, arid regions. AVhen small and not progressive, it is advisable not to interfere with pterygium. AArhen it is growing steadily, it should be tied off or removed by dissection. For the first method the pterygium is lifted at the mar- gin of the cornea, and a fine silk thread carried beneath it here. A second is carried beneath the base of the mass at the conjunctival fold. The ligatures are tied and cut short. In a few days they come away, and the vascular tuft disappears ; or a dull in- strument, as a strabismus-hook, may be insert- ed beneath the pterygium, which is gradually detached and divided with the scissors. One or two sutures are inserted to close the wound, where the base of the growth is cut away from the conjunctiva. Pinguecula. (Swanzy.) Pinguecula.—This is a small, yellow eleva- tion occasionally met with at the inner or outer margin of the cornea (Fig. 504). It occurs usually in the aged, and should not be molested unless it seriously interferes with vision or comfort. It is a simple hypertrophy of the tissues of the conjunctiva. Lupus of the conjunctiva is exceedingly rare, and does not require special consideration. Epithelioma here does not differ from this affection on other mucous surfaces. Cystic tumors occur in the conjunctiva in a certain proportion of cases, and demand extirpation. Polypus develops occasionally on the semilunar fold, or caruncula, and should be clipped off. THE CONJUNCTlArA AND CORNEA. 491 Lithlasis, or calcification of the secretion of the Meibomian glands, appears in the shape of little white spots or elevations on the inner sur- faces of the lids. As they produce considerable irritation of the conjunc- tiva and cornea, they should be picked out with a needle-point after anesthesia with cocaine is secured. JCerosis is a term applied to a dry condition of the conjunctiva re- sulting from changes in the structure of this membrane and deficient supply of the secretions which moisten this surface. The indications are to remove, if possible, any chronic inflammatory condition, and keep the eye moist by artificial means. Fig. 505.—Sichel's iris knife. Fig. 506.—Daviels's curette. Cornea. Foreign Bodies and Wounds.—Non-penetrating wounds of the cor- nea should be thoroughly cleansed with warm boracic-acid solution, and the lids closed with a bandage until repair is effected. A penetrating wound should be treated on the same principle as the incision for cataract. A foreign body lodged upon or buried in the cornea should be at once removed. Anaesthesia with cocaine is essential. Oblique illumination by means of the convex lens is of value in locating the body. A clean needle or knife-point may be used in lifting the foreign substance out. Fig. 507,—Desnmrres's retractors. Keratitis, or corneitls, may originate from injury or disease of the cornea proper or by extension of the inflammatory process from the conjunctiva or sclerotic, iris or choroid. The symptoms are pain vari- able in character, interference with vision, especially if the infiltration occurs toward the center of the cornea, and the appearance of a cloudy film upon the normally clear and transparent membrane. Diffuse idiopathic keratitis usually commences at the periphery and travels toward the center. Occurring as a feature of a constitutional dys- pasia (syphilis, tuberculosis, etc.), both eyes are usually, though not simultaneously, involved. Abscess of the cornea may be recognized by the grayish-yellow color 01 the pus collection and the greater density of the membrane at this P°mt. In many cases the transudation or escape of the purulent liquid 492 A TEXT-BOOK ON SURGERY. takes place into the anterior chamber, and may be seen to occupy the lower portion of this space {hypopyon). Treatment.—In traumatic keratitis the removal of all irritation, dis- infection with warm boracic-acid solution, relief from pain by cocaine locally or morphia internally, and the exclusion of light by the dark room, bandage, or shade, are the indications. When the disease is secondary to inflammation in other parts of the globe or conjunctiva, the treatment should be directed to the original malady as well as to the protection of the cornea. Diffuse keratitis demands active constitutional treatment to increase nutrition and neutralize the virus of general infection. In abscess, ten- sion should be relieved by careful puncture. Penetration of the anterior chamber with the instrument should be avoided, unless the pus here is rapidly increasing ; it should then be evacuated. Pannus is a term applied to a condition of opacity of the cornea due to the formation of a vascular network beneath the epithelial covering of this membrane. It is associated with a conjunctivitis, the vessels really extending from the conjunctiva into the cornea. If the disease is due to chronic granular lids, entropion, distichi- asis, etc., the cause should be at once eliminated. In milder cases of persistent pannus a cure may be effected by excision of a zone of conjunctiva and subconjunctival tissue from around the cornea (Nettleship). In severer cases the local use of jequirity-bean is ad- vised. Prof. David AVebster recommends the following: One jequirity-bean coarsely powdered is placed in an ounce of water for four hours. The patient is then required to bathe the affected eye very freely with this solution for ten or fifteen minutes, letting some of it get into the eye. One thorough washing will usually produce the characteristic membrane of the conjunctiva. If this does not succeed, the operation should be repeated. Or the Fig. 508. bean, very finely pulverized, may be applied to the whole palpebral conjunctiva. A convenient shade or screen for the eye is shown in Fig. 508. Ulcus Cornea.—Ulcers of the cornea may follow injury, or the erup- tion of herpes or small-pox; they are met with in conditions of general malnutrition (syphilis, tuberculosis, etc.), and may also occur with in- flammation of the other structures of the eyeball, or of the lids or con- junctiva. Herpetic vesicles occur at times upon the cornea, either as herpes zoster ophthalmicus or herpes cornea febrilis (Swanzy). They appear as groups of clear vesicles, the superficial covering of the vesicle giving way within a few hours and leaving a shallow ulcer. In treatment, herpes, or the resulting ulcer, demands little beyond protection from THE CONJUNCTIVA AND CORNEA. 493 light, the removal of all irritation by the bandage, and the prevention of infection by careful aseptic irrigation. PhlyctenulcB of the Conjunctiva and Cornea.—Phlyctenular ulcers occur almost invariably in strumous subjects, either with or without any direct exciting cause. AVhen first noticed they are usually papules or pustules on the conjunctiva or cornea or both. There is, however, a localized hypersemia in and near the spots where the elevation occurs which precedes the papule or pustule. Break- ing down and discharging their contents, ulcers of variable extent are formed. They frequent- ly develop on the conjunctiva and sclerotic without invading the cornea. Not infrequent- lv, however, the process of ulceration travels Fig. 509. -, , -, ,-, . n .-1 -, Phlyctenula of the conjunctiva on and toward the center 01 the cornea, leav- and cornea. (Travers.) ing behind a trail of enlarged vessels, giving to the whole a comet-like appearance (Fig. 509). Perforation may follow in a certain proportion of cases. These ulcers may occur in all ages, but are chiefly met with after the third year and before the twenty-fifth year of life. Ulcus Serpens.—The acute serpiginous ulcer is probably due to in- fection. It commences as a grayish film or spot, breaking down from the center, leaving sharp, precipitous edges (as in phagedenic chancre), " one part of which is more densely opaque than the rest; this infiltrated ad- vancing edge is the distinguishing mark of the ulcer " (JNTettleship). Treatment.—In phlyctenular keratitis and conjunctivitis warm appli- cations of boracic-acid water are useful. Pain should be relieved as heretofore directed. If blepharospasm is present, canthotomy may be necessary. The ulcers should be stimulated locally by use of nitrate of silver to those on the conjunctiva, the mitigated stick; while weaker solutions (gr. v-x, ^ j) may be used for the corneal ulcers. In given cases the ulcers may be scraped out or burned with the fine galvano-cautery platinum wire. The prevailing dyscrasia should be corrected by appro- priate remedies. The nutrition should be increased, and an out-of-door life advised. In acute serpiginous ulcer active measures are often imperative, the phagedenic process marching rapidly to perforation and collapse of the globe. Hot boracic-acid water applications at intervals of an hour or two are advised for relief of pain. . Cocaine may also be instilled. If the ulcer does not remain stationary, it should be carefully and thoroughly burned with the cautery needle upon the same principle as for chan- croidal ulcer of the skin. AAxhen the serpiginous ulcer dips down into the deeper corneal tissue and undermines it, it should be laid open by incision in its entire extent, Staphyloma Cornea. —Bulging of a portion of the corneal surface may result from intra-ocular tension upon a point weakened by ulcera- tion or cicatrization. Conical cornea differs from this in being due to atrophic (not inflammatory) changes in the central portion of the cornea, 494 A TEXT-BOOK ON SURGERY. this part projecting by reason of intra-ocular tension. AAThen perfora- tion takes place, the aqueous humor escapes and usually carries the iris with it, this latter structure being caught in the opening, where it ad- heres. This condition is known as anterior synechia. When the staphyloma involves a limited portion of the cornea, iridec- tomy should be done, making the artificial pupil behind the best remain- ing surface of the cornea. In complete staphyloma, vision being lost, Critchett's operation is advisable. Five half-curved needles, threaded with fine strong silk, are passed from above downward through the sclerotic, being made to enter and exit half-way between the insertions of the recti muscles and the posterior edge of the staphyloma. AVhen operation for staphyloma. (Abadie.) tied. (Swanzy.) the point of each needle has emerged about one quarter inch, it is al- lowed to remain, and the staphyloma is divided by a horizontal incision. The flaps are now snipped off with the scissors about one twelfth inch in front of the needles, this line (see the dotted line, Fig. 510) being through the sound sclerotic. The needles are next drawn through and the sutures tied, as in Fig. 511. In conical cornea, if any operative interference is deemed advisable, the conicity should be reduced by inducing cicatrization at and about the apex of the projection. Von Graefe^s Method.—Just to one side of the apex of the cone re- move with the knife a small bit of the surface of the cornea without penetrating the anterior chamber. Every third day for about two weeks this wound should be touched with the mitigated pencil of nitrate of silver. Then puncture through this scar every second or third day for one week, evacuating at each puncture the aqueous humor. The wound is now allowed to heal. Nebula, macida, and leucoma, are terms used to designate degrees of corneal opacity—the first being so slight as to be scarcely discernible, the second a more serious lesion, while in leucoma the opacity is com- plete. The grayish ring seen at the corneal margin in many old persons —circus senilis—is due to fatty degeneration of the cells of the cornea, near the sclerotic junction. This condition occasionally exists in the middle-aged and in young children. AA7hile not a contra-indication to operative interference, that it suggests faulty nutrition should not be forgotten in prognosis. SCLEROTIC—IRIS. 495 Sclerotic. Simple incised wounds of the sclerotic heal readily. Lacerations are more serious by reason of the greater violence accompanying such inju- ries. No special treatment is demanded beyond rest and cleanliness. Scleritis.—Inflammation of the sclera is usually circumscribed, and may or not be accompanied by an appreciable thickening of this tunic. As a rule, the affection is not painful, unless it extends so widely that the choroid, cornea, or iris is involved. Treatment should be directed to the prevailing dyscrasia. It is met with as a late manifestation of syphilis, and is also a symptom of rheu- matism. No local medication is advisable, beyond the limited instilla- tion of atropine to prevent iritis. Rest, and light cloths wet in warm boracic-acid solution locally, are advised. A single thorough applica- tion of the actual cautery will frequently abort this disease, which under other methods of treatment usually lasts many months. Iris. Iritis is most frequently seen as a late manifestation of syphilis or in chronic rheumatism. It also may occur with inflammation of the cornea or sclera. The symptoms are abnormal immobility, thickening and cloudiness of the organ, irregularity of the pupillary margin, and adhesions to the anterior surface of the capsule of the lens (posterior synechias). The injected zone is usually of a pinkish color. Vision is more or less affected; and pain, though not always a symptom, is usu- ally present. In rare cases the pupil is occluded by the formation of a membrane from the products of inflammation. The treatment of iritis is local and general. To prevent permanent adhesions and to relieve pain, the instillation of atropine solution—gr. iv to water ^ j—is imperative. From one to two minims should be dropped in the conjunctival sac every hour, in the first few days of the attack. The degree of synechia is evident as soon as the iris is affected by the atropine, and even when the adhesions between the capsule of the lens and the iris are not completely relieved, firmer and more injurious adhe- sions will be prevented. Bloodletting at the temples, either by scarifica- tion and cups, or dry cupping, hot fomentations, etc., are local remedies of value. Rest to the eyes should be complete, and exposure to draughts or extreme changes in temperature are to be avoided. Any constitu- tional disease should be treated or any diathesis corrected by internal medication. Saline laxatives are indicated, as in other inflammatory affections. In extreme cases, when all other remedial agents fail, iridectomy may be necessitated. This operation will be described hereafter. The permanent changes to which the iris is subject, after iritis, are adhe- sions (synechia), atrophy of the curtain at one or many points as the effusion disappears, and changes in color due to absorption of the normal pigment. 496 A TEXT-BOOK ON SURGERY. Choroid and Ciliary Body. Choroiditis is occasionally of traumatic origin. The lines of rupture are seen most frequently near the optic disk, and in recent injuries may be concealed by extravasation. Idiopathic choroiditis occurs often in the tertiary step of syphilis. A less frequent variety is of tuberculous origin. The diagnosis rests chiefly upon examinations with the ophthalmo- scope. Disease is evident from the abnormal paleness due to atrophy and diminution of the blood-supply. It may be general and symmetri- cal in the two eyes (syphilis), or confined to one or more isolated patches (tuberculosis). In the syphilitic variety, changes in the retina are more evident. In very old persons an extensive area of atrophy may occasion- ally be observed, situated, as a rule, at the fundus. The indications in treatment are to correct the prevailing dyscrasia, by specific remedies and tonics, and to give the eye as complete rest as possible. Cyclitis occurs rarely except as in conjunction with inflammation of the sclerotic choroid or iris. Sympathetic ophthalmitis is a term applied to inflammation in one eye, followed by a like disturbance in and threatened destruction of the other. It is very apt to occur, after traumatic cyclitis, from a pene- trating body. Dislocation of the lens, iritis, or any inflammatory process, without penetration, and the entrance of air or a foreign substance, may also cause this form of ophthalmitis. The invasion from one eye to the other is now believed to be by means of septic bacteria traveling along the optic nerve and chiasm. AVhen once declared, the remedy of most avail is enucleation of the diseased eye. It is important that this operation be not too long postponed. The chief difficulty to be surmounted is to determine when it is necessary to operate. The following rules may serve as a guide : AVhen a penetrating septic body has entered the eye and destroyed vision, it would be wise to enucleate even before iritis and cyclitis are established, and if these symptoms of ophthalmitis are present, operation is imperative. Enucleation is indicated in an eye in which a foreign body is lodged with vision not materially impaired when the earliest symptoms of irido-cyclitis supervene. Idiopathic inflammation of the interior of the globe, which destroys vision, also indicates enucleation. Operation.—Seize the conjunctiva with a mouse-tooth forceps near the margin of the cornea, and with delicate scissors divide the conjunctiva evenly all the way around close to the cornea. Introduce the strabismus- hook and divide the internal muscle at its insertion into the globe. The other recti muscles are then successively divided. The ball is then car- ried toward the nose and a dull-pointed scissors curved on the flat is car- ried (concavity to the globe) backward and the nerve divided close to the ball. The attachments of the oblique muscles are next cut through. An artificial eye should not be worn until the stump is healed, which requires about five weeks. CHOROID AND CILIARY BODY. 497 Glaucoma.— This disease is almost always met with after the forti- eth year, and is more common in the hypermetropic than in the myopic eye. The prevailing symptom is an increased tension of the eyeball. Glaucoma may be acute, subacute, or chronic. In rare instances, it occurs with great rapidity (g. fulmlnans). More frequently it is slower in its progress. The earliest symptom is dimness of vision. Patients usually complain of indistinctness of sight, as if they were looking through frosted glass. These attacks are at first commonly periodic, but the interference with vision soon becomes permanent. Halos or rainbows are seen when an artificial light is looked at. The cornea has a dead and glazed appearance, the pupil is dilated, the anterior chamber shallow, and the iris is not so movable as normal. If the pulp of the finger is pressed upon the eyeball, it is felt to be hard and abnormally inelastic. Pain is not always present. Inflammation may or may not occur. Blindness sooner or later supervenes, unless prevented by treatment. The causes of glaucoma are, as yet, not satisfactorily explained. It is more generally held that obstruction of the efferent lymph-channels, or of the vessels which carry off the intravascular fluids, is the chief cause of this disease. Fig. 515. Fio. 516. Curved iris scissors. Drum for trying the edge of eye instruments. Treatment—The chief reliance is in Iridectomy. AArith the iridec- tomy knife, enter the anterior chamber by cutting through the sclerotic near the corneal border, exposing the upper margin of the iris for at least one fifth of its circumference. Divide the iris at one end of the incision in a line radiating from its pupillary margin to its ciliary attachment, by traction tear it from the ciliary attachment and divide 498 A TEXT-BOOK ON SURGERY. with the scissors at the other limit, severing one fifth of the membrane (Fig. 517). No particle of iris should be allowed to be caught and remain in the wound. The after-treatment consists in bandaging the eye, and complete rest. In mild cases, a smaller section of the iris should be made. The edge may be drawn out with the Fio.517.-lridectomyfor fOTCePS aJld * l0°P °f MS CUPPed °ff wlth &* glaucoma. (De Wecker.) scissors. Crystalline Lens. Cataract, or opacity of the lens, although chiefly encountered after the fortieth year of age, may occur at any period of life. It may be divided into—1, congenital or Infantile cataract; 2, cataract of adult and middle life (before forty); 3, senile cataract Cataracts are also classified according to their location in the lens— nuclear, or central; cortical, or peripheral; and capsular. Nuclear cataract occupies the center of the lens, either permanently, or spreads gradually until the organ is entirely involved. It is at first observed as an opacity or cloudiness immediately behind the pupil, white or amber-brown in color. Cortical cataract commences near the margin of the lens, behind the iris, and is characterized by grayish-white lines or streaks projected toward the center of the pupil. In the capsular variety the cloudiness or opacity is confined to the anterior shell of the capsule, the substance of the lens not being affected. Cataracts which are congenital, or only observed in early infancy, are classified as anterior polar, or pyramidal; lamellar, or zonular; cen- tral, posterior polar, and fusiform. All of these types are compara- tively rare. The anterior polar variety is due to the formation of a chalky concre- tion in the center of the anterior lamellse of the lens, caused by inflam- mation and perforating ulcer of the cornea in the early days of life. Operative interference is not called for. In lamellar or zonular cataract the opacity is limited to a thin layer of lens-substance, about half way between the nucleus and the anterior and posterior surfaces. The nucleus and peripheral portions are normal. AVhen vision is seriously interfered with by this form of opacity, it may be improved by Iridectomy or incision through the anterior layer of the capsule (discission). In some cases extraction is advisable. In central cataract the deeper fibers of the lens only become opaque. It may be treated in the same way as the zonular opacity. Posterior polar cataract is seen deeply behind the center of the lens. Operative treatment is rarely demanded, and when indicated discission is advised. Fuslfwm opacity extends from the posterior to the anterior pole. It is very rare. Cataracts are primary when the opacity is developed independent of any other lesion of the eye, and secondary when some other lesion exists. CRYSTALLINE LENS. 499 A traumatic cataract occurs as a result of rupture of the capsule, with or without perforation, allowing the aqueous humor to invade the crys- talline substance. A Morgagnian cataract is one in which partial lique- faction of the cortex has taken place, and the nucleus drops to the lowest portion of the capsule. The opacity occurring in diabetes mellitus is called diabetic cataract. Cataracts are also termed senile, hard, and soft. Senile cataract oc- curs, as its name implies, in old persons, usually very late in life, but not unfrequently as young as the fortieth year. This variety, though usually firm or hard, is at times soft. Under forty years cataracts are usually soft. A cataract is said to be "ripe" when the entire lens has become opaque. Symptoms and Diagnosis.—AVith senile cataract the earlier symp- toms are disturbance of vision. Indistinctness of vision for distant ob- jects is usually first noticed, and, in certain cases, multiple images of one object are observed. If the cataract is nuclear or central, vision is im- proved by shading the eye, thus allowing the pupil to dilate. In cortical cataract this is not the case, but by dilatation of the pupil with atropine the presence of the peripheral opacity may be detected. AVhen a cata- ract is general and ripe, blindness for objects is complete, although light and darkness are appreciable. Examined in ordinary light a well-marked nuclear cataract may be recognized; but it is by focal illumination and by the ophthalmoscope that a diagnosis is positively made. The pupil should be dilated. A large nucleus with very fine radiating strise indicates a hard cata- ract, while a small nucleus and large strise suggest a soft opacity. If the cataract be ripe, no clear space will be discovered between the nucleus and the iris, and no shadow will be thrown upon the nucleus by the iris. Focal (oblique) illumination—i. e. concentrating by means of a prism the rays of a strong light let fall obliquely upon the cornea—is essential in this examination. By the ophthalmoscope the normal red reflex from the fundus is absent (Swanzy). As it is important to have a cataract ripe when an operation is under- taken, Foster submits the following general guide : Cataracts which are ripe, according to the tests just given, and in which there are no sectors shining like mother-of-pearl, are considered ripe for operation. In color they are white, yellow, or gray ; also when the lens is wholly occupied with a brownish-yellow nucleus. This may be semi-transparent, and the iris throw a distinct shadow. Treedment—When a cataract is not ready for operation, the vision may be improved by glasses, which shade the eyes, allowing the pupil to dilate, and by the instillation of weak atropine solution. These measures apply to opacities at or near the antero-posterior axis of the lens. Opacities of the lens may be removed by three methods : Solid extrac- tion, absorption after discission, and suction. The first method is ap- plicable to all forms of ripe cataract; the lamellar, central, posterior polar, and fusiform varieties are treated by discission when any opera- tive interference is indicated ; soft opacities are removable by suction. 500 A TEXT-BOOK ON SURGERY. Extraction is not imperative when only one lens is affected, vision being about perfect in the other, unless the cataract is becoming over- ripe. It is advisable to remove only one lens at a single operation, even in double ripe cataract. Operation is not advisable when any serious intraocular complication exists, or when insurmountable opacity of the cornea is j)resent. It is always advisable to allay any existing inflammation of the ball or ap- pendages before an operation for cataract. AAThen a cataract is not ripe, its solidification may be hastened by massage of the globe—that is, by pressure applied over the ball with the tips of the fingers. The massage should last a few minutes, and be repeated every few days as indicated. Operation of Extraction.—Two principal methods of extraction are at present employed, viz., (1) simple extraction and (2) extraction after Iridectomy. The former is the ideal operation, and, although at this date not so generally employed, is fast gaining in popularity. Fio. 518.—Graefe's speculum. Simple Extraction.—The most careful asepsis is demanded. The eye should be irrigated with warm boracic-acid solution (gr. x-xv to gj). The instruments should be thoroughly cleansed by boiling and immer- sion in alcohol. Ansesthesia is obtained by dropping several minims of 2-per-cent cocaine hydrochlorate into the eye, five minutes, and again three minutes, before the operation. The head should be so held that Fig. 519. —Graefe's fixation forceps. the cocaine rests in contact with the upper surface of the cornea through which the incision is made. AArhen ready to operate, the eye and con- junctival sac should be dried with absorbent boracic-acid cotton pellets. The speculum is introduced and secured, and the conjunctiva seized with fixation-forceps just below- the center of the lower margin of the cornea. The ball is drawn slightly downward and steadied, while the Fig. 520.—Graefe's linear knife. knife, cutting edge upward, is entered through the cornea just at the corneo-sclerotic junction, carried carefully across in front of the iris, which must not be touched, and out at a point corresponding to that of entrance (Fig. 521). By careful to-and-fro movements, the flap EXTRACTION. 501 is made by cutting upward through the cornea just anterior to the sclerotic junction. The line between the angles of this flap should cross the cornea a little more than one third the distance from the up- per to the lower margin. As this section is being made, and before the aqueous humor escapes, an as- sistant should slightly lift the spec- ulum, so that no pressure may be made by it upon the ball. The cystotome is now carried through the wound, kept clear of the iris by the operator, who very cautiously scratches through the an- terior capsule, through the whole width of the pupil. Care must be taken not to press so hard against the lens as to dislocate it. As soon as the capsule is opened, gentle pressure in an upward direction should be exercised by means of the spoon against the lower margin of the cor- nea, or pressure with the finger on the lower lid may suffice to deliver the Fig. 521. — Introduction of Graefe's knife, show- ing size of corneal flap in extraction of cata- ract. (Swanzy.) Fig. 522.—Cystotome and Daviels's spoon. lens through the pupil and out through the wound of incision. The pressure should be carefully gauged to effect only the exit of the cataract, and not to rupture the zonula. The wound should now be examined, and no particle of iris, lens, or capsule should be left in the incision. A drop of eserine solution (gr. ij-§ j) is now instilled into the conjunctival sac in order to contract the pupil. The eye is finally irrigated with the boracic- acid solution and the dressing applied, and both eyes closed by bandaging. The patient is required to remain quiet in a light room for a week. The first change of dressing should be made on the second day, and daily thereafter. Strict asepsis is essential at each change of dressing. The light should be excluded only from the eyes by bandages and shades, and not from the room. At the end of a week or ten ddVs a black silk shade may be substituted for the bandages, and in from two to three weeks the patient will need only medium smoke coquilles to protect his eyes from the strong light. He should not be fitted with cataract glasses until all signs of redness and sensitiveness have disappeared. Extraction with Iridectomy.—The speculum is introduced and se- cured, and the ball steadied by grasping a fold of the conjunctiva, just below the center of the lower margin of the cornea (Fig. 521), with a mouse-tooth fixation-forceps. The ball is drawn slightly downward, and the A^on Graefe knife, edge upward, is made to enter the cornea, just at the sclerotic junction, at a point three milimetres (about one eighth of an inch) below the highest margin of the cornea (or about one third of the distance between the upper and lower margins of the cornea). The 502 A TEXT-BOOK ON SURGERY. point is then made to emerge accurately opposite the entrance, when, by a gentle movement of the knife, the flap is completed by cutting thro'uo-h the cornea, just anterior to its junction with the sclerotic. As this flap^is made, a certain proportion of the aqueous humor escapes. The fixation- forceps being, at this stage, transferred to an assistant, the iris-forceps are introduced, and the iris seized at a point corresponding to the center of the incision, and carefully drawn out through the wound. A narrow strip, including the entire depth of the iris, is then excised. As soon as the iridectomy is completed the operator relieves the assist- ant of the fixation-forceps, directs that the speculum be lifted, so that no pressure is made on the eyeball, while, with the cystotome carried into the anterior chamber, he freely scratches through the anterior layer of the capsule. Care must be taken not to press so hard against the lens as to dislocate it. It is also important to see that no shred of the capsule is dragged out into the wound in withdrawing this instrument. The globe should now be depressed, either with the forceps or by the patient's volition, and the cataract extracted by gentle pressure with the spoon from the lower margin of the cornea upward. The pressure should be carefully gauged, and the wound examined as above described. Should bleeding occur, this may be checked by a light compress of cold boracic solution. The after-treatment is the same as just given. If the primary incision should not be large enough to allow the easy escape of the lens, it should be enlarged, preferably with the iris-scissors; it should be free, to begin with. If any fragments of the lens adhere to the capsule or are caught in the wound, they must be worked out by careful manipulation. Should the zonula be ruptured, allowing the vit- reous to escape, the lens should be extracted with the scoop. The vitre- ous should be divided with the scissors at the level of the wound. Should septic infection occur, suppuration of the wound follows, with usually destruction of the eye. The treatment should be frequent irriga- tion with boracic-acid solution, and the galvano-cautery wire applied to the margins of the wound. AVhen iritis is precipitated, atropine should be instilled and warm boracic-acid water dressings applied. Strong convex glasses are necessary after the operation, but the eyes should not be used for reading, etc., for three or four months. Two pairs of glasses should be prescribed-one for reading and another tor vision. Discission.— After dilatation with atropine, ether or chloroform should be administered to prevent any movement which might displace the lens, the speculum introduced, and the field of operation ren- dered aseptic. G.T1EMANN&C0 , Fig. 523.—Beers's straight needle. The point of the cataract-needle is made to pass through the cornea near the outer margin, and the point carried to the center of the pupil, where it enters the capsule of the lens (Fig. 524). The capsule and the THE VITREOUS.—THE RETINA. 503 anterior superficial layers of the lens are torn open by gentle move- ments of the point of the instrument, which is then withdrawn, being careful not to injure the iris. The pupil should be kept fully dilated, renewing the instillation every few hours, if necessary, for several days. Cold ap- plications and a dark room are the chief indications in the after-treatment. If successful, the lens becomes opaque after a week or more, and gradually disap- pears by absorption. A second operation may be necessary. Suction.—Dilate with atropine, admin- ister ether, incise the cornea half-way between its center and margin, perform discission, and introduce the nozzle of the syringe into the lens, when it and the capsule are broken up. The softened lens is sucked into the cylin- der by steady and gradual traction on the piston. Strict asepsis is essential. A single introduction of the instrument is advisable. The after-treatment is the same as for discission. Fig. 524. — Introduction of the needle in discission. (Swanzy.) The Vitreous. Hyalitis, or inflammation of the vitreous, may result from trauma- tism, with or without the presence of a foreign body, or by the exten- sion of some idiopathic inflammatory process from the choroid, iris, on any portion of the globe. Syphilitic choroiditis is especially apt to produce hyalitis. The immediate symptom is opacity due to extravasa- tion of blood, or the exudation of the products of inflammation. The vitreous breaks down, becoming more fluid than normal (synchisis). Flakes or small collections of more solid matter may be seen to change position as the position of the globe is changed. "Spots before the eyes" (musca volitantes) occur chiefly in myopic subjects, and are due to changes in the vitreous. The exact condition of the vitreous can usually be made out by care- ful examination with the ophthalmoscope. Foreign bodies, when composed of small bits of metal, may be removed by the electro-magnet. Should the wound in the sclerotic be not suffi- cient, it should be enlarged and the middle of the magnet carried into the vitreous. The metal, if not impacted, adheres to the magnet and is with- drawn. AArhen the foreign body is non-metallic, operative interference is of doubtful propriety unless general inflammation is taking place. Idio- pathic hyalitis should be treated by rest to the eye and by special medi- cation. The Retina. Inflammation of the retina (retinitis) may occur independently of lesion of any other portion of the eye, or it may be part of an infiam- 504 A TEXT-BOOK ON SURGERY. mation of the choroid, ciliary body, iris, vitreous, or by extension from the optic nerve. It is not uncommon in syphilis, and follows thrombosis and embolism of the vessels. It is met with in nephritis, in diabetes, and in severe cerebral hypersemia. Detachment of the retina from the choroid may be due to extravasa- tion of blood or transudation of serum. All these conditions may be determined by a careful analysis of the symptoms present and by ophthalmoscopic examination. The indica- tions in treatment are chiefly to correct the general condition of disease on which the retinitis depends. AVhen of traumatic origin, the chief reliance is upon complete rest and warm fomentations. In certain mor- bid conditions of the external portions of the retina, objects appear unusually small (micropsia). The opposite of this condition is known as megalopsia. Night-blindness (hemeralopia) is usually only a symptom of retinitis pigmentosa, but sometimes occurs in other diseases of the retina and optic nerve. % Day-blindness (nyctalopia) is generally due to exposure to strong light, as the glare of the ocean in the tropics, and may occur in persons of faulty nutrition. Optic Neuritis.—The optic nerve is at times the seat of neuritis which may originate here, or descend from the brain along the nerve; it may be secondary to retinitis, or become involved by contact with morbid changes occurring in the lymph spaces and other tissues contiguous to it. The subjective symptoms are varying degrees of interference with vision. Amblyopia (dimness of sight), or amaurosis (complete blindness), may be present. These symptoms may be present without perceptible change in the appearance of the retina or optic papilla. AAThen the lesion is be- yond the disk, atrophic or other changes of the papilla may be recognized by the ophthalmoscope. In some instances the obliteration of the retinal image is confined to a portion of the field of vision, usually one half (hemianopsia). If one eye only is involved, the lesion is peripheral and limited to the nerve or retina of the affected eye. If binocular, the lesion is in or posterior to the optic chiasm. The inner half of one and the outer half of the other eye are usually obscured. Color-Blindness.—There is a congenital defect of the retina in which the individual is incapable of recognizing certain colors, as red, green, and blue ; a little more than three per cent of males are so affected. Of thirteen hundred and eighty-three men in the employment of the Penn- sylvania Railroad Company examined by Dr. AVilliam Thomson, fifty- five were absolutely color-blind. It is less common in women. The usual method of testing is that with Professor Holmgren's colored wool- en threads. If the patient is wholly color-blind, he will be unable to differentiate between the principal colors. Partial color-blindness may be detected by a careful test with the woolen threads, requiring the suspected person to match to the leading colors those which to him appear of the same or nearly the same shades. STRABISMUS. 505 Strabismus. Strabismus, or "squint," may be convergent or divergent. The for mer is by far the more frequent variety, and is usually observed in young children. It results from a loss of the normal equilibrium in the mus- cles of the eye, and when first noticed is often intermittent, appearing in one eye and then the other (alternating). As a result of prolonged and repeated efforts at accommodation (contraction of the ciliary muscle causing relaxation of the zonula, with consequent increase in the antero-posterior diameter of the lens), the internal rectus becomes permanently shortened. The degree of convergence may be determined by the strabis- mometer (Fig. 525). Let the pa- tient fix his vision on a distant point directly in front of him ; place the center of the instrument directly beneath the center of the pupil, and measure the distance from this point to the inner angle of the eye. The same measurement on the affected side will determine the degree of convergence on that side. Treatment— Tenotomy is indicated in convergent strabismus for the relief of deformity, as well as for the correction of vision. The prospect of a perfect result is better in recent cases than in those of long standing, in which the external rectus has been overstretched and permanently weakened. In children, about the seventh year is the best period for e.t«»Mi» a.to. Fig. 525.—Lawrence's strabisniouieter B.TIEMANNiCO Fig. 526.—Graefe's strabismus hook. operation. Tenotomy of the internal rectus is thus done : The conjunc- tiva is first ansesthetized with cocaine solution, and two to four minims may be injected into and beneath the conjunctiva, immediately about the insertion of the muscle. The speculum is introduced, and the con- junctiva, just on the inner side of the eye, picked up with the forceps and divided with the scis- sors. The strabismus- hook (Fig. 526) is next carried into this opening and guided beneath and behind the tendon of the rectus internus, which is pulled forward and di- vided at its insertion into the sclerotic. The hook should be again introduced, to make sure that a thorough division w effected. A pad of cotton dipped in boracic-acid solution, held in 35 Fig. 527.—Strabismus scissors. 506 A TEXT-BOOK ON SURGERY. place by a dry cotton compress and bandage, should be worn for one or two days. AVhen strabismus makes its appearance in adult life, it is usually due to paralysis, partial or complete, of one or more of the orbital muscles. The lesion producing paralysis may be situated in the brain or in the orbit. Disease of the bones about the foramina of exit of the nerves which supply these muscles, the presence of syphilitic gummata, or any neoplasm, will produce, by pressure on the nerves or muscles, a more or less complete paralysis. Rheumatism is occasion- ally a cause of strabismus. In the treatment of strabismus due to paralysis, operative interfer- ence is not indicated until all other remedial agents have been exhausted in vain. AVhen operation is demanded, not only should division of the contracted muscle be effected as just described, but the weaker muscle may be shortened by advancing its Insertion. Take, for example, the external rectus. Perform tenotomy as here- tofore described. A small curved needle is threaded with fine silk and carried from the ocular side out through the divided muscle and the conjunctiva. Each end of this double suture is now threaded to a curved needle and passed beneath and through the conjunctiva, coming out near the margin of the cornea and about one eighth of an inch from the vertical meridian of the eye above and below (Fig. 528). The needles are cut away, and the two ends of the lower threads tied together, at the same time that an assistant ties the upper ends. These sut- ures are allowed to remain about forty-eight hours. The amount of shortening in the mus- Fig. 528.-Advancement of the cle advanced can be increased by carrying the rectus. (De Wecker.) first needle farther back through the muscle. In order to get the best possible result, the shortening should be slightly more than appears necessary at the time of operation. Refraction.—The Ophthalmoscope.* By the refraction of the eye we mean its power, when in a state of rest, of bringing parallel rays of light to a focus. In normal refraction, or emmetropla, the focus for parallel rays is upon the retina (Fig. 529). AYhen the focus for parallel rays is not on the retina, there is said to be an error of refraction. The term ametropia includes all the errors of refraction. The principal forms of ametropia are : 1, myopia ; 2, hyper- metropia. All the other forms of ametropia are included under the head of astigmatism, in which the refraction differs, in degree or kind, in opposite meridians of the same eye. * The author desires to acknowledge his indebtedness to his friend, Prof. David Webster, M. D., by whom this article on Refraction was written. REFRACTION.—THE OPHTHALMOSCOPE. 507 The difference in refraction of eyes is due to their difference in shape. AVhile the emmetropic eye is nearly spherical, the myopic eye Fio. 529.—Showing concentration of rays of light (a, b, c) on the retina (d) in normal refraction. (Swanzy.) is egg-shaped—too long in its antero-posterior diameter; and the hyper- metropic eye turnip-shaped—too short in its antero-posterior diameter. Thus, while the principal focus of the emmetropic eye is upon the retina, Fio. 530.—Showing rays converging to focus (at a) behind the retina (b, c). The hypermetropic eye. (Swanzy.) that of the hypermetropic eye is behind the retina (Fig. 530), and that of the myopic eye in front of it (Fig. 531). Fig. 531.—Showing concentration at (/) of rays of light (a, b) in front of retina (c, d) in myopia. (Swanzy.) Astigmatism is usually due to asymmetry, or irregularity of sur- face, of the cornea, probably sometimes to a like condition of the lens. The varieties of astigmatism are six in number: 1, simple myopic; 2, compound myopic; 3, simple hypermetropic; 4, compound hyper- metropic ; 5, mixed,; and, 6, irregular astigmatism. In simple myopic and simple hypermetropic astigmatism, the princi- pal focus of one meridian of the cornea is upon the retina, while the principal focus of the opposite meridian is anterior to the retina or be- hind it, accordingly as the astigmatism is myopic or hypermetropic. In compound myopic astigmatism all the meridians of the eye are 508 A TEXT-BOOK ON SURGERY. myopic, but one of them more so than any of the others, and the merid- ian at right angles to it less so than any of the others. In compound hypermetropic astigmatism all the meridians of the eye are hypermetropic ; but one of them more so than any of the others, and the meridian at right angles to it less so than any of the others. In mixed astigmatism one meridian of the eye is myopic, while the opposite meridian is hypermetropic. In irregular astigmatism different parts of the same meridian possess different degrees of refraction. Hence this form of astigmatism is the only error of refraction, which can not be cor- rected by glasses. It is, in every sense of the word, irremediable. It is obvious that persons with emmetropic eyes, and with unim- paired accommodation and well-balanced ocular muscles, do not need spectacles. Persons with any of the different forms of ametropia are liable to become the subjects of asthenopia from eye-strain. Such per- sons complain of inability to use their eyes, pain in their eyes and tem- ples, headache, nausea, and various nervous disorders. Hypermetropia is congenital, as a rule, and is said to be due to an arrest of development of the globe in its antero-posterior axis. It i.j sometimes the result of changes in the refractive media, as in the harden- ing of the crystalline lens that occurs in old age, or the removal of the lens by operations for cataract. Parallel rays of light passing through the hypermetropic pupil do not meet on the retina, but converge toward a point behind it. Objects are, therefore, seen under circles of diffusion ; and such eyes, in order to see distinctly, contract their ciliary muscles sufficiently to so increase the convexity of the crystalline lens that the focus will be brought for- ward upon the retina. This act is involuntary, and produces more or less strain upon the eyes. For such persons the strongest convex spher- ical glasses should be selected with which they can distinctly see objects distant twenty feet or more. If the asthenopic symptoms only accom- pany or follow the use of the eyes for reading and other near work, it may be sufficient to wear the glasses only for the near. But when the asthenopic symptoms are constant, and are only aggravated by near work, the glasses should be worn constantly. In selecting glasses for the relief of asthenopia, no matter what the error of refraction, it is always well to examine the eyes with the pupil dilated. AVhile sulphate of atropia is the most reliable mydriatic, if used in solution sufficiently strong to paralyze the accommodation, it incapacitates the eyes for near vision for at least ten days. AVhen the object is to ascertain the true refraction with as little in- convenience to the patient as possible, it is sufficient for all practical purposes to drop into, the eyes a few minims of a 3-per-cent solution of homatropine hydrobromate at intervals of fifteen minutes, until seven or eight instillatious have been made, and to test the refraction ten or fifteen minutes after the last instillation. If the homatropine produces redness of the eyes, as is often the case, this may be relieved by a single instillation of a 4-per-cent solution of cocaine hydrochlorate, which, at the same time, increases the effect of the homatropine in paralyzing the REFRACTION.—THE OPHTHALMOSCOPE. 509 ciliary muscle. The effect of these mydriatics passes off inside of twenty- four hours. In cases where it is desirable that the patient should have the benefit of a prolonged rest of his accommodation, regardless of in- convenience, it is better to use the sulphate of atropia (a 1-per-cent solution). In some cases of asthenopia from hypermetropia, glasses correcting the total error of refraction are worn with comfort from the start. In the majority of cases, however, when the accommodation reasserts itself, such glasses make the eyes practically myopic, and the indistinctness of vision thus produced so annoys the patient that he rejects them. It is safer, therefore, to wait until the hypermetrope has recovered from the effects of the mydriatic, and then to order the strongest convex glasses that he can wear with comfort. AAThen his eyes have become accustomed to these, they should be exchanged for stronger ones, and these changes should be repeated at intervals of two or three months until the total hypermetropia is corrected. After that it is probable that the patient will need no further change of glasses, and that the relief of his asthe- nopia will be permanent. Myopia may be apparent or real. Apparent myopia is due to spasm* of the ciliary muscle, and may be diagnosticated from true myopia by ascertaining the true refraction under the effects of atropine. Spasm of the ciliary muscle is usually the result of over-use of the eyes. Such patients should be kept under atropine for several weeks, wearing me- dium smoked coquille glasses to protect the retina from excessive light. When the spasm of the ciliary muscle fails to reassert itself after the use of the mydriatic is stopped, convex glasses, correcting the hyperme- tropia, which almost always exists in such cases, should be substituted for the coquilles, and the patient should be cautioned not to resume the excessive near use of his eyes. True myopia is the result of the lengthening of the antero-posterior diameter of the eyeball, and is rare- ly congenital. There often exists a hereditary tendency to myopia; and it is a matter of common observation, that where the father or mother is myopic the children are apt to develop the same condition during school-life. Myopia is frequently developed in children, however, where there is no traceable hereditary tendency. It almost invariably first shows itself during early school-life, and the first intimation of it is that the child fails to see the letters and figures on the blackboard across the school-room. It is encouraged by the use of the eyes by insufficient light in a vitiated atmosphere, and in a stooping position, during the period when the eyes are undergoing rapid development along with the other organs of the body. It is of the greatest importance that it should be arrested as soon as possible ; for highly myopic eyes are nearly always diseased eyes, and are in great danger of developing staphyloma posti- cum, retinal and choroidal changes, floating bodies in the vitreous, and detachment of the retina. Myopic patients should be fitted with glasses at as early a period as possible, the weakest concave glasses being selected for them, with which they can see distant objects distinctly. They should wear such glasses constantly ; by so doing, arrest of de- 510 A TEXT-BOOK ON SURGERY. velopment of the ciliary muscle will be avoided, as will also excessive strain upon the interni. Attention to their general health should not be neglected, and the amount of use of their eyes for near work should be limited. Their eyes should be tested at least once in six months, and a careful record kept of the results of such testings, for it is only in this way that we can tell whether the myopia is stationary or pro- gressive, and, if the latter, whether rapidly so or not. If the myopia is increasing rapidly, near work should be entirely stopped, and the patient should be put upon atropine and colored glasses, and turned out into the open air. Myopia usually ceases to be progressive somewhere between the ages of twenty and thirty. Aside from all consideration of the health of the eyes, myopes should wear the correcting glasses for educational reasons. Fig. 532.—Nachet's trial-set. Astigmatism, especially when only slight and correctable by an un- equal contraction of the ciliary muscle, is a prolific source of asthenopia. AA7hen it exists in the higher degrees, the patient makes no attempt to correct it; sees indistinctly at all distances, and is comparatively free from asthenopic symptoms. The slighter degrees, then, should be cor- rected with glasses for the relief of asthenopia ; the higher degrees for the purpose of procuring distinct vision. Of course, in fitting patients with glasses for the correction of astigmatism, convex and concave cylin- drical lenses are necessary. For simple hypermetropic astigmatism that- convex cylindrical glass should be selected which brings the focus of TESTING FOR GLASSES. 511 the hypermetropic meridian forward upon the retina, and thus makes distinct vision possible without an effort of accommodation. For sim- ple myopic astigmatism the concave cylindrical glass should be selected which throws the focus of the myopic meridian back upon the retina, and thus renders the eye practically emmetropic. For compound hyper- metropic astigmatism a convex spherical with a convex cylindrical glass is necessary ; while in compound myopic astigmatism the error of refrac- tion is corrected by the combination of a concave spherical and a con- cave cylindrical glass. Mixed astigmatism is corrected by a convex cylindric and a concave cylindric combined, and with their axes at right angles to one another. In prescribing glasses for astigmatism the greatest care should be taken to adjust the axes properly. The cylindric trial-glasses should always be placed before the eyes in trial-frames made for the purpose, and the direction of the axes read in degrees from the frames. Ophthal- mologists use Snellen's test-types in examining for errors of refraction, and the cases of trial-glasses made by Nachet (Fig. 532) are as good as any. Testing for Glasses. For determining errors of refraction and fitting patients-with spec- tacles, the surgeon should provide himself with Snellen's and Jaeger's test-types and with a case of trial-glasses, including spherical and cylin- drical glasses, convex and concave, trial-frames with the degrees of a semicircle marked upon them, etc. The patient should be placed at a distance of twenty feet from Snellen's test-type, with, the light shining upon the test-type and not upon the face of the patient. Each eye should be tested separately, the other being kept open and covered with a screen. Snellen's test-type is so constructed that the letters in each line sub- tend an angle of five minutes at the distance marked in feet above the line. The line marked 100 should therefore be read at one hundred feet ; that marked 20, at twenty feet, etc. Vision is recorded fractionally, the distance from the test-type being set down as the numerator, while the number of the line read is set down as the denominator. Thus, if a person with his right eye reads Snellen No. 70 at twenty feet, the vision would be recorded thus : R. V. — f£. If with his left eye he reads Snellen No. 20 at twenty feet, it is recorded L. V. = £#. The vision of the right eye would be two sevenths of the normal, while that of the left eye would be one, or normal. If a patient reads §# with each eye, we know that his vision is perfect in both eyes, but still he may be hypermetropic, and straining his accommodation in order to see distinctly. AAre should always test such a patient with convex spherical glasses. If the weakest glass blurs his vision, he has no manifest hypermetropia. The vision and refraction of such a patient should be recorded thus : R. A". = f$; E. L. X. = |f; E. (emmetropic). If the patient can read Snellen No. 20 at twenty feet through a convex spherical glass, the strongest one through which he can read it represents Ms manifest hypermetropia. Thus— 512 A TEXT-BOOK ON SURGERY. r. y. = 20 . Hm. 1-75 D. L. Ar. = f#; Hm. 1-50 D. would mean that the patient had perfect vision without a glass, or with any convex spherical glass from the weakest up to + T75 D., right eye, and + 1/50 D., left eye ; but that stronger glasses than those indicated would blur his vision. Those glasses should, therefore, be prescribed. If the patient sees less than f#, we may suspect myopia or astigmatism. For instance, the formula— R. V. = ffo ; U with - 4 D. L. V. = ^fr; ffr with -3D. means that, without glasses, the patient sees -ffo with his right eye, and T2o°o with his left eye, and that — 4 dioptries is the weakest concave glass with which he can read fft with his right eye, and — 3 dioptries the weakest with which he can read §£ with his left eye. * Again, the patient may be astigmatic. Suppose we find— •j. r. v. = u; U with + 1-25 D- c- ax- 90°- L. V. = f g-; ffr with + 1 D. s. C + 1*50 D. c. ax. 90°. AVe have here simple hypermetropic astigmatism in the right eye, and compound hypermetropic astigmatism in the left. In the right eye, the vision is brought up to §$- by a convex cylindric, one and a quarter diop- tries, axis 90° ; while in the left the combination of a convex spherical and a convex cylindrical is required. In another case— R. V. = ^o-V; ff with - 3-25 D. c. ax. 180°. L. V. = TJI-o ? f