THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. VOL. II. THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY A SYSTEMATIC TREATISE ON THE THEORY AND PRACTICE OF SURGERY BY AUTHORS OF VARIOUS NATIONS EDITED BY JOHN ASHHURST, Jr., M.D. PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PENNSYLVANIA HOSPITAL, ETC. .LUSTRATED WITH CHROMO-LITHOGRAPHS AND WOOD-CUTS IN SIX VOLUMES VOL. II. ' REVISED EDITION NEW YORK WILLIAM WOOD & COMPANY 1888 Copyright : WILLIAM WOOD & COMPANY 1 8 87. THE INTERNATIOIAL ENCYCLOPEDIA OF SURGERY. ARTICLES CONTAINED IN THE SECOND VOLUME. Contusions. By Hunter McGuire, M.D., Formerly Professor of Surgery in the Medical College of Virginia, Richmond. Page 1. Wounds. By Thomas Bryant, F.R.C.S., Surgeon to, and Lecturer on Surgery at, Guy’s Hospital, London. Page 11. The Antiseptic Method of Treating Wounds. By W. Watson Cheyne, M.B., F.R.C.S., Assistant Surgeon to King’s College Hospital and Demonstrator of Surgery in King’s College, London. Page 63. Poisoned Wounds. By John H. Packard, M.D., Surgeon to the Pennsyl- vania Hospital and to St. Joseph’s Hospital, Philadelphia. Page 85. Sabre and Bayonet Wounds ; Arrow Wounds. By J. H. Bill, M.D., Sur- geon and Brevet Lieutenant Colonel, United States Army. Page 103. Gunshot Wounds. By P. S. Conner, M.D., Professor of Surgery and Clinical Surgery in the Medical College of Ohio, Cincinnati; Professor of Surgery in the Dartmouth Medical College, etc. Page 121. Venereal Diseases: Gonorrhoea. By J. William White, M.D., Clinical Professor of Genito-urinary Diseases in the Hospital of the University of Pennsylvania; Surgeon to the Philadelphia Hospital, Philadelphia. Page 219. Venereal Diseases: The Simple Venereal Ulcer or Chancroid. By F. R. Sturgis, M.D., Professor of Venereal Diseases in the University of the City of New York (Medical Department); Visiting Surgeon to the Third Venereal Division of Charity Hospital, Blackwell’s Island, etc., New York. Page 301. VI THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. Venereal Diseases: Syphilis. By Arthur Van Harlingen, M.D., Pro- fessor of Diseases of the Skin in the Philadelphia Polyclinic; Consulting Physician to the Dispensary for Skin Diseases. Philadelphia. Page 341. Venereal Diseases: Bubon d’Emblee, Venereal Warts or Vegetations, Pseudo-Venereal Affections, Venereal Diseases in the Lower Animals. By H. R. Wharton, M.D., Instructor in Clinical Surgery in the University of Pennsylvania; Surgeon to the Children’s Hospital, etc., Philadelphia. Page 481. Injuries of Blood Vessels. By John A. Lidell, A.M., M.D., late Surgeon to Bellevue Hospital; also late Surgeon U. S. Volunteers in charge of Stanton U. S. A. General Hospital, Inspector of the Medical and Hos- pital Department of the Army of the Potomac, etc. Page 495. Surgical Diseases of the Vascular System. By John A. Wyeth, M.D., Professor of Surgery in the Hew York Polyclinic; Surgeon to Mt. Sinai Hospital, Hew York. Page 775. Aneurism. By Richard Barwell, F.R.C.S., Surgeon to Charing Cross Hospital, London. Page 825. ALPHABETICAL LIST OF AUTHORS. (YOL. II.) RICHARD BARWELL, J. H. BILL, THOMAS BRYANT, W. WATSON CHEYNE, P. S. CONNER, JOHN A. LIDELL, HUNTER McGUIRE, JOHN H. PACKARD, F. R. STURGIS, ARTHUR VAN HARLINGEN, H. R. WHARTON, J. WILLIAM WHITE, JOHN A. WYETH. VII CONTENTS. PAGE: List of Articles in Vol. II. ...... v Alphabetical List of Authors in Vol. II. . . . . vii List of Illustrations ....... xxxvii CONTUSIONS. By HUNTER McGUIRE, M.D., FORMERLY PROFESSOR OF SURGERY IN THE MEDICAL COLLEGE OF VIRGINIA, RICHMOND. Definition ......... 1 Causes of contusion ........1 Degrees of contusion . .. .....2 Symptoms of contusion . . .....3 Shock .........3 Pain .........3 Swelling ......... 3 Medico-legal import of extravasation and ecchymosis . . 4 Discoloration ...... * . 4 Vesicles or blebs . . . .... 4 Absorption or organization of extravasated substances ... 5 Prognosis of contusions . . . .... 6 Treatment of contusions . . . ... 6 Constitutional treatment ...... 8 Strangulation of parts •*•-...9 Treatment of strangulation ...... 9 Brush-burn •••*....,9 Treatment • •*•«... 10 IX X CONTENTS. WOUNDS. By THOMAS BRYANT, F.R.C.S., SURGEON TO, AND LECTURER ON SURGERY AT, GUY’S HOSPITAL, LONDON. PAGE Open and subcutaneous woundc, . . . . . .11 Classification of open wounds . . . . . . .11 Incised wounds . . . . . . . .12 Gaping of incised wounds . . . . . .12 Hemorrhage from incised wounds . . . . .12 Pain of incised wounds . . . . . . .13 Local and constitutional effects of incised wounds . . . ,13 Local effects . . • . • . . .13 Constitutional effects . . . . . • .14 Shock . • « • . . a .14 Reaction . . . • . . . .14 Traumatic fever . . . . . . .15 Process of repair in wounds . . . . . . .15 Immediate union ....... 15 Primary adhesion • . . . . . .15 Cicatrization . . . . . . . .16 Repair by granulation . . . . . . .18 Secondary adhesion . . . . . . .19 Repair by scabbing ....... 20 Nature of healing process ....... 20 Regeneration of tissues .... ... 20 Repair in muscle . . . . . . .21 Repair in nerves ........ 22 Sources of interference with healing of wounds . . . .23 Presence of foreign bodies . . . . . .23 Hemorrhage . . . ... . . .23 Contusion and laceration . . . . .23 Constitutional condition of patient . . . . .24 Defects in treatment . . . . . , .24 Treatment of wounds . . . . . . . .25 Cleansing wounds ....... 26 Arrest of bleeding . . . . . . .27 On the question of repair by primary or secondary adhesion . . .27 Treatment to help quick or primary union . .... 28 Coaptation of wound ....... 28 Interrupted suture . . . * . . . .29 Continued suture . . - . . . . .29 Twisted or hare-lip suture ...... 30 India-rubber suture . > . . . . . 30 Quilled suture .......30 CONTENTS. XI PAGE Button suture ....... 31 Material for suture . . . • . . .31 Pressure ......... 31 Immobility ........ 31 Drainage ........ 32 Protection of wound ... . . . . .33 On the second dressing of a closed wound . . . . . 34 • Subsequent dressings ....... 36 Contused and lacerated wounds ...... 36 Hemorrhage from contused and lacerated wounds . . . 36 Secondary hemorrhage ...... 37 Subcutaneous contused wounds . . . . . .37 Treatment of contused, lacerated, and open wounds healing by granulation . 37 Punctured wounds ........ 38 Treatment of punctured wounds ...... 39 Tooth wounds ........ 40 Treatment of an open or granulating wound . . . . .40 Treatment of wounds to promote healing by secondary adhesion . . 41 Special modes of treating wounds ...... 41 Treatment of wounds by occlusion . . . . . . 42 Cotton dressing ....... 42 Summary ........ 43 Open treatment of wounds . . . . . .44 Summary ........ 45 Treatment of wounds by irrigation . . . . .46 Treatment by water-dressing, with and without antiseptics in solution . 46 Dry dressing of wounds ....... 48 Earth dressings ........ 49 Alcoholic dressing of wounds ...... 49 Pneumatic aspiration and occlusion . . . . .50 Antiseptic irrigation of wounds ...... 50 Subcutaneous wounds ....... 52 Repair of subcutaneous wounds . . . . . .53 Treatment of subcutaneous wounds . . . . .54 Complications of wounds ....... 55 Consecutive hemorrhage or recurrent bleeding . . . .56 Secondary hemorrhage ....... 57 Pain ......... 57 Muscular spasms ........ 58 Defect in the healing process and diseases of granulations . . .58 Deficiency of action . . . . . . .58 Defects of the healing process from excess of action or inflammation . 59 Diseases of granulations ...... .60 XII CONTENTS. THE ANTISEPTIC METHOD OF TREATING WOUNDS. By W. WATSON CHEYNE, M.B., F.R.C.S., ASSISTANT SURGEON T6 KING’S COLLEGE HOSPITAL AND DEMONSTRATOR OF SURGERY IN KING’S COLLEGE, LONDON. PAGR Origin of the antiseptic method ...... 63 The germ theory ........ 64 Principles of the antiseptic method ...... 66 Antiseptic and aseptic surgery ....... 67 Aseptic surgery and Listerism ....... 68 The aseptic method . . . . . . . .70 Application of the aseptic method to operations . . . .74 The aseptic method applied to wounds not made by the surgeon . . 79 Wounds which come under observation early . . . .79 Lacerated wounds ....... 80 Gunshot wounds ....... 80 Burns ........ 80 Wounds in which fermentation already exists . • • .81 The corrosive sublimate dressing . . ... 82 POISONED WOUNDS. By JOHN II. PACKARD, M.D., SURGEON TO THE PENNSYLVANIA HOSPITAL AND TO ST. JOSEPH’S HOSPITAL, PHILADELPHIA. Introductory remarks ........ 85- Dissection wounds . . . . . . . .86 Symptoms of dissection wounds ...... 87 Treatment of dissection wounds ...... 90 Other forms of injury analogous to dissection wounds . . . .91 Fish-wounds . . . . . • . .91 Oyster-shell wounds . . .... 91 Animal typhus . . . . . . • .91 Poisonous effluvia . . . . . . • .92 Wool-sorter’s disease . . . . . • .92 Insect-stings .,..,....93 Snake-bites ........ .96 Poison apparatus . . . . . • • .96 Mortality from snake-bites . . . . . • 97 Symptoms of snake-bites . . . . • • .97 Pathology and morbid anatomy ...... 98 Treatment of snake-bites 99 Bites of other animals ........ 101 CONTENTS. XIII SABRE AND BAYONET WOUNDS; ARROW WOUNDS. By J. H. BILL, M.D., SURGEON AND BREVET LIEUTENANT COLONEL, UNITED STATES ARMY. PAGE Sabre and bayonet wounds . . . . . . .103 Statistics of sabre and bayonet wounds . . . . .103 Sabre wounds of the head . . . . . .104 Sabre wounds of the abdomen . . . . . .104 Sabre wounds of the forearm . . . . . .104 Bayonet wounds . . . . . . . .105 Arrow wounds ......... 105 History of arrow wounds . . . . . . .105 Arrow of the North American Indian ..... 106 Bird arrow . . . . . . . .107 Range and penetration of arrows . . . . . .107 Correctness of aim and rapidity of discharge .... 108 Poisoned arrows . . . . • . . .108 Appearance of arrow wounds . . . . . .108 Parts oftenest wounded . . . , . . .109 Causes of death . . . . . . . .109 Prognosis ......... 109 Treatment of arrow wounds in general ..... 110 Treatment of wounds of special parts . . . . .116 Arrow wounds of nerves ...... 116. Arrow wounds of vessels . . . . . ,116 Arrow wounds of joints . . . . . .116 Arrow wounds of the head . . . . . .116 Arrow wounds of the face ...... 117 Arrow wounds of the neck ...... 118 Arrow wounds of the chest ...... 118 Arrow wounds of the abdomen and pelvis . . . .119 GUNSHOT WOUNDS. By P. S. CONNER, M.D., PROFESSOR OF SURGERY AND CLINICAL SURGERY IN THE MEDICAL COLLEGE OF OHIO, CINCINNATI J PROFESSOR OF SURGERY IN THE DARTMOUTH MEDICAL COLLEGE, ETC. Introductory remarks . . . . . . . .121 Missiles ......... 121 Effects of gunshot wounds upon the various tissues . . . .123 Skin ......... 123 XIV CONTENTS. PAGE Fasciae . • . . . • • • .123 Muscles ......... 124 Bloodvessels . . . . . . • .124 Nerves . . . . . . . . .124 Bones ......... 12o Diagnosis of gunshot wounds . . . . . . .12.) Wounds of entrance and exit . . . . . . .126 Multiple wounds ........ 127 Effects of gunshot wounds . . . . . . .129 Bain . . . . . . . . . 129 Hemorrhage . . . . . • . .129 Shock ......... 130 Secondary effects ........ 130 Complications of gunshot wounds . . . . . .131 Secondary hemorrhage . . . . . • .131 Septicaemia and pyaemia . . . . . . .132 Gangrene . . . . . . . . .133 Traumatic gangrene . . . . . . .133 Hospital gangrene . . . . . . .134 Erysipelas ......... 136 Tetanus . . . . . . . . .136 Prognosis of gunshot wounds . . . . . . .137 Treatment of gunshot wounds . . . . . . .137 Removal of foreign bodies . . . . . . .137 Treatment of primary effects; hemorrhage . . . .140 Compression . . . . . . . .140 Styptics . . . . . . . .140 Actual cautery . . . . . . *141 Ligature . . . . . . • .141 • Venous wounds . . . . . . .141 Treatment of secondary effects . . . • . .143 Treatment of complications . . . . . .143 Traumatic gangrene . . . . . . .143 Hospital gangrene . . . . . • .144 Pyaemia, septicaemia, etc. . . . . . .145 Tetanus . . . . . . . .145 Antiseptic dressings in gunshot wounds . . . . .145 Gunshot injuries of bones and joints . . . . . .147 Contusion of bone . . . . . . . .147 Treatment . . . . . . . . .148 Fracture from gunshot injury . . . . . . .149 Treatment of gunshot fractures. . . . . • .151 Exsection in gunshot fracture . . . . . . .153 Amputation for gunshot injury ._. . . . . .155 Gunshot injuries of joints . . • • • • • 155 Gunshot injuries of the shoulder . . • . • .157 Prognosis ...*••••• 158 Treatment 158 CONTENTS. XV PAGE Amputation . . . . , . . .158 Excision ......... 150 Expectant treatment . . . . . . .161 Gunshot injuries of the elbow . . . . . . .162 Amputation . . . . . . . .163 Excision .163 Expectancy . . . . . . . .164 Gunshot injuries of the wrist . . . . . . -165 Gunshot injuries of the hip . . . . . . *167 Diagnosis and prognosis . . . . . . .168 Treatment . . . . . . . . .168 Gunshot injuries of the knee . * . . . . -169 Expectant treatment . . . , . . *169 Amputation and excision . . . . . . *170 Gunshot injuries of the ankle . . . . . . ' Treatment ......... U2 Gunshot injuries of the head ....... 173 Scalp • . . . . . . . *173 Cranial bones ........ 174 Contusion of cranium ....... 174 Treatment ........ 175 Fractures of cranium . . « . . . .176 Diagnosis ........ 177 Prognosis ........ 173 Treatment . . . . . . . -179 Treatment of cerebral complications • . . . .180 Gunshot injuries of the face ....... igi Complications of face wounds ...... 182 Treatment ......... 183 Gunshot injuries of the neck ••••••• 184 Prognosis ......... 186 Treatment . . . . . . . . .186 Gunshot injuries of the chest ..••••. 187 Non-penetrating wounds .»•••.. 187 Treatment ........ 188 Penetrating wounds . . . . . . .188 Hernia of lung ....... 189 Diagnosis of penetrating wounds • • . . .190 Prognosis . . . . . . . .190 Treatment ........ 191 Gunshot injuries of the abdomen ...... 193 Contusion ....••••• 193 Parietal wounds . . . . . . . .193 Penetrating wounds . . • • . . .193 Diagnosis of abdominal wounds • • • • • .194 Prognosis . . . • . • • . .194 Treatment 196 XVI CONTENTS. PAGE Gunshot injuries of the pelvis ...•••• 109 Diagnosis of pelvic injuries . • • • • .201 Prognosis . . . . • • • • .201 Treatment . . . • • • • • • 202 Gunshot injuries of the vertebrae ...... 203 Diagnosis of spinal injuries ...... 204 Prognosis . . . ' • • • • • • 205 Treatment ...•••••• 206 Gunshot injuries of the extremities ...... 207 Upper extremity . . ...... 207 Flesh wounds ..•••••* 207 Gunshot fractures .••••••• 208 Prognosis •••••••• 209 Treatment 209 Lower extremity . . • • • • * .210 Flesh wounds . . . • • • - .210 Gunshot fractures . . . • • • • .211 Treatment ......#. 212 VENEREAL DISEASES: GONORRHCEA. By J. WILLIAM WHITE, M.D., CLINICAL PROFESSOR OF GENITO-URINARY DISEASES IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA ; SURGEON TO THE PHILADELPHIA HOSPITAL, PHILADELPHIA. Nomenclature ......... 219 History of gonorrhoea . . . . . . . .219 Nature of gonorrhoea ........ 220 Varieties of gonorrhoea . . . . . . . .224 Acute inflammatory gonorrhoea of male urethra ..... 225 Symptoms of first or increasing stage of gonorrhoea .... 225 Changes in meatus ....... 225 Chordee ........ 225 Frequent urination with vesical tenesmus . . . .226 Character of discharge in first stage ..... 227 Complications of first stage ....... 227 Balanitis ........ 227 Balano-posthitis ....... 228 Phimosis ........ 228 Paraphimosis . . . . . . . .229 Symptoms and complications of second or stationary stage . . . 229 Follicular and peri-urethral abscesses ..... 230 Lymphangeitis........ 230 Bubo ......... 230 Cowperitis . . ...... 231 CONTENTS. XVII PAGE Prostatitis ........ 231 Cystitis ........ 233 Symptoms and complications of third stage, or that of subsidence . 235 Epididymitis ........ 235 Pyaemia, pelvic cellulitis, and peritonitis .... 238 Subacute or catarrhal gonorrhoea ...... 238 Complications of catarrhal gonorrhoea . . . . . 240 Gonorrhoeal rheumatism or urethral synovitis . . . 240 Gonorrhoeal ophthalmia and gonorrhoeal conjunctivitis . . 242 Irritative or abortive gonorrhoea ...... 244 Chronic urethral discharges ....... 245 Urethral catarrh ........ 245 Chronic gonorrhoea ....... 245 Gleet ......... 246 Stricture of large calibre 246 Diagnosis of chronic urethral discharges ..... 250 Seminal plethora and urethral hyperaesthesia ..... 252 Urethral anaesthesia ........ 253 Neuralgia from urethral irritation ...... 253 Treatment of gonorrhoea in the male ...... 254 Prophylactic measures ....... 254 Curative treatment ....... 255 Treatment of ardor urinae ...... 260 Treatment of chordee . . . . . .261 Soluble bougies ....... 262 Urethral injections in early stage . . . . .263 Anti-blenorrhagic remedies ...... 265 Astringent injections ....... 267 Treatment of persistent urethral discharges .... 268 Treatment of urethral catarrh . . . . .269 Treatment of chronic gonorrhoea ..... 270 Irrigation of urethra . . . . . . .271 Treatment of gleet . . . . . . .272 Treatment of strictures of large calibre .... 273 Treatment of complications 275 Balanitis and balano-posthitis . • • . . 275 Phimosis . . . . . . . .275 Paraphimosis . . . • . . . .276 Follicular abscess . . . . . • .277 Peri-urethral abscess ....... 277, Lymphangeitis ....... 277 Bubo ......... 277 Cowperitis ........ 278 Prostatitis, prostato-cystitis, and cystitis . . • .278 Retention of urine . . . . . . .278 Prostatic abscess . . . • • . .279 Chronic prostatitis . . . . . . .279 Epididymitis . . • • « • . » • 280 XVIII CONTENTS. . Gonorrhoeal rheumatism ...... 282 Gonorrhoeal ophthalmia ...... 284 Gonorrhoeal conjunctivitis ...... 284 Gonorrhoea in the female ....... 284 Vulvitis ......... 285 Symptoms ......... 285 Complications ........ 286 Bubo ......... 286 Follicular inflammation ...... 286 Vulvo-vaginal abscess. ...... 286 Mucous patches ....... 287 Vaginitis . ...... 287 Phlegmon ........ 288 Nymphomania ....... 288 Chronic vulvitis ........ 288 Vaginitis ......... 288 Causes ......... 288 Symptoms and complications ...... 290 Chronic vaginitis . . . . . . . .291 Urethritis . . > . . . . . . .291 Causes . . . . . . . . .291 Symptoms ......... 292 Uterine gonorrhoea ........ 292 Treatment of gonorrhoea in women ...... 293 Treatment of vulvitis ....... 293 Treatment of vulvo-vaginal abscess ..... 294 Treatment of vaginitis ....... 294 Treatment of urethritis ....... 297 Treatment of uterine gonorrhoea ...... 297 Gonorrhoea in anomalous situations ...... 297 The micrococcus of gonorrhoea . . . . . . .299 VENEREAL DISEASES: THE SIMPLE VENEREAL ULCER OR CHANCROID. By F. R. STURGIS, M.D., PROFESSOR OF VENEREAL DISEASES IN THE UNIVERSITY OF THE CITY OF NEW YORK (MEDICAL department), visiting surgeon to the third venereal division of charity hospital, Blackwell’s island, etc., new york. Synonyms ....... . 801 History and nomenclature ....... 302 Characteristics of the simple venereal ulcer . . . . .306 Is not indurated ........ 306 Has an irregular floor, and is attended with profuse discharge . . 307 CONTENTS. XIX PAGE Characteristics of the simple venereal ulcer— Is auto-inoculable ........ 308 Question of virus ........ 308 Inoculability of simple venereal ulcer (Tables I.-IV.) . . .313 Is ordinarily multiple . . . . . . .314 Multiplicity as compared with initial lesion of syphilis (Table V.-X.) . 314 Has no period of incubation. . . . . . .316 Time of appearance of simple venereal ulcer (Tables XI.-XIY.) . . 316 Varieties of the simple venereal ulcer . . . . . .318 Locality of the simple venereal ulcer ...... 318 Localities of simple venereal ulcer and of initial lesion of syphilis (Tables XV.-XX. ........ 319 Cephalic chancroid . . . . . . . .321 Origin of the simple venereal ulcer . . . . . .324 Anatomy of the simple venereal ulcer . . . . . .327 Complications of the simple venereal ulcer ..... 329 Frequency of complications (Table XXI.) ..... 329 Bubo ......... 329 Frequency of bubo in cases of simple venereal ulcer (Tables XXII.- XXIV. ......... 330 Phimosis and paraphimosis . . . . . . .331 Balanitis and phagedsena . . . . . . .331 Mixed chancre . . . . . . . .332 Diagnosis of simple venereal ulcer ...... 333 Relative frequency of simple venereal ulcer and initial lesion of syphilis (Tables XXV. ....... 333 Prognosis of simple venereal ulcer . . . . . .335 Treatment of simple venereal ulcer . . . . . .335 Application of caustics . . . . . . .336 Subsequent dressings . . . . . . .336 Treatment of complications ....... 337 Treatment of bubo ........ 337 Treatment of phimosis and paraphimosis ..... 338 Treatment of balanitis, concealed chancroids, and phagedama . . . 338 Treatment of mixed sore .... 339 VENEREAL DISEASES: SYPHILIS. By ARTHUR VAN HARLINGEN, M.D., PROFESSOR OF DISEASES OF THE SKIN IN THE PHILADELPHIA POLYCLINIC ; CONSULTING PHYSICIAN TO THE DISPENSARY FOR SKIN DISEASES, PHILADELPHIA. History of syphilis . . • • • . . .341 General pathology . • • • • • • .343 Sources of syphilitic contagion ...... 344 XX PAGE General pathology of syphilis—■ Modes of contagion 344 Immediate contagion . . . . . . .344 Mediate contagion ....... 343 Yaccino-syphilis ........ 340 General syphilis always follows a chancre ..... 348 Syphilization . . . . • . . . . 349 Syphilis in animals ....... 350 Reinfection in syphilis ....... 350 Evolution of syphilis ...... . 350 Chancre ......... 351 Induration of chancre ....... 352 Various forms of chancre ....... 353 # Chancre usually solitary ....... 353 Chancre involves neighboring lymphatic glands .... 354 Rarely complicated by inflammation or pliagedaena . . . 354 May be transformed into mucous patch ..... 354 Localities of chancre . . . . . . 354 Genital chancres . . . . . . . • . 355 Chancres of urethra ....... 355 Chancres of cervix uteri . . . . . . .350 Chancres of vagina ....... 357 Extra-genital chancres . . . . . . . . 358 Buccal chancres . . . . . . . .358 Anal and rectal chancres . . . . • . .359 Chancres of mammary region ...... 359 Digital chancres . . . . . • . .360 Relative frequency of chancre and chancroid ..... 360 Lesions occurring concomitantly with chancre ..... 361 Lymphangeitis and adenitis . . . . . .361 Diagnosis of chancre ........ 363 Differential diagnosis between chancre and chancroid . . . 365 Prognosis of chancre ........ 366 Treatment of chancre ........ 368 Period of the generalized lesions of syphilis ..... 369 General condition before and during outbreak of early generalized symp- toms ......... 370 Condition of blood in syphilis . . . . . .370 Syphilitic fever . . . . . . . .371 Varieties of syphilitic fever . . . . . .371 Diagnosis of syphilitic fever . . . • . .373 Prognosis of syphilitic fever ... . . 373 Treatment of syphilitic fever ...... 373 Affections of lymphatic glands . . . . . .374 Condition of spleen . . . . . . .374 Enlargement of tonsils . . . . . • .374 Supra-renal capsules . . . . . • .474 Affections of the osseous system . . . . . .375 CONTENTS. CONTENTS. XXI PAGE Affections of the liver in early syphilis . . . • .375 Disturbances of the urinary function ..... 376 Albuminuria • . . . . . . .376 Glycosuria . . . . . . . .376 Disturbances of the uterine functions . . . . .376 Affections of the nervous system ...... 377 Lesions of articulations and of synovial cavities of tendons . . 380 Muscular contraction . . . . . . .381 Influence of syphilis on intercurrent affections .... 382 The syphilodermata ........ 382 Classification of the syphilodermata ..... 384 Erythematous sypliiloderm ...... 385 Papular sypliiloderm ....... 387 Small papular syphiloderm ...... 387 Large papular syphiloderm ...... 387 Moist papule ....... 388 Vegetating papule ....... 389 Papulo-squamous syphiloderm ..... 389 Palmar and plantar syphiloderm .... 390 Diagnosis of papulo-squamous syphiloderm . .. « 390 Vesicular syphiloderm ....... 392 Pustular syphiloderm ....... 392 Small acuminated pustular syphiloderm .... 393 Large acuminated pustular syphiloderm .... 393 Small flat pustular syphiloderm ..... 394 Large flat pustular syphiloderm . . . . .394 'Tubercular syphiloderm ....... 395 Serpiginous form ....... 395 Vegetating form . . . • • . .396 Gummatous syphiloderm .•••••. 396 Bullous syphiloderm ....... 397 Pigmentary syphiloderm ....... 398 Local treatment of the syphilodermata ..... 398 Lesions of the appendages of the skin ...... 399 Onyxis ......... 399 Perionyxis ......... 400 Alopecia . . . . . . • • ’ 401 Syphilis of the mucous membranes ...... 402 Seat of moist papules and mucous patches ..... 402 Treatment of mucous patches ...... 404 Syphilis of the cellular tissue ; gummatous tumors .... 404 Diagnosis of gummata ....... 405 Prognosis of gummata . . . . . . .406 Treatment of gummata ....... 406 Syphilis of the alimentary tract ...... 407 Mouth ......... 407 Tongue ......... 408 Treatment of lingual syphilis . . . . .410 XXII CONTENTS. PAGE Syphilis of the pharynx . . . . . . . .411 (Esophagus . . . . . . . .412 Stomach and intestines . . , . # . .412 Rectum and anus . . . . , 0 . .412 Treatment of anal and rectal syphilis . . . . .413 Syphilis of olfactory and auditory appparatus . . . . .414 Olfactory apparatus . . . . . . .414 Rhinitis . . . . . . . .414 Olfactory neuritis . . . . . . .415 Auditory apparatus . . . . . . .415 Syphilis of eyelids and lachrymal apparatus . . . . .415 Syphilis of generative apparatus . . . . . .416 Penis and urethra . . . . . . . .416 Testicle . . . . . . . . .416 Syphilitic epididymitis . . . . . .416 Syphilitic orchitis . . . j . . .417 Syphilis of female generative organs ..... 418 Syphilis of the kidney . . . . . . . .419 Syphilis of the liver . . . . . . . .419 Eaidy hepatic syphilis . . . . . . .419 Late hepatic syphilis ....... 420 Diagnosis of hepatic syphilis ...... 422 Treatment of hepatic syphilis ...... 423 Syphilis of the racemose glands ...... 423 Mammary glands ........ 423 Salivary glands ........ 423 Pancreas ......... 424 Syphilis of the spleen, supra-renal capsules, and thyroid gland . . . 424 Syphilis of the respiratory passages ...... 424 Larynx ......... 424 Trachea and bronchi . • . . « . .426 Lungs . . ...... . 428 Syphilis of the circulatory system ...... 429 Heart ......... 429 Bloodvessels ........ 430 Syphilis of the lymphatic vessels and ganglia ..... 430 Syphilis of muscles and tendons ...... 431 Muscles ......... 431 Tendons ......... 432 Syphilis of periosteum and bone ...... 433 Osteocopic pains ........ 433 Diffuse gummatous infiltration ...... 433 Circumscribed gtfmmatous infiltration ..... 434 Comparative frequency of various forms of syphilitic bone disease . . 436 Locality of bone lesions ....... 437 Syphilis of cervical vertebrae ...... 437 Syphilis of cranium ....... 437 Syphilis of bones of orbit . . . • . . .437 CONTENTS. XXIII PAGE Syphilis of maxillary, palate, and nasal bones • • • . 438 Syphilitic dactylitis ....... 433, Syphilis of the articulations 439 Syphilis of the bursie . . . . . . . .441 Syphilis of the nervous system . . . . . . .441 Pathological anatomy of nervous syphilis ..... 442 Lesions of cranial meninges ...... 442 Lesions of encephalon ...... 442 Lesions of spinal meninges and cord ..... 442 Lesions of nerves ••..... 442 Symptomatology of nervous syphilis ..... 443 Headache 443 Paralysis ........ 443 Paralysis of sensory nerves ...... 443 Paralysis of motor nerves of eye ..... 444 Hemiplegia ........ 444 Paraplegia ........ 445 Epilepsy ........ 445 Aphasia ........ 447 Anaemic, congestive, and apoplectiform symptoms; coma . . 447 Intellectual disturbances . .... 448 Visceral disturbances due to nervous lesions .... 448 Incoordination of movement; ataxy ..... 449 Prognosis and treatment of nervous syphilis .... 449 Hereditary syphilis . . . . . . . .450 Etiology of hereditary syphilis ...... 450 Pathology of hereditary syphilis ...... 452 Syphilis of the placenta ...... 452 Symptomatology of hereditary syphilis . . . . .452 Date of appearance of lesions • • • . . 452 Skin manifestations in hereditary syphilis . . 453 Erythematous syphiloderm ..... 453 Papular syphiloderm . . . . . .454 Vesicular syphiloderm . . . . . .454 Pustular syphiloderm . . . . . .454 Furunculoid syphiloderm ..... 455 Tubercular syphiloderm ...... 455 Gummata of the skin ...... 455 Bullar eruptions ....... 455 Affections of the mucous membranes . . . .456 Affections of viscera in hereditary syphilis . . . .457 Affections of bones in hereditary syphilis .... 457 Osteo-chondritis ....... 457 Periostitis ....... 457 Dactylitis syphilitica ...... 458 Connection of syphilis with rickets .... 458 Cornea and teeth in hereditary syphilis .... 458 Affections of nervous system in hereditary syphilis ... 459 XXIV CONTENTS. PAGE Treatment of hereditary syphilis ...... 460 General treatment of syphilis . . . . . . .462 Expectant treatment ....... 462 Hygienic and general tonic treatment ..... 462 Specific treatment ........ 463 Mercurials ........ 463 Iodine and its compounds ...... 469 Mixed treatment . . . . . . .471 Local treatment . . . . . . .472 Syphilis in its relation to marriage . . . . . .474 Scheme for examination of persons supposed to ha\Te contracted syphilis . 476 Connection of syphilis with scrofula, etc. . . . . .478 Legal measures to prevent spread of syphilis . . . .479 VENEREAL DISEASES: BUBON D’EMBLEE, VENEREAL WARTS OR VEGETATIONS, PSEUDO-VENEREAL AFFECTIONS, VENEREAL DISEASES IN THE LOWER ANIMALS. By H. R. WHARTON, M.D., INSTRUCTOR IN CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA ; SURGEON TO THE CHILDREN’S HOSPITAL, PHILADELPHIA. Bubon d’emblee . . . . . . . . .481 Venereal warts or vegetations . . . . . . .482 Pseudo-venereal affections ....... 485 Yaws ......... 485 Symptoms of yaws . . . . . . .485 Treatment of yaAvs . . . . . . .487 Parangi ......... 488 Verrugas ......... 488 Sibbens or sivvens ........ 488 Radesyge or radzyge . . . . . . .489 ■Scherlievo or fiume ........ 489 Palcadina ......... 490 Amboyna pimple ........ 490 Disease of St. Euphemia ....... 490 Pian of Nerac ........ 490 Disease of St. Paul’s Bay . . . . . . .490 Disease of Chavanne Lure . . . . . . .491 Venereal diseases in the loAver animals . . . . . .491 CONTENTS. XXV INJURIES OF BLOODVESSELS. By JOHN A. LIDELL, A.M., M.D. LATE SURGEON TO BELLEVUE HOSPITAL ; ALSO LATE SURGEON U. S. VOLUNTEERS IN CHARGE OF STANTON U. S. ARMY GENERAL HOSPITAL, INSPECTOR OF THE MEDICAL AND HOSPITAL DEPARTMENT OF THE ARMY OF THE POTOMAC, ETC. PAGE Surgical hemorrhage ........ 495 Importance of subject . . . . . o .496 Nomenclature of hemorrhage ...... 497 Arterial hemorrhage ...... o 497 Venous hemorrhage ....... 498- Capillary hemorrhage ....... 499’ Constitutional signs of hemorrhage ..... 501 Hemorrhagic fever ....... 502' Hemorrhagic convulsions ...... SOS- Spontaneous arrest of arterial hemorrhage ..... 504 Contraction of artery ....... 504 Retraction of artery ....... 505 Coagulation of blood ....... 505 Increased coagulability of blood ...... 505 Diminished force of heart ....... 505 Phenomena of spontaneous arrest of arterial bleeding . . . 505 General considerations concerning treatment of surgical hemorrhage . . 500 Chemico-vital treatment . . . . . o o 513 Cold . 513. Alcohol . . . . . . . o ol4 Oil of turpentine _. . . . . • • 514 Perchloride and persulphate of iron . . . . .515 Surgical treatment of hemorrhage . . . . . 0 516 Position ........ o 516 Compression ........ 517 Digital compression . . . . . . .517 Pads, tampons, and compresses ..... 520 Tourniquets ........ 521 Esmarch’s apparatus ....... 524 Ligation ......... 529 Instruments required for ligation of arteries . . „ . 532 Mode of ligating divided artery ..... 535 Repair of arteries after ligation ..... 538 Animal ligatures . . ., . . . . 540 Metallic ligatures . . . * . . . 542 Appreciation of different ligatures . . . o .543 Torsion ......... 544 Constriction or crushing arteries for arrest of hemorrhage . . . 547 XXVI CONTENTS. PAGE Surgical treatment of hemorrhage— Acupressure . . . • • • • .549 Direct compression ...•••• 549 Compression with wire ..•••. 549 Compression by torsion ...... 550 Aerteri version ........ 550 Cauterization ........ 552 Appreciation of various haemostatics . . • • . .554 Internal haemostatics ........ 554 After-treatment of hemorrhage ....... 555 Transfusion ........ 556 Transfusion of milk ....... 559 Wounds of arteries . ...... 559 Punctured wounds of arteries ...... 559 Causes . . . . . . . . 566 Symptoms ........ 566 Consequences ........ 567 Treatment ........ 567 Punctured wounds of special arteries ..... 568 Vertebral artery . . . . . . .568 Carotid artery . . . . . . .569 Occipital, temporal, and facial arteries .... 570 Axillary artery . . . . . . .570 Brachial artery . . . • • • .570 Arteries of the forearm . . . • . .571 Palmar arch . . . o • • . .571 Femoral artery and branches ...... 575 Popliteal artery . . . . • • .574 Tibial arteries . . . . . • .574 Plantar arch . . . . . • • .574 Gluteal and sciatic arteries ...... 575 Internal pudic artery . . . . . . .575 Ilio-lumbar artery . . . • . . .576 Gluteal artery . . . . • . .576 Internal epigastric and circumflex iliac arteries . . . 577 Internal mammary artery . . • . . .579 Intercostal arteries ....... 582 Contused wounds of arteries ...... 585 Treatment of contused wounds of arteries ... . . 590 Lacerated wounds and ruptures of arteries • • • .591 Treatment ........ 594 Ruptures of special arteries ...... 595 Femoral artery . . . . • . . 595 External circumflex artery ...... 597 Popliteal artery ..••••• 598 Anterior tibial artery ...... 599 Brachial artery 599 CONTENTS. XXVII PAGE Ruptures of special arteries— Axillary artery ....... 600 Lacerations of arteries caused by fractures of long bones . • .612 Symptoms of arterial laceration from fracture .... 614 Methods of treatment . . . . . . .615 Gunshot wounds of arteries ...... 618 Partial or incomplete division by gunshot missiles . . . 620 Complete division by gunshot missiles .... 625 Incised wounds of arteries ....... 636 Wounds of veins ........ 644 Symptoms of venous wounds ...... 645 Incised and punctured wounds of veins ..... 647 Contused wounds of veins ....... 650 Lacerated wounds and ruptures of veins ..... 652 Gunshot wounds of veins ....... 654 Wounds of sinuses of dura mater ...... 657 Septicaemia from wounds of veins ...... 659 Ligation of veins ........ 660 Ligation of artery and vein simultaneously, for venous hemorrhage . 662 Entrance of air into veins . . . . . . .664 Dangerous region ....... 667 Causes ........ 668 Symptoms ........ 668 Pathology ........ 669 Treatment ........ 669 Wounds of the aorta, innominate and subclavian arteries, venae cavae, vena azygos, heart, pulmonary artery, and pulmonary veins . . .670 Wounds of the aorta . . . . . . .670 Wounds of the innominate artery . . . . . .674 Wounds of the subclavian artery . . . . . .675 Wounds of the venae cavae . . . . . . . 675 Wounds of the vena azygos . . . . . .676 Wounds of the pericardium ...... 677 Wounds of the heart ....... 677 Symptoms of heart wounds . . . . . . 680 Traumatic carditis ....... 680 Treatment ........ 680 Wounds of the pulmonary artery ...... 681 Wounds of the pulmonary vein . . . . . .681 Wounds of the middle meningeal artery ..... 681 Wounds of the abdominal and pelvic bloodvessels .... 683 Wounds of the common iliac artery ..... 685 Wounds of the internal iliac artery ..... 685 Wounds of the iliac veins ...... 687 Traumatic aneurism ........ 688 Definition ......... 688 Etiology ......... 688 Varieties . . . . . . . . . 688 XXVIII CONTENTS. PASH Traumatic aneurism— Diffused traumatic aneurism ...... G88 Symptoms ........ 688 Treatment ........ 689 Circumscribed traumatic aneurism ..... 690 Symptoms ........ 692 Treatment ........ 692 Palmar aneurisms ........ 695 Traumatic aneurisms of the vertebral artery .... 695 Arterio-venous wounds: aneurismal varix and varicose aneurism . . 695 Aneurismal varix . . ... . . . .696 Symptoms ........ 696 Varicose aneurism ........ 698 Symptoms ........ 698 Localities of arterio-venous aneurism ..... 698 Treatment of arterio-venous aneurism ..... 699 Gangrene from arterial and venous occlusion . . . * „ . 701 Symptoms ,. . . . . . . . /01 Causes . . . . . . . . .701 Gangrene from arterial occlusion . . . . . .702 Gangrene from venous obstruction . . . . . .702 Gangrene from obstruction of the collateral circulation . . .702 Treatment of gangrene from vascular obstruction . . . .704 Haemophilia or the hemorrhagic diathesis . . . . .704 Definition ......... 704 History and geographical distribution . . . . 705 Etiology ......... 705 Symptoms ......... 709 Morbid anatomy and pathology . . . . . .710 Prognosis . . . . . . . . .711 Treatment . . . . . . . . .711 Intermediary hemorrhage . . . . . . .713 Treatment of intermediary hemorrhage . . . . .716 Secondary hemorrhage . . . . . . . .717 Causes of secondary hemorrhage . . . . . .717 Treatment of secondary hemorrhage ..... 726 Parenchymatous hemorrhage . . . . . . .729 Primary parenchymatous hemorrhage ..... 730 Intermediary parenchymatous hemorrhage .... 731 Secondary parenchymatous hemorrhage . . . . .731 Scorbutic parenchymatous hemorrhage . . . . .732 Treatment of parenchymatous hemorrhage . . . .733 Deligation of arteries . . . . . . . .733 General rules for exposing and ligating the principal arteries in their continuity . . . . . . . 735 Ligation of the innominate artery . . . . . .737 Mott’s operation . . . . . . .737 Sedillot’s operation ....... 737 XXIX CONTENTS. . PAGE Ligation of the innominate artery— Manec’s operation ...... # 738 Appreciation ........ 738 Ligation of the common carotid artery ... . 739 Surgical anatomy . ...... 739 Ligation of the external and internal carotid arteries . . .742 External carotid artery . . . . . . 742 Relations ....... 742 Operation . . . . . . .742 Internal carotid artery ..... 743 Operation ....... 744 Ligation of the superior thyroid artery ..... 744 Operation ........ 744 Ligation of the lingual artery . . . . . .744 Surgical anatomy ....... 744 Operation ........ 745 Esmarch’s operation ...... 743 Ligation of the facial artery ...... 748 Surgical anatomy . ...... 748 Operation ........ 747 Ligation of the temporal artery ...... 747 Operation ........ 747 Ligation of the occipital artery ...... 747 Operation ........ 748 Ligation of the vertebral artery ...... 748 Surgical anatomy ••..... 748 Operation ........ 748^ Ligation of the inferior thyroid artery ..... 749 Operation . . . . . . . . 749 Ligation of the internal mammary artery ..... 750 Goyrand’s operation ....... 759 Ligation of the subclavian artery . . . . . . 750 Surgical anatomy 750 Relations ........ 751 Operation at first part ...... 752 Operation at second part . . . . . .752 Operation at third part or point of election .... 752 Ligation of the axillary artery ...... 754 Surgical anatomy . . . . . ... 754 Relations ........ 754 Hodgson’s operation . . . . . . .754 Chamberlaine’s operation ...... 755 Delpech’s operation ....... 758 Operation in axillary hollow or armpit .... 756 Ligation of the brachial artery ...... 757 Operation in upper third of arm ..... 757 Operation in middle third of arm ..... 757 Operation at elbow ..... . . 757 PAGE Deligation of arteries— Ligation of the radial artery . . . . . . 758 Operation in upper third ...... 758 Operation in lower third ...... 758 Operation on dorsum of wrist ...... 759 Ligation of the ulnar artery . . . . . .759 Operation in upper third . . . . . . 760 Operation in lower third . . . . . .760 Ligation of the abdominal aorta ...... 761 Cooper’s operation . . . . . . .761 Murray’s operation . . . . . . .761 Ligation of the common iliac artery . . . . .761 Surgical anatomy ....... 761 Operation . . . . . . . .762 Ligation of the internal iliac artery . . . . .763 Surgical anatomy . . . . . . .763 Operation ........ 763 Ligation of the gluteal artery . . . . . .763 Surgical anatomy . . . . . . .763 Operation . . . . . . . .763 Ligation of the iscliiatic artery . . , . . . .764 Surgical anatomy . . . . . . .764 Operation ........ 764 Ligation of the internal pudic artery ..... 764 Surgical anatomy ....... 764 Operation . . . . . . . . 765 Ligation of the arteria dorsalis penis ..... 765 Operation . . . . . . . .765 Ligation of the external iliac artery . . . . .765 Surgical anatomy . . . . . . . 765 Abernethy’s operation . . . . . .765 Cooper’s operation . . . . . . .766 Appreciation . . . . . . . .766 Esmarch’s operation . . . . . . .767 Ligation of the epigastric artery ...... 767 Operation . . . . . . . .767 Ligation of the circumflex iliac artery . . . . .768 Ligation of the femoral artery ...... 768 Surgical anatomy ....... 768 Relations ........ 768 Operation on common femoral . . . . .769 Operation on superficial femoral at apex of Scarpa’s triangle . .769 Operation on superficial femoral at lower third . . .770 Ligation of the popliteal artery ...... 770 Operation ........ 770 Ligation of the posterior tibial artery . . . . .771 Operation at upper third ...... 771 Operation at middle third . . . . . .771 XXX CONTENTS. XXXI CONTENTS. PAGE Ligation of the posterior tibial artery— Operation at lower third ...... 772 Operation at inner side of ankle ..... 772 Ligation of the peroneal artery . . . . . .772 Operation . . . . . . . .773 Ligation of the anterior tibial artery . . . . .773 Relations . . . . . . . .773 Operation at upper third . . . . . .773 Operation at middle third . . . . . .773 Operation at lower third . . . . . .774 Ligation of arteria dorsalis pedis . . . . . .774 Operation . . . • . • . .774 SURGICAL DISEASES OF THE VASCULAR SYSTEM. By JOHN A. WYETH, M.D., PROFESSOR OF SURGERY IN THE NEW YORK POLYCLINIC ; SURGEON TO MT. SINAI HOSPITAL, NEW YORK. Phlebitis ......... 775 Definition and Morbid anatomy ...... 775 Endophlebitis . . . . . . .775 Mesophlebitis . . . . . . .775 Periphlebitis . . . . . . . .775 Causes and clinical history of phlebitis . . . . .778 Idiopathic phlebitis . . . . . . .778 Syphilitic phlebitis . . . . . . .778 Gouty phlebitis ....... 778 Acute idiopathic phlebitis . . . . . .779 Traumatic phlebitis . . . . . . .779 Treatment of phlebitis . . . . . . .780 Arteritis ......... 780 Endarteritis ........ 780 Mesarteritis . . . . . . . .780 Periarteritis . . . . . . . .780 Pathogeny of arteritis . . . . . . . 782 Traumatic arteritis . . . . . . .782 Traumatic arteritis from external causes . . . .782 Treatment . . . . . . .785 Traumatic arteritis from internal causes .... 785 Chronic arteritis . . . . . . .786 Non-traumatic or idiopathic arteritis ..... 787 Atheroma and calcification . . . . . .787 Syphilitic arteritis . . . . . . .791 Relation of visceral syphilis to arteritis . . . . .794 XXXII CONTENTS. PAGE Arteritis— Rheumatic arteritis 800 Treatment of rheumatic arteritis ..... 800 Arterial thrombosis and embolism ...... 801 Vascular tumors ........ 803 Arterial varix ........ 803 Treatment ........ 803 Cirsoid arterial tumor or cirsoid aneurism ..... 803 Symptoms ........ 804 Treatment ........ 804 Table of ligations of common carotid artery for aneurism by anastomosis and arterial varix ....... 808 Table of ligations of external carotid artery for aneurism by anastomosis and arterial varix . . . . . . .814 Angeiomata ........ 817 Structure and symptoms . . . . . .817 Prognosis ........ 819 Diagnosis ........ 819 Treatment . . . . . . . .819 Venous varix, varix, or varicose veins ..... 820 Treatment ........ 822 Moles 823 Nsevus pigmentosus or port-wine mark .... 823 Nasvus pilosus ....... 823 Treatment ........ 824 ANEURISM. By RICHARD BARWELL, F.R.C.S. SURGEON TO CHARING CROSS HOSPITAL, LONDON. Definition and Classification ....... 825 True aneurism ......... 825 False aneurism ......... 825 Fusiform aneurism . . . . . . . .826 Aneurismal dilatation ........ 826 Sacculated aneurism . . . . . . . . 826 Dissecting aneurism ........ 826 Arterio-venous aneurism: aneurismal varix and varicose aneurism . . 827 Racemose or cirsoid aneurism and aneurism by anastomosis . . . 827 Diffused aneurism ........ 827 Causes of aneurism ........ 828 Wounds ......... 828 External violence without wound ...... 828 Muscular effort ........ 829 XXXIII CONTENTS. PAGE Causes of aneurism— Constriction by clothing ....... 829 Posture 830 Embolism . . . • • • . » • 831 Atheroma and ossification ....... 832 Peri-arteritis ........ 833 Endarteritis ...»•»»• 833 Syphilis ..••••»». 837 Rheumatism ........ 839 Alcoholism ..••••.. 839 Structure of an aneurism • 839 Contents of an aneurism ....... 839 Sac of an aneurism ....... 840 Symptoms of aneurism . ....... 840 Intrinsic symptoms ....... 840 Extrinsic symptoms ....... 840 Pulsation ......... 840 Bruit ......... 841 Pressure symptoms ....... 842 Differential diagnosis of aneurism ...... 843 Pulsatile tumors that are not aneurisms ..... 844 Abscess ........ 844 Cyst of neck ........ 845 Haematocele of neck . . . . . . .845 Cyst or abscess coexisting with aneurism .... 846 Solid tumor overlying an artery . . . . .846 Malignant tumors, especially of bone ..... 847 Aneurisms which are not pulsatile ...... 848 Ruptured aneurisms . . . . . . .848 Progress of aneurism ........ 849 Rupture of aneurism ....... 849 Rupture into an abscess . . • • • .851 Suppuration of the sac . • • • . .851 Spontaneous cure of aneurism ....... 853 Spontaneous cure by coagulation ...... 853 Cure by rupture of aneurism ...... 856 Cure by inflammation of sac ...... 857 Suppuration ........ 858 Gangrene of sac ....... 858 Treatment of aneurism in general ...... 859 Medical treatment of aneurism ...... 859 Venesection . . . . • • . . 859 Tufnell’s diet treatment . . . • . .860 Belladonna . . . • • • » . 861 Hydrocyanic acid . . • • • » .861 Digitalis ........ 861 Aconite „ . . • • • • .861 Veratrum . . . • • • • .861 XXXIV CONTENTS. PAGE Medical treatment of aneurism— Bromide of potassium 8G1 Iodide of potassium . . . • • . . 861 Surgical treatment of aneurism 862 Cauteries ........ 862 Injection of coagulating fluids . • • • . 863 Introduction of foreign bodies ..... 864 Galvano-puncture ....... 865 Parenchymatous injection of ergotine ..... 867 Manipulation . ....... 869 Compression . . . . . • . .870 Direct compression . . . • • . .870 Indirect compression . . . • • . .871 Indirect instrumental pressure . • • . .872 Digital pressure . . . . . . .873 Rapid pressure method . . . • . . 874 General compression . . . • . . .875 Compression by flexion ...... 877 Choice of cases for different forms of pressure .• . . .878 Flexion ........ 878 Indirect pressure (gradual) . . . . .878 Rapid method . . . . . . .878 Esmarch bandage . . . . • .879 Defects and dangers of compression . . . . .879 Ligation ........ 881 Proximal deligation ...... 882 Distal deligation ....... 882 Method of Anel ....... 882 Method of Hunter . . . . . . 882 Method of Brasdor . . . . • . . 884 Method of Wardrop ...... 884 Temporary ligature . . . . . . . . 889 Speir’s artery compressor ..... 890 Soluble ligatures . . . . . . .891 Secondary hemorrhage after arterial deligation . . . 895 Suppuration of aneurismal sac after arterial deligation . . 898 Gangrene after arterial deligation ..... 900 Indications for and against deligation . . . . * . 900 Heart disease ....... 900 Atheroma . . . . . . .901- Aortic disease ....... 901 Local disease of the artery . . . . .901 Conditions of the aneurism itself .... 901 Aneurisms of the lower extremity ...... 902 Aneurism of dorsal artery of foot ...... 902 Plantar aneurism ........ 904 Aneurism of anterior tibial artery ...... 904 Deligation of anterior tibial artery in its lower portion „ . 904 CONTENTS. XXXV PAGE Aneurism of anterior tibial artery— Ligature of the anterior tibial artery above the lower third of the leg . 905 Aneurism of posterior tibial artery ..... 905 Ligation of posterior tibial artery ..... 906 Popliteal aneurism ....... 908 Flexion ........ 908 Esmarch bandage (Reid’s method) . . . . .910 Indirect pressure for popliteal aneurism . . . .911 Digital pressure . . . . . . .911 Weight pressure . . . . . . .911 Instrumental pressure . . . . . .912 Statistics of compression . . . . . .913 Deligation of superficial femoral artery for popliteal aneurism . 914 Femoro-popliteal, femoral, and inguinal aneurism . . . .917 Pressure . . . . . . . .917 Esmarch bandage . . . . . . .918 Ligation of common femoral artery . . . . . 918 Deligation of external iliac artery . . . . .918 Statistics ........ 919 Gluteal and sciatic aneurisms . . • . . .921 Diagnosis ........ 922 Treatment . ....... 924 Expectant method ...... 924 Direct compression ...... 924 Proximal pressure ...... 924 Injection of coagulating fluids . . . ... 924 Opening the sac . ...... 924 Anel’s method ....... 924 Deligation of internal or common iliac artery . . . 924 Abdominal aneurisms . . . . . . . .926 Treatment ......... 927 Distal pressure ....... 928 Proximal pressure ....... 928 Deligation of abdominal aorta ..... 930 Aneurisms of the upper extremity ...... 931 Aneurisms of the palm and wrist . . . . . .931 Ligation of radial artery above wrist ..... 932 Ligation of radial artery in upper portion .... 932 Ligation of ulnar artery . . . . . .932 Ligation of brachial artery at elbow ..... 933 Brachial aneurism ........ 933 Ligation of brachial artery . . . . . . 933 Ligation of axillary artery . . . . . .934 Chamberlaine’s operation ..... 935 Roux’s operation . . . . . . 935 • Guthrie’s operation ...... 935 Axillary aneurism ........ 936 Diet and rest ........ 93fi. XXXVI CONTENTS. PAGE Axillary aneurism— Manipulation ........ 936 Proximal pressure . . . . . . .936 Distal and direct pressure ...... 937 Galvano-puncture . . . . . . .937 Injection of perchloride of iron. . . . . .937 Ligation of subclavian artery . . . . . .937 Aneurisms of the head and neck ....... 941 Intracranial aneurism . . . . . . .941 Orbital aneurism . . . . . . . .942 Cirsoid aneurism of orbit . . . . . .944 Circumscribed aneurism within orbit . . , . .944 Arterio-venous aneurism . . . . . .944 Treatment of pulsating orbital tumors . . . . .945 Carotid aneurism ... .... 946 Ligation of carotid above omo-hyoid . . . . .948 Ligation of carotid below omo-hyoid . . . . .949 Aneurism of the vertebral artery ...... 952 Aneurisms at the root of the neck . . . . . .954 Aneurism of the third part of the subclavian artery . . .954 Low carotid aneurism . . . . . . .956 Innominate aneurism ....... 957 Treatment of aneurisms at the root of the neck .... 959 Rest and diet ........ 959 Proximal compression ....... 960 Direct compression . . . . . . .960 Manipulation . . . . . .960 Parenchymatous injection of ergo tine . . . . .961 Injection of perchloride of iron into sac . . . .961 Temporary ligature and acupressure . . . . .961 Amputation at shoulder-joint ...... 961 Ligature of subclavian in its terminal division . . . .962 Deligation of first part of subclavian artery . . . .962 Deligation of right subclavian artery in its first part . . . 963 Deligation of innominate artery ..... 965 Deligation of left subclavian artery in its first part . . . 966* Temporary compression or ligature of innominate artery . . 967 Deligation of axillary artery for subclavian aneurism . . .967 Distal deligation of carotid artery . . . . .967 Aneurism of the arch of the aorta . . . . . .970 Symptoms of aneurism of aortic arch . . . . .975 Treatment of aneurism of aortic arch . . . . .977 Arterio-venous aneurism . . . . . . . .981 Aneurismal varix ........ 982 Varicose aneurism . . . •. . . . .982 Diagnosis of arterio-venous aneurism ..... 985 Treatment of arterio-venous aneurism . . . . .986 Appendix ......... 988 LIST OF ILLUSTRATIONS. CHROMO-LITHOGRAPHS. PLATE PAGE XV. 1. Acute gonorrhoea with partial phimosis. 2. Balano-posthitis with herpetiform ulceration. 3. Paraphimosis, with consequent ulceration. 4. Gonorrhoea in women ...... 227 XVI. 1. Epididymitis. 2, 3. Gonorrhoeal conjunctivitis. 4. Yulvo-vaginal abscess ........ 236 XVII. Chancroids ........ 318 XVIII. Various forms of chancre . . . . . .352 XIX. Moist papules of scrotum and buttocks; mucous patches of mouth and tongue ......... 388 XX. Syphiloderm of palm and sole . . . . . .390 XXI. Tubercular ulcerating syphiloderm . . . . .396 XXII. Late lesions of syphilis ....... 397 XXIII. Infantile syphilis ....... 454 XXIV. Vegetations of vulva and penis ...... 483 XXV. Angeioma of the face, in a child . . . . . .818 WOOD-CUTS, ETC. FIG. 215. Group of placoids in different stages of growth . . . .16 216. Semi-diagrammatic view of section through healing ulcer . . 17 217. Bloodvessel forming in granulation tissue . . . . .18 218. Spindle cells developed from placoids, from walls of a forming bloodvessel 18 219. Epithelium developing from granulation cells . . . .19 220. Process of regeneration in striped muscular fibre after injury . . 21 221. 222. Regeneration of nerves ...... 22 223. Irrigating bottle ........ 26 224. Ward carriage, with irrigating apparatus for cleansing wounds . .26 225. Interrupted suture ....... 29 226. Continued suture ........ 29 227. Harelip or twisted suture ....... 30 228. 229. Quilled suture ....... 30 230. Button suture ........ 30 XXXVII XXXVIII LIST OF ILLUSTRATIONS. FIG* PAGE 231. Diagram to show principle of spray-producer . . . .71 232. Steam spray-producer employed by Mr. Lister . . . .71 233. Method of using protective and deeper layer of gauze . . .72 234. Aseptic dressing in case of abscess of hip-joint . . . .73 235. Ordinary drainage tube ....... 76 236. Lister’s button stitch ....... 77 237. Wound adjusted with three kinds of stitches and drainage tube . . 77 238. 239. Volkmann’s sharp spoons ...... 81 240. Penetration of superciliary ridge and brain by arrow . . . 107 241, 242. Ribs of buffalo transfixed by arrows . . . . .107 243. Wire loop applied to arrow head . . . . . .111 244. Application of wire loop to arrow head imbedded in bone; loop adjusted with wire-twister and porte-meche . . . . .112 245. Strong forceps for extraction of arrows . . . . .112 246. Modified “ crocodile” forceps ...... 115 247. Bending of arrow heads ....... 115 248. Arrow wound of temporal bone . . . . . .118 249. Round musket ball ....... 122 250. Springfield rifle ball . . . . . , .122 251. Enfield rifle ball ........ 122 252. Ball for Snider gun . . . . . . .122 253. Ball for needle-gun . . . . . . .122 254. Austrian ball . . . . . . . .122 255. Chassepot (French) ball . . . . . . .122 256. Bavarian ball . . . . . . . .122 257. Martini-Henry (English) ball . . . . . .122 258. Mitrailleuse (French) ball . . . . . .122 259. Nelaton’s bullet probe . . . . . . .126 260. Section of frontal bone with split musket ball impacted . . . 127 261. Interior view of same bone ...... 127 262. Section of parietal bone with split conoidal ball .... 128 263. Interior view of same bone . . . , , .128 264. Head and neck of humerus perforated by pistol ball ... 128 265. Pistol ball split by striking upon bone . . . . .128 266. Sayre’s vertebrated probe ...... 138 267. Bullet forceps ........ 139 268. Coxeter’s bullet extractor . . . . . . .139 269. Bardeleben’s antiseptic tampon . . . . . .146 270. Transverse fracture of clavicle by conical ball .... 150 271. Fissured gunshot fracture of humerus ..... 151 272. Fissured gunshot fracture of femur ..... 151 273. Necrosed humerus, etc., removed by excision .... 154 274. Musket ball impacted in head of humerus . . . .158 275. Stromeyer’s cushion for excisions of shoulder-joint . . ,160 276. Application of Stromeyer’s cushion . . . . .160 277. Shot perforation of humerus at lower third . . . .163 278. Esmarch’s bracketed elbow splint . . . . .164 279. Deformity following removal of fragments from radius ... 166 XXXIX LIST OF ILLUSTRATIONS. FIG. PAGE 280. Deformity following excision of lower part of radius . . .166 281. Upper end of femur perforated by conoidal ball . . . .168 282. Partial fracture of femur by lodged conoidal ball . . . .170 283. End of femur and head of tibia with impacted ball . . . 170 284. Diagram of gunshot wound of tibia with fissure entering knee-joint, . 171 285. Necrosis following gunshot fracture of parietal bone . . .174 286. Interior view of same bone ...... 174 287. Mediate irrigation ; coil applied to head . . . . .175 288. Perforation of skull by conoidal bone . . . . .176 289. Shell fracture of skull . . . . . . .176 290. Frontal bone with fissure over supra-orbital region . . .176 291. Interior view of same bone, showing splintering of vitreous table . 176 292. Gunshot fracture of rib ....... 188 293. Loops of ileum with shot-perforations ..... 193 294. Gunshot perforation of stomach . . . . . .194 295. Jejunum perforated by pistol ball, showing eversion of mucous membrane 195 296. Gunshot perforation of liver ...... 195 297. Pancreas with conoidal ball imbedded ..... 196 298. Gunshot perforation of kidney ...... 196 299. Lembert’s suture ........ 197 300. 301, 302. First, second, and third steps of application of Gely’s suture . 197 303. Gunshot perforations of ileum closed with sutures . . .198 304,305. Suture of bowel by Jobert’s method .... 198 306. Dupuytren’s enterotome . . . . . . .199 307. Gross’s enterotome . . . . . . .199 308. Gunshot perforation of ilium . . . . . .199 309. Gunshot perforation of bladder ...... 199 310. Gunshot perforation of penis dividing urethra .... 200 311. Gunshot perforation of common iliac artery .... 200 312. Dorsal vertebrae with conoidal ball in vertebral canal . . . 204 313. Musket ball lodged in lumbar vertebra ..... 204 314. Shell fracture of humerus ...... 208 315. Gunshot laceration of femoral vein . . . . .211 316. Partially consolidated gunshot fracture of femur . . . .211 317. Relations of prostate to neck of bladder and rectum . . . 232 318. BougieA-boule or bulbous-pointed bougie ..... 250 319. Dressing of absorbent cotton applied to glans penis . . . 259 320. Application of lint dressing to glans penis . . • « 259 321. Lint dressing applied to glans penis ..... 260 322. Mode of administering a urethral injection .... 264 323. Prostatic syringe . . . . . . . . 27Q 324. Irrigating apparatus for gleet . . . . . .271 325. Taylor’s syringe for sub-preputial injections .... 275 326. Reduction of paraphimosis by ordinary method . . . .276 327. Reduction of paraphimosis by another method . . . .276 328. Reduction of paraphimosis by Eddowes’s method .... 277 329. Strapping a testicle ; application of initial strap .... 281 330. Testicle strapped . . . . . . .281 XL LIST OF ILLUSTRATIONS. FI<3, PAGE 331. Section made through a chancroid ..... 327 332. Section made through a chancroid (higher power) . . . 328 333. Outlines of chancre and herpes, showing polycyclic contour of herpetic lesions ......... 334 334. Gumma of the nose ....... 396 335. Periostosis (node) of bones of forearm from hereditary syphilis . . 434 336. Necrosis of cranium with loss of entire thickness of bone following gum- matous disease ........ 435 337. Hereditary syphilitic disease of bones of hand (Dactylitis syphilitica) . 435 338. Necrosis of cranium following circumscribed gummatous disease . . 436 339-344. Syphilitic teeth ....... 459 345. Vegetations around anus in a child • • » . , 483 346. Digital compression of the carotid artery (Esmarch) . . . 513 347. Digital compression of the subclavian artery (Esmarch) . . *518 848. Digital compression of the brachial artery (Esmarch) . . * 519 349. Digital compression of the femoral artery (Esmarch) . . * 519 350. Application of a conical tampon made of antiseptic balls (Esmarch) . 520 351. Graduated compress (oblong) (Esmarch) ..... 521 352. Pyramidal compress . . . . . . . 521 353. Field tourniquet ........ 521 354. Charriere’s screw tourniquet . . . . . .521 355. Tiemann & Co.’s tourniquet ...... 522 356. Compression of brachial artery by screw tourniquet (Esmarch) . . 522 357. Compression of femoral artery by screw tourniquet (Esmarch) . 522 358. Improvised torsion or old soldiers’ tourniquet (Esmarch) . 523 359. Improvised double-stick tourniquet of Volkers (Esmarch) 523 360. Esmarch’s apparatus for elastic compression .... 524 361. Elastic tube or ligature fastened with a brass ring . . . 524 362. Langenbeck’s clamp for fastening Esmarch’s elastic roller . . 524 563. Open brass ring for fastening the elastic tube .... 525 364. Elastic tube fastened with a brass ring compressing the femoral artery . 525 365. Right foot and leg with elastic roller and ligature in place . . 525 366. Foulis’s fastening-apparatus for the elastic ligature . . . 525 367. Compression of the femoral artery with Esmarch’s elastic ligature fastened with Foulis’s clasp . . . . . . 526 368. Nicaise’s elastic belt for compressing arteries of the extremities (Esmarch) 527 369. Nicaise’s elastic belt applied to compress the brachial artery (Esmarch) . 527 370. Elastic compression of the axillary and other arteries of the shoulder (Esmarch) . . . . . ... < 528 371. Elastic ligature applied to the penis and scrotum (Esmarch) . . 528 372. Elastic compression of the common femoral artery (Esmarch) . . 528 373. Elastic compression of the external iliac artery (Esmarch) . . 528 374. Improvised compression of the aorta with pad and elastic roller (Esmarch) 529 375 Compression of the abdominal aorta by Brandis’s method (Esmarch) . 529 376. Spring-catch artery forceps . . . . . . 532 377. Langenbeck’s artery forceps ...... 532 378. Prof. Hamilton’s spring-catch fenestrated artery forceps . . . 533 379. Dr. David Prince’s tenaculum forceps ..... 533 LIST OF ILLUSTRATIONS. XLI FIG. PAGE 380. Professor Bigelow’s forceps for tying deep-seated arteries . . . 533 381. Professor Wight’s meningeal artery forceps .... 534 382. Professor Gross’s artery compressor ..... 534 383. Professor Wight’s artery and needle forceps .... 534 384. Milne’s artery compression forceps ..... 534 385. Straight and angular serre-fines, Langenbeck’s serre-fine ... 534 386. The “ reef” or square knot ...... 535 387. The “ granny” knot ....... 535 388. The surgeon’s knot '. . . . . . . 535 389. How to draw the knot ....... 536 390. Thrombus in left brachial artery two days after amputation . . 537 391. Occluding coagula six days after ligation of left subclavian artery . 537 392. Coagulum in the distal part of left carotid artery six days after ligation . 537 393. Common carotid artery permanently occluded .... 539 394. Proximal end of left common carotid artery after separation of the ligature ........ 539’ 395. Slide-catch artery torsion and needle forceps .... 545- 396. Professor Wood’s artery forceps ...... 545 397. Amussat’s plan of making torsion ..... 546 398. Hewson’s artery torsion forceps ...... 546 399. Speir’s artery constrictor ....... 547 400. Artery placed within the grasp of the constrictor .... 548 401. Constrictor applied and closed ...... 548 402. Constrictor in the course of removal ..... 548 403. Diagram showing the effects of constriction .... 548 404. Coagulum formed after constriction ..... 548 405. External appearance of the constricted artery .... 548 406. Effects of constriction applied in the continuity of an artery . . 548 407. Acupressure by the first method ...... 549 408. Acupressure by torsion ....... 550 409. Introduction of the aerteriverter . . . . . .551 410. Appearance of the artery when the inversion is completed . .551 411. Retroverted part of the artery fastened with a delicate peg . . 551 412. Straight cautery-irons ....... 552 413. Bent cautery-irons ....... 552 414. Blowpipe for heating the cautery-irons ..... 552 415. Cautery-irons improvised from telegraph wire after Brandis (Esmarch) . 553 416. Tiemann’s thermo-cautery apparatus ..... 553 417. Chassaignac’s drainage tube and drainage trocar .... 555 418. Transfusion apparatus of Dr. B. E. Fryer, U. S. Army ... 557 419. Drawing showing incision in Isham’s case of ligation of the right common iliac artery . . . . . . . „ 562 420. Perforation of right subclavian artery by a fragment of the first rib . 564 421. First rib fractured obliquely by gunshot, with perforation of the right sub- clavian artery . . . . . . . .564 422. Arteries of the pelvis . . . . . . . 576- 423. Erichsen’s artery compressor . . . . . .577 424. Skey’s artery compressor . . . . • • . 578* XLII LIST OF ILLUSTRATIONS. FIG. PAGE 425. Longitudinal plan of arteries of the trunk . . . .579 426. Drainage-tube carrier of Dr. John B. Hamilton .... 591 427. Gunshot wound of the right axillary artery .... 620 428. Shot-wound of the external carotid artery .... 621 429. Shot-wound of external carotid artery and ligation of common carotid artery ......... 622 430. Perforation of the aorta by a swallowed bone . . . .672 431. Perforation of the rasophagus and aorta by a five-franc piece . . 672 432. Perforation of the inferior thyroid artery by a swallowed bone . . 673 433. Perforation of the aorta and oesophagus by a very irregular bone . .673 434. Relations of heart, aorta, vena cava, etc., to the other viscera . . 675 435. Shot-wound dividing the descending cava and perforating the left lung . 676 436. Heart, showing incised wound of right auricle .... 677 437. Sternum, showing oblique incision ..... 6.77 438. Upper half of left lung with conoidal ball embedded . . . 681 439. Ball and piece of lead removed . . . . . .681 440. Bloodvessels, nerves, and viscera of the pelvis .... 686 441. Mott’s aneurism needle ....... 690 442. Circumscribed traumatic aneurism of the superior mesenteric artery . 691 443. Circumscribed traumatic aneurism of the right axillary artery . .691 444. Diagram showing application of ligature in Anel’s, Hunter’s, Brasdor’s, and Wardrop’s operations ...... 693 445. Ligation of left subclavian artery for traumatic circumscribed aneurism of axillary artery ........ 693 446. Diagram showing incision in case of large circumscribed traumatic aneurism 694 447. Diagram to illustrate an arterio-venous wound of the neck . . 695 448. Diagram illustrating aneurismal varix ..... 696 449. Aneurismal varix of left thigh ...... 697 450. Varicose aneurism ...... 698 451. Remarkable varicose aneurism of aorta and vena cava . . , 698 452. May’s tourniquet for the treatment of aneurism . . . .700 453. Briddon’s artery-compressor for the treatment of aneurism . . 700 454. Right subclavian artery divided by a ligature in its third part . . 712 455. Gunshot contusion of left axillary artery ..... 718 456. Ligature of the right subclavian artery within the scaleni muscles . . 719 457. Hemorrhage from sloughing of the left subscapular artery . . .721 458. Ligature of the right subclavian artery for secondary hemorrhage . 721 459. Ligature of the radial and brachial arteries for secondary hemorrhage . 722 460. Axillary artery a fortnight after ligation . . . . .723 461. Ligation of the right axillary artery in the first part of its course . . 723 462. Ligation of the right carotid artery . . • • • 724 463. Ulceration of the common carotid artery . . . . . 727 464. Scalpel . . . . . , . • • . 733 465. Liston’s artery forceps ....... 734 466. Silver probes . . . . . . . .734 467. Plain American aneurism needle . . . . . .734 468. Syme’s aneurism needle ....... 734 469. Improved American aneurism needle . . . . .735 LIST OR ILLUSTRATIONS. XLIII FIG< - PAGE 470. Introducing the probe (Esmarch) • • • • • 736 471. Introducing the aneurism needle (Esmarch) .... 736 472. Tying the knot (Esmarch) •••... 736 473. Sedillot’s method of tying the innominate artery (Sedillot) . . 733 474. Manec’s plan of tying the innominate artery (Sedillot) . . . 738 475. Surgical anatomy of the neck (Sedillot) ..... 740 476. Ligation of the right common carotid artery (Sedillot) . . . 740 477. Ligation of the left common carotid artery (Sedillot) . . . 741 478. Surgical anatomy of the anterior superior cervical triangle . .743 479. Ligation of the lingual artery (Sedillot) ..... 746 480. Ligation of the facial and temporal arteries (Sedillot ) . .747 481. Ligation of the occipital artery (Sedillot) ..... 748 482. Surgical relations of subclavian artery and subclavian vein (Sedillot) . 751 483. Hodgson’s operation for tying the subclavian artery (Sedillot) . . 753 484. Surgical anatomy of the axillary region (Sedillot) . . . 755 485. Hodgson’s operation for tying the axillary artery (Sedillot) . . 755 486. Chamberlaine’s operation for tying the axillary artery (Sedillot) . . 756 487. Delpech’s operation for tying the axillary artery (Sedillot) . . 756 488. Ligation of the axillary artery in the armpit (Sedillot) . . . 757 489. Ligation of the brachial artery in the middle of the arm (Sedillot) . 758 490. Ligation of the brachial artery at the elbow (Sedillot) . . , 758 491. Ligation of the radial artery in its upper third (Sedillot) . . . 758 492. Ligation of the radial artery in its lower third (Sedillot) . . . 759 493. Ligation of the radial artery on the dorsum of the wrist (Sedillot) . 759 494. Ligation of the ulnar artery at junction of upper and middle thirds of the forearm ........ 760 495. Ligation of the ulnar artery above the wrist (Sedillot) . . .760 496. Ligation of the ulnar artery below the pisiform bone (Sedillot) . . 760 497. Cooper’s method of tying the abdomihal aorta .... 761 498. Relations of the common, external, and internal iliac arteries to their ac- companying veins ....... 762 499. McKee’s operation for tying the left internal and common iliac arteries . 762 500. Ligation of the left gluteal artery (Follin) .... 763 501. Ligation of the ischiatic artery ...... 764 502. Ligation of the internal pudic artery ..... 764 503. Sir A. Cooper’s operation for tying the external iliac artery (Sddillot) . 766 504. Surgical anatomy of the femoral artery (Sedillot) . . . 768 505. Ligation of the common femoral artery (Sedillot) . . . 769 506. Ligation of the superficial femoral artery (Sedillot) . . . 769 507. Ligation of the femoral artery in the adductor canal (Sedillot) . . 770 508. Ligation of the popliteal artery in lower part of popliteal space (Sedillot) 770 509. Ligation of the popliteal artery below the inner condyle of the femur (Sedillot) . . . . . . < .771 510. Ligation of the posterior tibial artery at the middle third of the leg (Sedillot) . rjrjl 511. Ligation of the posterior tibial artery at the lower third of the leg (Se- dillot) . , . . 9 * 772 512. Ligation of the anterior tibial artery at the middle third of its course (Se- dillot) 773 XLIV LIST OF ILLUST11ATI0NS. FIG* PAGE 513. Ligation of the arteria dorsalis pedis (Sedillot) .... 774 514. Traumatic arteritis (Cornil and Ranvier) .... 783 515. Endarteritis obliterans, not syphilitic (Welch) .... 784 516. Traumatic endarteritis . ..... 784 517. Arteritis with fatty degeneration (Cornil and Ranvier) ... 785 518. Form of fatty degeneration after arteritis (Green) . . . 785 519. Arteritis with fatty degeneration (Cornil and Ranvier) . . . 78G 520. Atheroma following arteritis (Green) ..... 787 521. Showing calcareous degeneration of the media (Wardwell) . . 789 522. Arteritis with primary calcification (Wardwell) .... 789 523. Arteritis with coagulation necrosis (Wardwell) .... 790 524. Posterior tibial artery, showing coagulation necrosis (Wardwell) . • 791 525. Syphilitic arteritis of basilar artery ..... 792 526. Syphilitic arteritis of small cerebral artery .... 797 527. Syphilitic arteritis of small cerebellar artery .... 797 528. Syphilitic arteritis : the same specimen magnified ... 798 529. Syphilitic arteritis of middle cerebral artery .... 799 530. Syphilitic arteritis of artery of pia mater ..... 799 53L Arteritis with chronic nephritis ...... 800 532. Longitudinal section of the artery of a dog fifty days after ligature (Weber) 801 533. Traumatic endarteritis ....... 802 534. Cavernous angeioma of the liver ...... 818 535. Aneurism by anastomosis in parietal bone (Erichsen) . . .819 536. Erichsen’s method of introducing the double ligature for the cure of vas- cular tumors ........ 820 537. Aneurism of thoracic aorta, eroding vertebras and ribs . . . 843 538. Method of Antyllus ....... 885 539. Method of Anel ........ 885 540. Method of Hunter ....... 885 541. Wardrop’s “ New Operation” ...... 885 542. Method of Brasdor ....... 885 543. Popliteal aneurism growing forward ..... 908 544. Carte’s compressor, groin portion . . . . . • 912 545. Carte’s compressor, thigh portion ...... 912 546. Aneurism needle with hinged end ..... 926 547. Area of pulsation in early innominate aneurism .... 958 548. Case of Robert Watson, innominate aneurism . ' . . . 909 549. Case of Robert Watson, seven weeks after operation ... 969 550. Axes of heart, aorta, and carotids . . . . .971 551. Arch of aOrta and large branches ...... 973 552. Aneurism of innominate artery involving aorta and left carotid artery . 974 1 THE INTERNATIONAL ENCYCLOPEDIA OF SURGERY. CONTUSIONS. BY HUNTER McGUIRE M.D., FORMERLY PROFESSOR OF SURGERY IN THE MEDICAL COLLEGE OF VIRGINIA, RICHMOND. A Contusion may be defined to be a laceration of the subcutaneous tissues without solution of continuity of the skin. When the force which produces the contusion divides the skin, the injury becomes what is known as a con- tused wound. If the cuticle alone is implicated, the injury is an abrasion. But while the skin is not primarily broken in contusions, it is frequently so injured that its vitality is destroyed, and that sloughing takes place subse- quently. Causes of Contusions. Contusions are caused in a variety of ways: by blows, falls, or violent pres- sure. Tbe force which produces a contusion may be direct, as is seen in the case of the “black eye” which follows a blow of the fist, or in that of the laceration of the muscles of a limb produced by contact with a partially spent cannon ball; or it may be indirect, as in the case of a fall upon the hand, when the arm is extended, causing contusion of the shoulder; or in that of a fall from a height, the patient striking upon his buttocks, producing injury of the skull, with concussion and contusion of the brain. We see examples of contusion from severe pressure, in railway injuries, in those caused by ma- chinery in rapid motion, and in those which result from the passage of the wheels of a vehicle over the body. A good illustration of contusion by pres- sure is sometimes observed, after difficult parturition, in the bruised scalp of the infant, and in the swollen vagina and vulva of the mother—the injury in some cases terminating in sloughing and the formation of vesico-vaginal o* recto-vaginal fistulre. 2 contusions. Degrees of Contusion. The degree of a contusion may vary from a slight bruise or pinch of the skin and subcutaneous fascia to a complete crushing and disintegration of a part, according to the amount of violence employed, the resistance of the tis- sues, and the health of the individual injured. Persons whose blood has been impoverished by long-wasting disease are easily bruised. Fat, anaemic women, young or old, especially if bed-ridden for any length of time, are the subjects of frequent ecchymoses produced by the most trilling causes—such as turning over in bed, if the mattress is hard or uneven; or the grasp of the nurse’s hand, in assisting them to move. These bruised spots, or ecchymoses, appear chiefly on the hips, back, and arms; but may come on any part of the body. Individuals who are subjects of the scorbutic or of the hemorrhagic diathe- sis, are peculiarly liable to ecchymosis; but purpuric spots and patches must not be confounded with the discoloration of a bruise. The term bruise, or ecchymosis, is applied to cases in which the contusion is slight, and in which but a small quantity of blood and blood-stained fluid is effused into the sub- cutaneous tissue; a contusion which is indicated by the familiar bluish-black discoloration which follows. If the contusion is more severe, involving deeper structures, laceration of larger vessels occurs, and a greater quantity of blood is poured out. In these cases the discoloration which attends the extravasa- tion may not be seen for several days, as it takes some time for the effused blood to make its way through the tissues to the surface. The discoloration may also appear at a distance from the site of injury. When the extrava- sated blood is coagulated, it is known as a thrombus ; if it is collected into a cavity and remains fluid, it is called a hcematoma. The more vascular and yielding the part—other things being equal—the greater is the hemorrhage. The blood which escapes from the bloodvessels and is confined in the tissues, coagulates over and compresses the lacerated vessels, and in this way, to a great extent, the bleeding is stopped. When the contusion is of the highest degree, and the part is completely crushed and disorganized, it is said by some authors to be jndpejied. In these extensive injuries the skin may also be involved, and show some signs of le- sion ; but frequently its great strength and elasticity enable it to escape un- hurt. The skull may be crushed into numberless fragments, and the brain may be lacerated by a portion of a shell, and yet the scalp may remain appa- rently uninjured; or the wheel of a carriage may pass over a limb, breaking the bones and reducing the soft parts to a pulp, while the skin continues un- broken. When a contusion is severe, the muscles and other soft parts being broken up, a large bloodvessel may be ruptured, and hemorrhage, even to the extent of causing fatal syncope, may ensue; or the contusion and disintegra- tion may be followed by rapid sloughing, or even by acute gangrene of the parts. In such cases the bloodvessels sometimes appear at first to have escaped injury; but they speedily succumb to the mortification which follows. In some instances there are lacerations of internal organs, such as the lungs, liver, spleen, bladder, brain, or spinal cord, leading perhaps to extravasation of blood into a serous cavity. If the case is one of simple bruise, or ecchymosis, the bleeding takes place in the areolar tissue just below the skin, and usually in small quantity; but Mr. Erichsen has related a case in which a school-boy was beaten to death by his teacher, and in which, at the post-mortem examination, the subcutaneous areolar tissue of the arms and legs was found separated from the fascia below, the space between being filled with extravasated blood. Death in this in- stance was attributed principally to the interstitial hemorrhage. 3 SYMPTOMS OF CONTUSIONS. Symptoms of Contusions. The symptoms which generally follow contusions are shock, pain, swelling, and discoloration. Shock.—Unless the individual has some unusual nervous susceptibility, shock is rarely present in cases of slight contusion; and even in those of a more serious character, it is not generally as severe as the gravity of the acci- dent would lead us to expect. If some of the internal viscera, however, are involved, the shock may be at once fatal, or may become so after a feeble attempt at reaction. In the case of a soldier whom I saw, struck by a Minie ball on the metal buckle of his sword-belt, the injury producing contusion of the front wall of the belly, with violent concussion of the abdominal contents, but without any appreciable lesion of the internal viscera, death from shock followed in a few moments. Contusion of the testicle is attended by severe shock and by nausea and vomiting, with great loss of muscular power, and with a tendency to fainting. Pain.—The effect first experienced from a contusion is commonly more or less paralysis of motion and sensation. A violent blow upon the leg may cause the recipient to fall from sudden loss of muscular power. The numb- ness or dead feeling which first follows the blow is soon succeeded by heavy, aching pain, severe and lasting according to the violence of the injury and the nature of the part struck. If the trunk of a nerve be involved in the injury, the pain is burning and tingling, and may extend to the terminal * branches of the nerve. If the soft parts alone are contused, the pain soon disappears, and, if the injury is slight, is relieved by rubbing with the hand. But when fibrous tissue, such as that found about a joint or a superficial bone, is involved, the part remains tender and intolerant of any manipulation or pressure for a long time. Swelling occurs soon after the injury. At first the parts may be condensed or compressed by the blow, as is sometimes seen in injuries of the scalp, where, the skin and cellular tissue being compressed, and the vessels paralyzed at the seat of injury, swelling takes place in the parts around. This condi- tion may easily be mistaken for fracture with depression of the bone, or, even if fracture be present, the depression may be thought to be greater than it really is. This compressed state of the soft parts, when present, slowly passes oft*, and the part then becomes swollen from the effusion of blood which escapes from the ruptured vessels, and from the exudation of serum and fi brin which are poured out from the bloodvessels of the contused parts. It is to the latter cause that the swelling of contusion is principally due. The “ bump” produced on a child’s head by a blow, and the welts on an animal’s skin caused by the lash of a whip, are the result of exudation of bloody serum poured out from the vessels of the contused part, the violence inflicted causing rapid determination of blood to the site of injury, and sudden distension and elonga- tion of the bloodvessels. The extent of the swelling will depend upon the size of the injured vessels, the violence of the lesion, and the looseness or firmness of the tissue involved. In the eyelids, scrotum, penis, and labia, the swelling is generally very great. The extravasation comes for the most part from the veins, the walls of which are more easily injured than those of the arteries. When an artery of any size is lacerated, blood is poured out rapidly, forming a spurious aneurism, 4 CONTUSIONS. with distinct pulsation. The blood accumulation thus formed may, according to the character of the tissues in which it is placed, be circumscribed, or sjiread over a large surface, and may, after a time, settle by gravity to the most dependent position. Medico-legal Import of Extravasation and Ecchymosis.—When a blow or other injury is inflicted on a body after death, venous blood in small quantities may be effused under or upon the skin, but not into the substance of the cutis vera. When the extravasation is extensive, or the skin thickened, having greater firmness and tenacity from infiltration of blood, it is fair to conclude that the injury has been received before death. This condition of the true skin, while not necessarily present in every case of contusion in the living, cannot be produced by blows upon the dead body. An ecchymosis following an injury received during life, may not make its appearance until some hours after death; or a small bruised patch, seen during life, may increase in size after death. A contusion received some hours or days before death, may often be recognized as an injury of some duration by the changes which have taken place in its color, the borders of the ecchymosed patch having become lighter and faded, and portions of the bruise looking greenish or yellow. It is well to recollect, in medico-legal investigations, that a severe blow is not always followed by visible discoloration. The injury may bave been sufficient to cause death, and yet no mark of violence may be seen on the skin or subjacent tissues. It should also be remembered that a very slight contusion, causing little or no pain, may produce extensive ecchymosis in purpuric individuals, or in “ bleeders,” or in persons who have a large quantity of subcutaneous fat. Discoloration often makes its appearance in a few moments after the in- jury lias been inflicted. Sometimes, however, several days pass before it is seen, and when this is the case it indicates a deep-seated lesion. After frac- tures, discoloration is frequently not seen until two or three days have elapsed. The ecchymosis may reach its full extent in a few minutes, extravasation of blood and exudation of bloody serum ceasing soon after the blow; or it may go on for several days, gradually extending for some distance under the skin. The discoloration at first may he black, or a deep purplish-blue, or, in some cases, pink or crimson. Blackness usually indicates a severe in- jury and extravasation of pure blood ; various shades of purple or blue are produced when blood is mixed in different proportions with blood-stained serum; a pink or crimson hue shows that the ecchymosis is superficial, and that oxygen from the atmosphere is admitted through the thin epidermis or mucous covering of the part. We see examples of the latter condition in ecchymosis of the eye, where the crimson color contrasts strongly with the deep blue or black bruise of the lids and surrounding soft parts, after injuries in that region; and in the pink or red color of a superficial blood-blister just below the epidermis; when the contusion is more deeply seated, the blister is black. The discoloration changes in ordinary cases after the lapse of one or two days. Gradually it becomes lighter, changing from black, or blue, to an olive-brown; then to a greenish-yellow; and finally to a lemon hue, aftei which it disappears. These changes in color are probably due to the influ- ence of air and light upon the extravasated material, as in deeper parts— among the muscles for instance—the shade of color is always that of either venous or arterial blood, or of a mixture of these fluids. Vesicles or blebs tilled with bloody serum not unfrequently follow bruises, and, when the discoloration is black or purple, the appearance of the part re- sembles that of gangrene. The phlyctense of mortification, however, are filled with putrid serum ; and as the scarf skin is detached for some distance around ABSORPTION OR ORGANIZATION OF EXTRAVASATED SUBSTANCES. 5 the bleb, the serum can be made, by slight pressure, to move about from one point to another. This is not the case with the vesicles of a bruise. The latter are also attended by pain and heat; those of gangrene by an absence of both heat and sensibility. In gangrene an offensive odor, and crepitation from the presence of gases, may also be observed. Absorption or Organization of Extravasated Substances. When the contusion is simple, and not followed by much inflammation, the extravasated fluids are soon absorbed, and the parts restored so fully to their original healthy condition that no evidence of injury can be found. This is sometimes the case in the contusions which attend severe fractures, the absorbents gradually taking up the deposit, which eventually is carried out of the body by some of its emunetories. The fluid portion of the extrava- sation is rapidly absorbed; the coagulated portion more slowly. When, how- ever, the injury is severe; or when it occurs in an individual whose health is impaired by some vice of constitution, the effusion of blood and bloody serum may remain for many weeks, or even months, unchanged. It may continue liquid, or may become solid, or may be partly solid and partly fluid. When the laceration is severe, and blood collects in a cavity, the effusion is called, as has been said, a blood tumor or haematoma. The walls of this cav- ity are formed of blood-clot, and condensed, cellular and other tissue. The tumor is thus circumscribed, having its boundaries well defined. We find such accumulations frequently accompanying contusions of the back, nates, and loins, and in other places where the cellular tissue is abundant. When the blood remains for some time unabsorbed, its presence causes adhesive inflammation, which closes the cells of the tissues around the deposit, and a thin layer of plastic matter is thrown out, which becomes organized and which is eventually lined by a layer of secreting cells. The walls of an old hrematoma look very much like those of a thin-walled cyst or abscess. The diagnosis between blood tumor and abscess, or malignant disease, is not always easy. The affections may usually be distinguished by the history of the case —the hsematoma coming on soon after contusion—and by the absence of signs of inflammation and engorgement of the parts around the swelling; and, if necessary, by use of the exploring needle and by microscopic examination of the contents of the swelling. The question whether blood extravasated in a contusion can be organized and become the nidus of a new growth, is an important and interesting one. John Hunter1 declared that he had reason “to believe that the coagulum has the power, under necessary circumstances, to form vessels in and of itself,” and this theory was practically accepted by Sir Astley Cooper and others of that day. Sir James Paget2 says: “There is sufficient reason to be- lieve that blood extravasated in a contusion may be organized;” but he adds, “Nevertheless, it is not probable that this organizing of blood is frequent after contusions; and the more exact the researches that are made, the less reason is there found to adopt the belief that blood extravasated in a contu- sion can become a tumor of any kind.” Rindfleisch says that the process of organization is effected by leucocytes which come from the tissues in the neighborhood of the clot, and not from the clot itself. It seems not at all improbable that the new growth lias its origin, not in the clot, but in some plastic deposit left there by inflammation originally set up by the force which 1 Treatise on the Blood, etc. Works (edited by J. F. Palmer), vol. iii. p. 119. London, 1835. 2 Article on Contusions. Holmes’s System of Surgery, Second edition, vol. i. p. 623. London, 1869. 6 CONTUSIONS. produced the contusion; or possibly caused by the mere presence of the blood itself. Whatever the process may be—and it is certainly an obscure one— the fact that tumors, benign and malignant, follow severe contusions, is in ac- cordance with the experience of many observant practitioners of surgery. Prognosis of Contusions. Unless the parts involved in contusions are important to life, or the injury is extensive, or the patient old or unhealthy, recovery usually takes place, and the parts are completely restored to their original condition. The prog- nosis, however, is not always favorable. If an internal organ, such as the liver, kidney, or bowel, be involved, the result may be quickly fatal. Con- tusion of the prostate gland, in the operation for stone in the bladder, is not an uncommon cause of death after lithotomy and lithotrity. In old people, or those of unsound health, a bruise may be followed by inflammation, suppu- ration, and sloughing, attended by great suffering and danger; or the effused blood may become decomposed, and the case end in septicaemia from absorp- tion of the poisonous fluids and gases thus generated. When the injury is severe and the ecchymosis extensive, contusion fre- quently terminates in abscess. The blood acts as a foreign bod}’, leading to irritation and inflammation, which continue until suppuration, ulceration, and not unfrequently sloughing, take place. The discharge at first consists of decomposed blood, mixed with pus and the debris of tissue, but after a short time becomes like that of an ordinary acute abscess. Suppuration is most apt to follow contusions in feeble and unhealthy individuals, or in cases in which a breach of continuity in the skin has allowed the admission of air to the blood deposit. In persons whose constitution has been impaired by in- temperance, scurvy, anaemia, or other cause, severe bruises are apt to termi- nate in suppuration of a diffuse character. If, together with the contusion of the superficial tissues, some larger joint be involved, bloodvessels or nerves be ruptured, or bones be broken, the prog- nosis, is, of course, unfavorable. Contusions involving the periosteum are some- times followed by permanent induration and thickening of that membrane, at- tended by great tenderness and pain. Sometimes the site of a bruise remains very sensitive for months without apparent induration or enlargement of the- part. In such a case it is probable that some nerve has been injured. When the trunk of a nerve has been ruptured, or its fibres crushed, paralysis of the muscles to which it is distributed results, or the site of the injury may become the seat of severe and persistent pain, often neuralgic in character. Contusions occurring in people who have a rheumatic, or, still more, a gouty diathesis, produce much pain and trouble. A blow or fall upon the foot or hand,, which would scarcely be noticed in a healthy subject, often provokes severe and prolonged suffering in an individual subject to gout or rheumatism. The same may be said of persons suffering from syphilis or scrofula. Contusions of periosteum or bone in such patients often end in active inflammation and its consequences. Treatment of Contusions. Slight bruises get well of themselves, and require no treatment. When the injury is severe, the first indication is to stop further extravasation of blood. Arrest of bleeding may have occurred spontaneously, before the arrival of the surgeon. If it has not, the best means of preventing further effusion are elevation of the part, rest, and the application of cold. In simple TREATMENT OF CONTUSIONS. 7 eases, cold water, or lotions containing spirit of camphor, tincture of arnica, or the hydrochlorate of ammonium, answer a good purpose. Three or four thicknesses of old linen or cotton cloth should he saturated with one of these lotions, and applied to the contused part. The cloth should be kept con- stantly wet. One of the best applications I have tried in such cases is a mix- ture of equal parts of whiskey and water. Lotions containing sugar of lead, sulphate of zinc, carbolic acid, acetic acid, vinegar, alum, or common salt, are also used. These applications not only prevent further effusion, but, acting as sorbefacients, encourage the absorbents to take up the blood and serum which has been poured out. Tincture of has long been the favorite local application among pugilists for contusions received in their encounters. It is still used by these people, and is probably more efficacious than the pro- fession generally supposes. If some one of the larger vessels has been ruptured, and the subcutaneous hemorrhage threatens to be serious, pounded ice, in bladders or rubber bags, should be kept applied to the part. The effect of ice used in this way should be carefully watched, as the vitality of the injured portion is already low, and the depressing effect of cold carried too far may provoke sloughing which otherwise would not occur. In some contusions of the limbs, when the bones have been broken, joints involved, or important vessels injured, but when it is thought that the limb may be saved from amputation, cold, applied by suspending over the injured part a basket filled with ice, is a valuable agent in limiting and controlling inflammation. The contused limb should be laid in a simple fracture-box, the bottom of which is covered with a layer of bran from one to two inches in depth, or, which is better, fine sawdust; this should also be gently packed along the sides of the limb to give support to the broken bones. The limb should be carefully watched, and the basket of ice elevated or lowered, as the condition of the part may demand. This can be effected by attaching to the basket a cord, which should run through a pulley suspended from the ceiling, or any other convenient point. The in- jured part receives the dripping from the basket, and is kept continually bathed in the cold air which descends from the melting ice. The application of cold by any of the plans suggested prevents further extravasation, and limits the inflammation which, in severe cases, is sure to follow to a greater or less extent. In aggravated cases of contusion, when the effusion is very great, the cir- culation feeble, the temperature low, and the vitality of the part endangered, dry and warm applications are demanded. The contused part should then be surrounded with flannel or raw cotton, and this covered with oiled silk. Dry is better here than moist heat. After the extravasation has been arrested, and when the danger from inflammation has passed away, compression very gently applied by means of a bandage is often useful. It gives a comforting support to the part, relieves pain, and stimulates the absorbents to take up the effused liquids. In slight cases compression may be used with advantage from the first. The formation of a “ bump” on a child’s head after a fall or blow on the forehead, is frequently prevented by the mother’s pressing the spot with a piece of ice or the handle of a spoon. The pressure arrests the subcutaneous hemorrhage, and diffuses the blood already poured out into the surrounding tissues, whence it can more readily be absorbed. Upon the same principle, when absorption is slow, and when there are no symptoms of inflammation present, rubbing and kneading the part hastens the process of cure. Writers on surgery generally teach that no attempt should he made to draw off the extravasated blood unless symptoms of suppuration are present. If 8 CONTUSIONS. air be admitted, we are told, decomposition of the blood will take place, and putrefactive suppuration will be set up. To this rule, however, there will be found exceptions. I have, with a common hypodermic syringe, tapped the soft bag of blood which follows contusions of the face, and have thus drawn off by aspiration the greater portion of the effused fluid without the slightest bad consequences. On the contrary, the cures have been more rapid, and the time during which the sufferer has been confined to his room because of a black eye, materially lessened. A common practice among pugilists is to make an opening in the bruised and swollen eyelid and gently press out the blood, and afterwards to apply a cold compress. When it is important to get rid of the ecchymosis quickly, there is no reason why the needle should not be inserted at several points, if entire evacuation cannot be effected by one insertion. When the extravasated blood is making injurious pressure on important parts, or giving rise to great pain, it should be evacuated in some way. Con- tusion of the ends of the fingers or toes sometimes produces extravasation of blood under the nails. The pressure upon the delicate and sensitive structures in this locality occasionally gives rise to great pain, which only the evacua- tion of the blood can relieve. If the toe or finger be immersed in hot water for half an hour or longer, the nail will be so softened that an opening can easily be made through it, and some of the blood permitted to escape. The application of leeches to ecehymoses, so frequently resorted to with the view of drawing out the extravasated blood, should never be attempted. These fastidious little creatures will never drink from the “ stagnant pool when they can get at a running stream.” They not only do no good as far as getting rid of the “ bruised blood” is concerned, but their bites produce irritation, and increase the probability of suppuration. They should be employed only when it is necessary to subdue high inflammatory reaction, which often follows in- juries of this character, and then they should be applied at some distance from the bruised spot. When the contused part becomes hot, red, painful, and throbbing, and suppuration threatens or is actually present, a free, dependent incision should be made, and the blood and serum thoroughly evacuated. The cavity left should be washed out with warm water containing hydrate of chloral or car- bolic acid; and, after the bleeding has ceased, a light linseed-meal poultice should be applied. Afterwards, every means should be used to encourage §ranulation and to promote the closure of the wound. A compress and ban- age to keep the walls of the cavity in contact, will hasten the reunion of the parts. If at any time during the course of a contusion, a slough forms, its separation should be encouraged by means of a poultice, and the part, as well as the room, bed, and patient’s clothes, deodorized and disinfected by some of the numerous agents employed for this purpose. The best are probably the hydrate of chloral, carbolic acid, the permanganate of potassium, and chlori- nated soda. When the contusion is complicated by the rupture of a large artery and the formation of a diffused aneurism, a free incision should be mado, and both ends of the vessel searched for and tied. When the soft parts are mashed or “ pulpefied,” the bones comminuted, the large blood- vessels or nerves ruptured, or the joints opened—the circulation being feeble and the temperature lowered—amputation to prevent gangrene will be ne- cessary. Constitutional Treatment.—In tlie earlier stages of a contusion, when absorption of the extravasated blood is being sought for, a low diet should be enjoined, and antiphlogistic treatment generally should be practised. Absorp- tion of the effusion may sometimes be hastened by free purging. When sup- STRANGULATION OF PARTS—BRUSH-BURN. 9 puration or sloughing has taken place, the patient will need a supporting treatment, and iron, quinine, and nutritious food should be given. At all times, when suffering is great, opium or some other anodyne should be ad- ministered, to allay pain and produce sleep. Contusions of internal organs are usually serious and dangerous injuries, the symptoms and treatment of which will be considered in other portions of the work. Strangulation of Parts. When a cord or tourniquet tightly encircles a portion of the body, cutting oft* all circulation through the bloodvessels, the part below the seat of con- striction dies. Surgeons frequently employ this method of strangulation in getting rid of hemorrhoids, vascular tumors, etc. It is not necessary, how- ever, in order to kill the part, that the cord should be tight enough to cut off all circulation; if it simply interferes with it, greatly lessening the arterial supply or preventing venous return, death of the part may equally follow, but it is effected by a slower and more painful process. The cases which come under the observation of the surgeon are generally those of partial constric- tion, as where a ring has been accidentally slipped over the wrong finger, which it encircles too tightly ; or where a bandage has been unskilfully ap- plied to a limb; or, as in hernia, where the bowel escapes through a small opening in the abdominal wall, and strangulation of the intestine is the con- sequence. The first effect of this partial constriction is accumulation of venous blood in the vessels of the part, and effusion of the watery portions of the blood into the surrounding parenchyma. At first the part looks glossy .and cedematous; obstruction to venous return continuing, inflammation sets in; the vessels become still more over-distended; complete stagnation of blood takes place; vitality ceases ; and gangrene ensues. The part changes its appearance, becoming mottled, purplish, and finally black in color. Tying a string around the penis, as has been stupidly done by nurses to prevent children from wetting their beds, or slipping a ring over the penis, has frequently caused mortification of the organ, and sometimes the death of Ihe patient. Treatment of Strangulation.—The treatment is of course to remove the source of constriction as soon as possible. A grooved director can generally be passed under a ring, and by means of a file or cutting-pliers this can be divided and removed. Contracting the penis or finger by the application of ice, will sometimes enable the surgeon to get the ring ofi; or by wrapping a silk thread tightly around the finger from its point to the ring, slipping the free end of the thread under the ring by means of a needle, and then .slowly unwrapping the cord, the ring will be made to follow. Brush-Burn. Mr. Erichsen has employed this name for a peculiar kind of contused wound, made by severe friction of some portion of the surface of the body. It is frequently caused by the belting or other parts of machinery in rapid motion, coming in contact with the body; or by a rope, which an individual is holding, passing with great velocity through his closed hand. I have seen an extensive “brush-burn” produced on the buttocks and back of a boy, who slipped from his sled while sliding or “ coasting” rapidly down a steep hill 10 CONTUSIONS. covered with ice and snow. Heat is developed by the friction, and the in- tegument is abraded, and in severe cases the subcutaneous tissues are more or less contused. Treatment.—The injured part should be protected from the air, as in the case of an ordinary burn. The separation of sloughs, if formed, should be encouraged by the use of water dressing or poultices, and the resulting sores treated on general principles, liepair will be effected by granulation. WOUNDS. BY THOMAS BRYANT, F.R.C.S., SURGEON TO, AND LECTURER ON SURGERY AT, GUY’S HOSPITAL, LONDON. From a clinical point of view, wounds may be divided into the “ open” and the “ subcutaneous,” if we exclude those by which animal poisons are intro- duced into the system, such as dissection wounds, the stings of insects, bites of snakes and rabid animals, and the wounds which afford an entrance to the poisons of glanders, malignant pustule, and, last but not least, syphilis. The term open is applied to all injuries caused by external violence—the result either of accident, or, as in operation, of design—in which there is a solution of continuity in the soft tissues, and in which the deeper parts are exposed to the influence of the air, through a more or less gaping orifice. The term subcutaneous is applied to such injuries as follow external violence, and in which the deeper tissues, bones, or viscera, are broken, ruptured, lacerated, or crushed, without any breach in the continuity of the soft parts covering them, and consequently without their exposure to the influence of the external air, as well as to such operations as may be done by the surgeon through a small external or open wound—as in tenotomy, myotomy, and osteotomy. Open wounds are more serious as a rule than the subcutaneous, though when large vessels and viscera are concerned, the latter are among the gravest injuries the surgeon has to deal with. Open wounds, moreover, heal by a more com- plicated process than the subcutaneous, and are exposed to risks from which, the latter are free. Classification of Open Wounds. When made by a sharp-edged instrument, either by accident or in an opera- tion, wounds are said to be incised; when inflicted by a blunt instrument that tears, they are called lacerated; and when caused by one that bruises, contused. Wounds caused by the thrust of a pointed instrument are called 'punctured, though when the weapon is sharp, the tissues are simply pierced and cut deeply; but when blunt, irregular in shape, or increasing in diameter from the point towards the handle, the soft parts are forced asunder as by a wedge, and are consequently stretched and contused. A punctured wound thus under some circumstances approaches the character of the incised, and under other circumstances that of the contused form of injury. As a matter of fact, however, all wounds of soft parts are more or less contused, those inflicted with a very sharp instrument being, of course, the least so. A wound is called “simple,” when it has been made by a clean, sharp-edged instrument, in a healthy subject, and when there is nothing in the nature of the wound itself, or in the state of the patient, to prevent or retard repair,, provided that the injured part be placed in a favorable position for the repara- 12 WOUNDS. tive process to be carried out. The wound is called “complicated,” when there are foreign bodies lodged in the part to interfere with repair; when it is attended with hemorrhage, or with much contusion or laceration of tissue; or when from the peculiarity of the patient there are nervous symptoms, severe pain, constitutional disturbance, or local inflammation; or when repair is interfered with by the presence of such complications as bad health or old age. Incised Wounds. Open incised wounds are best seen as the result of operations, hut they may also he well studied as clean cuts, accidentally made with sharp-edged instru- ments. They may gape from the elasticity or contractility of the tissues divided; may bleed from the division or wound of small or large vessels; and may give rise to variable degrees of pain, according to the number or character of the nerves involved, and according to the susceptibility of the patient. G aping of Incised Wounds.—The amount of gaping in a wound varies with the tissue divided. Skin, which is the most elastic tissue in the body, retracts when divided far more than other tissues, and transverse wounds of skin gape more than those which are longitudinal. Arteries, when wounded transversely or obliquely, gape much, and when completely divided across, retract far into the tissues. Divided veins retract less than arteries. Muscles, when their fibres are cut across, shorten rapidly by contraction, and thus aid the gaping of a wound. Fibrous tissues and nerves, when divided, retract but little. All wounds, however, which are made in parts in a state of tension, gape much, and tissues which are on the stretch when divided, retract far more than they would do if they were relaxed. Thus an incision made into the full breast of a suckling woman, will probably by gaping appear as wide as it is long; while one made into the same organ in a flaccid state, would gape but little. Some tissues, on the other hand, never gape on division; this is best seen in wounds of the palm of the hand, and of the sole of the foot. The surgeon takes advantage of these known conditions of gaping and retraction of tissues, and in his operations so places on the stretch the parts to he divided, as to enable him to make a clean and decisive section of the tissues with which he is dealing—a single sweep of the knife, made under these cir- cumstances, doing the work of many when made under others less favorable. Hemorrhage from Incised Wounds.—The bleeding that attends an incised wound depends principally upon the size, number, and character of the ves- sels that are divided, although it may be influenced by the personal pecu- liarities of the patient, and more particularly by the fact of his being a “bleeder,” or not; or, in other words, by his being, or not being, a subject of the “hemorrhagic diathesis.” The condition of the wounded part, moreover, whether inflamed, or otherwise more than normally supplied with blood, has some influence; and the effects of position must always be taken into account. Putting aside, however, these peculiarities, constitutional and local, the my- riads of vessels that are divided in a wound made in a healthy subject with sound tissues, rapidly if not instantaneously close on the removal of the dividing medium; for it is a fact that capillary bleeding after an incised wound rapidly ceases by natural processes, and that what goes by the name of “hemorrhage” is due to the issue of blood from wounded arteries of some size, or from wounded veins, the bleeding, if it does not prove rapidly fatal, persisting till nature’s haemostatic processes—unassisted or assisted by art— nave had time to act. LOCAL AND CONSTITUTIONAL EFFECTS OF INCISED WOUNDS. 13 Pain of Incised Wounds.—The pain attending an incised wound varies in its nature and degree, according to the position of the wound and the tissue- wounded. Some portions of the body, such as the skin of the face and fingers, orifices of the mucous tracts, periosteum, or tense tendons, are far more sensi- tive than the skin of the back or buttocks, the bones, and the fasciae. The sensibility of the patient has likewise much to do with the degree of pain experienced, as has the condition of the nervous system at the time at which the wound is received. Not only may one subject of an operation be far more- sensitive than another, but the same person may feel pain more acutely at one than at another time, the general condition of the physical powers, and more particularly of the nervous system, greatly influencing sensibility. Unexpected or unseen wounds, or wounds received during drunkenness, or when the mind is intent on other things, as in the excitement of battle, are often unfelt, or felt but slightly; whereas when the mind of a patient is fixed upon the performance of an operation, the evil influence of anticipation- aggravates his suffering. Local and Constitutional Effects of Incised Wounds. The local effects of a simple incised wound, in a healthy subject, may extend little beyond the breach of surface, and the slight pain and bleeding which attend the injury. The constitutional effects may be so slight as to be un- observed. In a general way, however, local as well as constitutional effects show themselves, and these are greatly influenced by the extent of the wound, the general condition of the patient, and the treatment to which the injured part and the patient have been subjected. Local Effects.—The local effects of a wound are best studied in a deep,, incised cut, which has passed through skin, subcutaneous fat, and fascia. The wound, directly after its infliction, will gape, and, after the lapse of but a brief interval of time, this gaping will increase, so that the subcutaneous fat will appear as if it were being pressed out of its position, and as if the- divided edge of true skin were retracting from it, and becoming everted. Within an hour, or an hour and a half, the edges of the wound will be seen to- be swollen and slightly red, from increased vascularity, and, where the con- nective tissue of the wounded part is loose—as in the eyelid or the male- genital organs—puffed up and osdematous. To the patient, the part will feel hot and stiff', and it will be the seat of a dull, aching, or burning pain. The- edges of the wound will also probably be more sensitive, the amount of pain depending much upon the tension of the parts, and upon the treatment to which they have been subjected. If the edges of the wound have been stitched together, and the parts are much swollen and cedematous, there will be tension upon.the wound, and a disposition to separate and gape. In a healthy sub- ject, however, when repair goes on well, all these local phenomena will sub- side and disappear in the course of two, three, or four days, according to the- rapidity and perfection of the healing process, and a cure will then take place. But should the local phenomena above described be more persistent, increase in severity, spread beyond the margins of the wound into surrounding parts, or alter in character for the worse, what has been a physiological, reparative process will pass into a pathological or diseased one, and the parts will then be said to be “inflamed.”1 1 See vol. i. p. 65. 14 WOUNDS. Constitutional Effects.—The constitutional phenomena associated with these local changes, vary greatly. In some subjects, a trivial, local injury, a mere cut, may give rise to severe shock, or to a disturbance of the nervous system which expresses itself in convulsions; whereas in another, a severe and extensive wound may be followed by few if any constitutional symptoms. Shock.—The gradations of shock and collapse are innumerable, and the symptoms by which they are characterized vary from a passing faintness or disturbance of the heart’s action, to fatal syncope. The state of collapse may be regarded as a chronic syncope. Patients may unquestionably die from shock following slight injuries or minor operations, though no satisfactory cause for death may subsequently be discovered, the heart’s action in these cases being suddenly stopped through some central nervous influence. The degree of shock that attends an accident or operation depends as a rule, how- ever, upon the importance of the injured organ in the animal economy, the extent and nature of the violence which the tissues have sustained, the size of the bloodvessels which have been involved, and the amount of blood which has been lost. A patient, in good general health, will bear a severe wound or operation with little shock, while another with diseased viscera, and more particularly with diseased kidneys, will be subjected to severe shock from even a trivial injury. The age and constitutional condition of the patient have an im- portant influence under all circumstances. Reaction.—When what lias been described as the period of “shock” after an accidental or operative wound, has passed away, the stage of “reaction” is reached, and in a general sense it may be assumed that the intensity of this stage is fairly governed by the intensity of that which preceded it. That is to say, where there has been little shock, there will be but feeble reaction; and where the shock has been severe or prolonged, the stage of reaction will be of a like type. Still this rule has innumerable exceptions, and these ex- ceptions seem to depend more on the individual peculiarities of the patient than upon anything else: one person, after a slight injury or operation, ex- periences little shock, but sharp reaction; while another, suffering from a severe injury or operation, will have a prolonged stage of shock, followed by no more reaction than seems to be necessary to restore the circulation to its normal condition, and to allow the functions of the body to work efficiently. Children and women, and the subjects of neurotic tendencies, always react rapidly and in a marked way from all kinds of shock, whether mental or physical, but at the same time these subjects, as a rule, do well. The rigors, nervous tremblings, and fears, which are often met with in nervous subjects after operations, and which often cause alarm, are but rarely followed by any bad results. The symptoms of reaction, in their mildest expression, are simply those of the restoration of the nervous and circulatory functions to their normal con- dition—the heart, with the circulation generally, so rallying from the depressed condition into which it has been thrown by the “ shock” of the accident or operation, as to come up to the usual standard of health; and the nervous system so recovering from the temporary state of depression, if not of unconsciousness, into which it has been cast, as to resume its normal power of governing and controlling the actions of the body over which it presides. The reparative process consequently, under these circumstances, maybe expected to go on uninterruptedly to a successful issue; the wound will undergo repair, and heal, and the subject of the wound will suffer little or no constitutional evil beyond that occasioned directly by the injury. The PROCESS OF REPAIR IN WOUNDS. 15 stage of reaction, in a clinical sense, will then be normal; it will be such as may be said fairly to balance that of shock, and to tend towards recovery. Traumatic Fever.—When the symptoms of reaction, either with respect to intensity or duration, exceed this normal standard; when the circulatory system acts powerfully and rapidly, the respirations increase in quickness, the brain and special senses become abnormally active, and the temperature of the body rises, and remains above that of health; and when, with this ele- vation of temperature, the functions of the body generally are disturbed and work badly, as indicated by thirst, a foul tongue, loss of appetite, constipa- tion, diminished secretion of urine, want of sleep, or disturbed rest—trau- matic fever is said to exist. This fever may show itself the day after the injury or operation, or may not appear till the second day, and it may last for twenty-four, forty-eight, or even seventy-two hours. When the case is going on satisfactorily towards recovery, the fever seldom lasts beyond this period. Should the symptoms, however, continue, dangers are to be apprehended, and difficulties looked for. When the fever runs on into the fifth or sixth day, the surgeon may be sure that some complication is present, and, should the symptoms be still more fixed, the probabilities are that the case is not only badly complicated, but that it will pass on to a fatal issue.1 Under all circumstances, and in the treatment of every wound, accidental or operative, the eye of the surgeon should be steadily fixed on the temperature chart—such a chart affording the surest indication of the advance or presence of any evil complication. Process or Repair in Wounds. Before entering into details, it is well to know, as a primary truth, that the processes of repair are identical in all tissues; that the reparative process in bone or muscle, integument or tendon, soft or hard parts, is the same, such modifications alone showing themselves as necessarily appertain to the anatomy of the tissue or special circumstance of its position. Thus, tissues that are highly vascular, may undergo more rapid and more perfect repair than others less fortunately circumstanced, and bone tissue may require more time to unite than skin, yet in all the process is alike. Let us therefore inquire what the process is, and see what changes take place in parts undergoing repair; and then look at them where they are best seen, where an incision is made through the skin and the edges are brought together. Immediate Union.—The chief points that can be observed have reference to the capillaries. In these, at the margin of the wound, the blood will be found coagulated up to the nearest anastomosis, and the capillary vessels in the neighborhood will be seen to he dilated—this dilatation being caused by the increase of pressure to which the capillaries have been subjected by the altered circulation of the blood in the immediate vicinity of the wound. When wounds unite by immediate union (the “first intention” of Hunter), no other changes than these take place, beyond the gradual restoration of the capillary circulation through the parts that have been divided, and under these somewhat rare circumstances no scar or cicatrix is left. The soft parts at first simply adhere together, and consequently become continuous. Primary Adhesion.—Should the wound unite by what is called adhesive union or primary adhesion, in which a cicatrix is formed, other changes are to be • See a paper by the author, in the Lancet for June 5, 1880. 16 WOUNDS. seen; and these take place in the connective tissue—in which the vessels of the part ramify—a tissue that pervades every other, and which is made up of cell elements and inter-cellular tissue, the cell elements varying according to the nature of the part in which it is found. These changes consist of cell multiplication, and, under the circumstances supposed, we find between the edges of the wound a vast accumulation of cells, filling up in various degrees the spaces of this wounded tissue. It is through these cells that cica- trization takes place, these cells being in part simple nucleated cells, which may be called “embryo cells,” with connective-tissue corpuscles containing a nu- cleus and nucleoli—Klein’s “ Placoid Cells.”1 (Fie;.. 215.) Whether this cell multiplication depends upon changes in the cell itself, as Virchow affirms, or whether the cells are the white corpuscles of the blood which have escaped by exudation from the capillaries, as Colmheim would lead us to believe, I do not now care to inquire. All admit, however, the multiplication of cells in the affected tissues. Professor Redfern writes:2 “the facts must be recognized; the floating blood- cells are really the very cells which once formed the substance of the lymphatic glands, the spleen, and other organs; and they do, in fact, move through the walls of the blood passages, and wander about freely in what are called solid tissues.” When we recollect how penetrable the tissues of an animal are, we shall cease to be startled at seeing those parts become the seat of entirely new deposits, or finding them traversed by migrating blood-corpuscles as freely as a colloid is penetrated by a crystalloid. Fig. 215. A group of placoids in different stages of growth; a, embryo cell wandering. (After Golding-Bird.) Cicatrization.—Let us now inquire briefly how cicatrization proceeds, and note that it is in the cells that the most important changes are to he recog- nized. Those nearest the injured part gradually assume a spindle shape, and the intercellular tissue into which these spindle-shaped cells are infiltrated becomes denser. The spindle-shaped cells then gradually change into ordinary connective-tissue corpuscles, and in this way new cicatricial tissue is formed. (Fig. 216.) This new tissue, however, again undergoes changes—changes of consolidation. The intercellular tissue becomes gradually more condensed— the spindle-shaped cells also assuming the flat shape of connective-tissue cor- puscles, and in a measure disappearing, the nucleus often alone remaining— the fluid that existed in the newly formed tissue is absorbed, and the new cicatrix by degrees thus becomes firmer and denser, gradually contracting, so that at last the delicate scar of a large wound becomes solid and compact— the cicatrix in smaller wounds appearing only as a thin, red, and at a later period as a white line. Changes in the capillaries of the part are, however, going on during all this period, and how far all the changes that have been briefly described are due directly to the capillary action, is not yet determined. If Cohnheim’s views be adopted, it is to the capillaries that the chief action in the tissues must be ascribed, but if those of other pathologists, such as Virchow and Billroth, be accepted, the capillary action takes a secondary place, and the cell elements 1 Figs. 215-219 are taken from a valuable paper written by my friend, Mr. Golding-Bird, and published in Guy’s Hospital Reports, 3d s., vol. xxiv (1879). 2 Address at meeting of British Association, 1874. PROCESS OF REPAIR IN WOUNDS. 17 Semi-diagrammatic view of a section through a healing ulcer. 1, Epithelium formed ; 2, Placoid cells developing into epithelium ; 3, Region of granulation tissue ; most of the cells are embryonic and free in the meshes of protoplasm ; placoids exist in numbers to form—above, epithelium—and below, fibrous tissue ; the cells with a round granular nucleus are transitional; 4, Tissue undergoing cicatrization; it contains but few embryo cells ; the protoplasm is arranging itself in transversely elongated meshes above, but below it becomes fibrillatea; the placoid nuclei, which appear as dark rods, become the connective-tissue corpuscles of the new fibrous tissue. (After Golding-Bird.) Fig. 216. VOL. II.—2 18 WOUNDS. take the leading one. On either theory, the importance of the capillaries cannot he overlooked. With regard to the changes in the capillaries, it has been already pointed out that, at the beginning of the reparative process, those of the part become sealed, and the collateral circulation in the neighborhood becomes irregular and pressed upon; and that the coagula in these obliterated capillaries become reabsorbed or possibly reorganized as repair progresses, since it is certain that the capillary network soon becomes continuous through the newly formed cicatricial tissue, and that the capillary meshes of the one side join, by loops projected through the new tissue, similar meshes of the opposite side. What influence the nerves of the part have upon the reparative process, we do not know. That they have an important influence there can be little doubt, since all physiologists recognize their power upon secretion and nutri- tion ; the vaso-motor nerves doubtless have the greater power. But we must learn something more of nerve power generally, and of nerve distribution— something of the way in which the nerves terminate in the tissues, and what relation they bear to the capillaries—before we can hope to find out or under- stand the exact influence which nerve supply has on repair. Repair by Granulation.—All wounds do not, however, heal by immediate union, or by primary adhesion, and wounds that gape cannot so unite. The process of repair in these, therefore, differs somewhat in its character from the process in those which we have been considering; it takes place by granu- lation, or the “ second intention” of Hunter. If we closely examine the surface of a wound thus exposed, we shall find that it becomes, within a few hours of its exposure, covered with a film of a peculiar, gelatinous, grayish-white appearance. This will be seen with the aid of the microscope to be composed of granulation-cells or white blood-cells, Hunter’s “plastic lymph.’’ After an Fig. 217. Fig. 218. Bloodvessel forming in a, granulation tissue ; the wall, b, forming from placoids and proto- plasm. (After Golding-Bird.) Spindle cells, developed from placoids, from the walls of a forming bloodvessel. (After Golding. Bird.) interval of some hours, the parts covered with this gelatinous grayish film become more vascular, as indicated by redness, and the surface more even. The film itself assumes a tougher character, and a yellow fluid, which is mixed with small yellow sloughs of fibrinous tissue, is secreted. The wound begins “to clean,” and to have a smooth and consistent surface. After the lapse of another day, or some days, perhaps, this surface is covered with a number of elevations, known by the name of granulations, varying in size from a millet- PROCESS OF REPAIR IN WOUNDS. 19 seed to a liemp-seed, the smaller being highly vascular and red, the larger being, as a rule, paler and more bloodless. The wound at this time is “granu- lating.” The secretion from these granulations is now of a creamy-yellow character, and is called pus. They are made up of cells called granulation cells, which resemble inflammatory lymph-cells, each granulation being com- posed of a capillary loop surrounded by simple, nucleated, embryo cells, and by connective-tissue or placoid corpuscles (Figs. 217 and 218). Of the nuclei, Paget says;— “ Some of these nuclei are arranged longitudinally, others transversely, to the axis of the vessels.” In the development of these vessels changes occur, answering to those seen in ordinary embryonic development. “Organization makes some progress before ever blood comes to the very substance of the growing part; for the form of cells may be assumed before the granulations become vascular. But for their continuous active growth and development, fresh material from blood, and that brought close to them, is essential. For this, the bloodvessels are formed; and their size and number appear always proportionate to the volume and rapidity of life of the granulations. No instance would show the relation of blood to an actively growing or developing part better than it is shown in one of the vascular loops of a granulation embedded .... among the crowd of living cells, and maintaining their continual mutations. Nor is it in any case plainer than in that of granulations, that the supply of blood in a part is proportionate to the activity of its changes, and not to its mere structural development. The vascular loops lie embedded among the simplest primary cells, or, when granulations degenerate, among structures of yet lower organization ; and as the structures are developed, and con- nective tissue formed, so the bloodvessels become less numerous, till the whole of the new material assumes the paleness and low vascularity of a common scar.1” If at this time, when the granulations have attained to the level of the skin, we look to the margins of the wound, we shall see a dry, red hand of newly formed tissue, with an outer border of a bluish- white color, where it comes into contact with sound integument. This band is the new skin forming, and is caused by the gradual growth of the epider- mis from the margin of the sound skin towards the centre of the sore. Such a process is called cicatrization. The cicatrix is at first red, as in the linear cicatrix to which we have already alluded, but, as it then contracts, it subsequently becomes paler, and more compact and adherent. The nature of the scar or cicatrix varies with the tissue in which it is formed, the new connecting medium or cicatrix under all circumstances having a powerful tendency to adapt itself to the peculiar character of the tissue in which it is placed. Thus, a cicatrix in skin, in time closely resembles true skin ; a cicatrix in bone, true bone; and a cicatrix in tendon becomes tough and hard, like tendon; the consolidating, reparative material in every instance partakes of the character of the parts which it connects. It is corpuscular in its origin, and clearly fibrinous in its nature; but whatever the origin may be (though there is considerable divergence of opinion about it), its existence is undoubted, and through it and by it all repair takes place. Secondary Adhesion.—When two granulating surfaces are brought to- gether, and union takes place between them, healing by secondary adhesion, Fig. 219. Epithelium developing from granulation cells in the order of the figures 1, 2, 3; No. 3 shows the fully-formed “eog-wheel” cell, at a, becoming vacuolated by the loss of its nucleus. (After Golding-Bird.) 1 Paget, Lectures on Surgical Pathology, Third edition, page 165. London, 1870. 20 WOUNDS. or by the third intention, is said to occur. The process of repair under these circumstances is similar to that of adhesive union, the two layers of granu- lations adhering in the one case, as the two surfaces of divided tissue do in the other, by means of new material. The capillaries and embryo-cells under both circumstances undergo changes such as have been described. For this form of union to take place, the granulations, however, must be healthy. Repair by Scabbing.—When wounds heal by scabbing, granulations do not form. In this process, the reparative material which is poured out, under- goes at once similar changes to those already described as taking place in adhesive union, and the wound cicatrizes rapidly beneath the scab ; for the serum of the blood, when effused on the surface of a wound, is of a highly plastic character, and quickly coagulates to form a film of a protective na- ture, under which repair may rapidly proceed, the embryo cells, with this plasma—Hunter’s “plastic lymph”—being the medium of repair. Advan- tage is taken of this fact in the treatment of superficial wounds, the value of felt, cotton-wool, or any similar material, when applied to an open wound, entirely depending upon this plastic property of blood. Repair by scabbing is doubtless the best form of healing, although it is, unfortunately, somewhat rarely obtained. Nature of Healing Process. The nature of the healing process is physiological, and resembles closely that of development and growth; the changes in the cell elements which have been described in repair, and the gradual development of the most elementary tissue into cicatricial tissue or higher structures of the human body, are simi- lar in nature, if not in form, to those which are witnessed in the embryo, when the blastoderm cells in the ovum, or primary nucleated mass of proto- plasm, grow, develop, and differentiate into the various structures of the human animal. In both of these processes, there must be pabulum for nourishment, such as the blood, and there must be a sufficient supply of it; there must likewise be a regulating force to control and direct the formative process, and this force doubtless comes from the nerves. When the vascular supply is deficient, repair, growth, or development must suffer, and the phy- siological process of repair cannot go on; when the vascular supply is in excess, what would have been a physiological, becomes a pathological process, and the part undergoing repair after injury is said to be “ inflamed.” The process of construction under these circumstances ceases, and that of de- struction may ensue; or there may be other changes in the inflamed and for- merly repairing wound or granulating surface, which will be considered on a subsequent page, under the heading of Diseases of Granulations. What I would now impress upon the reader, is, that whatever action is required for the healing process is physiological, and is just equal to its purpose; when it is excessive, it becomes pathological, and is known as inflammation—im flammation, when it attacks a wound, at first checking repair, subsequently undoing it, and, at a still later period, bringing about disorganizing changes; inflammation, under all circumstances, having a destructive tendency. Regeneration of Tissues. It has already been asserted that the processes of repair are identical in all tissues; that the reparative process in bone or muscle, integument or tendon, 21 REGENERATION OF TISSUES. capillary or nerve, is the same, such modifications alone showing themselves as necessarily appertain to the anatomy of the tissues. It is well that this physiological truth should be fully recognized, but, at the same time, it is to be equally recognized that all tissues are not formed out of cicatricial or connective tissue, and that the higher forms of structure, such as muscle, nerve, bone, etc., are repaired by the regenerating influence of the injured tissue itself, new cells springing or growing by a kind of budding process from the divided ends of the injured part, and the new cells in contact with, or poured out by, the injured tissue, whether as embryo cells, connective-tissue cells, nerve cells, muscle cells, or bone cells, being so influenced by the tissue with which they are in contact, and from which they probably have origi- nated, that they anatomically partake of its nature, and more or less thor- oughly bring about its repair. Repair ix Muscle.—Thus, when muscular tissue is wounded, or more or less destroyed, 0. Weber tells us that it may be restored, and that the young muscular fibres are formed out of the old by the division of the protoplasmic material of their extremities, the repair of muscle being thus brought about by agencies closely simulating those of foetal development, in which the young muscular elements are formed almost entirely out of the cells contained within the old muscular fibres. Gussenbauer even gives a drawing of the process (Fig. 220), but Billroth declares that he has never seen anything which Pig, 220. Process of regeneration in striped muscular fibre after injury. Magnified about 500 times. (After’Gussenbauer and Billroth.) he could regard as a re-formation of muscular fibres, and that the cicatrix in muscle is almost entirely connective tissue; the extremities of the muscular fibres, after division and repair, uniting with the cicatricial tissue in the same way as they do with the tendons. My own observations go to confirm those of Billroth. 22 WOUNDS. Repair of Xerves.—It may with confidence be asserted that an injured or even a divided nerve may be thoroughly repaired, since conclusive evidence has in recent times been adduced to prove that such a large nerve-trunk as the median, the ulnar, or the great sciatic, may be divided and subsequently so joined by surgical skill as to secure, after the lapse of a certain interval of time, perfect union of the divided ends, as proved by the complete restoration Fig. 221. Fig. 222. Regeneration of nerves From a rabbit, fifteen days after section ; young spindle cells in the nerve-ends, developed from the connective-tissue, and ultimately connected with the neurilemma. (After Billroth.) From a frog, ten weeks after section ; develop- ment of young nerve cells from spindle cells. Magnified 300 times. (After Hjelt and Billroth.) of the functions of the nerve in their physiological perfection.1 It is like- wise true that new cicatricial tissues become sensitive, and that parts which, by accident or operation, have been deprived of the influence of one nerve regain their sensibility, either by the growth of new nerves, or by the assump- tion on the part of another branch of the same nerve, or of another nerve, of the physiological functions of the one that has been destroyed. Hence the- conclusion is clear that nerve-tissue must he regenerated, and that the divided ends of nerve must re-unite by new nerve material. It seems, moreover, highly probable that new nerves may be developed. In a physiological point of view, these facts are not only very remarkable, but they tend to demonstrate the perfection of the reparative process, since to allow of the conduction of nerve-force to and from the nerve-centres, very perfect conductors are un- questionably required. The process by which this repair is brought about has been carefully studied by Schifl*, Iljelt, and others, and is much after the following fashion, as given by Billroth (Figs. 221, 222):— “ There is, first of all, a degeneration of the medullary sheath, possibly also of the axis cylinder, for a certain distance from the injury, which is quickly followed by the- production of cells in the neurilemma; these develop into spindle cells and spread into- the tissue which intervenes between the nerve-fibrils, and which extends also between the cut extremities of the nerves. From these cells, as in the embryo, new nerve-fibres are developed,” and these new fibres “ ultimately cannot be distinguished from ordinary nerve-fibres.”2 1 Weir Mitchell, American Journal of the Medical Sciences, April, 1876 ; Hulke, Transactions of the Clinical Society of London, vol. xii. 2 Billroth, Lectures on Surgical Pathology and Therapeutics, vol. i. p. 152. London, New Sydenham Society, 1877. SOURCES OF INTERFERENCE WITH HEALING OF WOUNDS. 23 Sources of Interference with Healing of Wounds. The different modes of healing, and the processes by which injured tissues are repaired, having been fully described, I propose to consider next the causes that interfere with, retard, or prevent repair; and these may be found either in the subject of the wound, in the wound itself,, or in its treatment. Presence of Foreign Bodies.—Amongst the causes which pertain to the wound itself, the presence of any foreign matter whatever must be placed first, since it is clear that where such is found, even to a very limited extent, repair by immediate, primary, or quick union is impossible ; the foreign mat- ter not only, by its presence, mechanically prevents the adhesion of the sur- faces between which it is placed, but also acts as an irritant, or as a promoter of septic changes, and thus excites an action in the wound which is not repara- tive, but inflammatory. The truth of this general rule is not disproved by the fact that, in exceptional cases, foreign bodies become encysted in tissues, and give rise to but little trouble. Hemorrhage.—The occurrence or persistence of bleeding in the wbund is a second local cause of non-repair, the reparative process not commencing until all bleeding, even capillary oozing, has been arrested. When the hem- orrhage is great, this interference may be serious, and even when little, it is enough to retard and prevent the reparative process from being carried out. Blood, if effused to any extent between the sides of a wound, interferes with the reparative process much in the same way as does a foreign body, and for- bids all healing by quick or primary adhesion. If effused in very small quantities between the divided surfaces, it may at times possibly change into cicatricial tissue, and form a bond of union between the divided parts; and under other conditions it may become organized, as when poured out on the brain; but, as a rule, the effusion of much blood into a wounded part is a retarder of repair, or a cause of 11011-repair. When a wound has to heal by granulation, a clot of blood, as a covering, kept aseptic, is beneficial, since it acts as a protector to the surface of the wound, and allows the granulating process to go on uninterruptedly. It has been said that such clots become organized, but it is far more probable that they simply act, as above described, as a protection to surfaces that are granulating. Contusion and Laceration.—A contused or lacerated surface in a wound is a third local cause of non-repair, and it is well to recognize this important fact, since, with such a condition of parts, the surgeon knows that immediate or primary union of the wound is not to be expected. Under these circum- stances, a line of treatment will be indicated, which will be far more likely to he efficient than one based on the hope of obtaining quick repair. When the contusion or laceration is slight, the hope of securing primary union of the divided parts may indeed be entertained, but, under opposite conditions* such a hope would be altogether groundless. The gradations of contusion and laceration between these two extremes are numberless; but it will be wiser for the surgeon to believe—and upon such a belief to act—that in con- tused and lacerated wounds the prospect of obtaining quick union is slight, than for him to act upon an opposite view, and attempt to obtain, in severe cases, a mode of healing the occurrence of which is improbable, if not impos- sible. In a contused or lacerated wound, the surgeon should mentally see dying or dead matter, which, of necessity, must be separated from the living parts 24 WOUNDS. and got rid of, either by molecular disintegration or by a coarser, sloughing process, before the act of healing can rightly be said to begin; and under these circumstances he will at once recognize the futility of entertaining a hope of obtaining the repair of the wound by quick union. Constitutional Condition of Patient.—Of the causes of non-repair which are to be put down to the account of the subject of the wound, age is all impor- tant, the reparative process in a man on the wrong side of fifty being conducted with less vigor than in one who is on the right side. In the very old, repair is at its lowest mark. The same remarks are applicable to patients who are the sub- jects of organic disease, or of degenerative changes in their tissues, and especially to fat and soft-tissued people; the old in years, or in infirmities, not possess- ing the recuperative powers of the young and vigorous. Under these circum- stances, in the case of a wound resulting from accident or operation, in a patient over fifty years of age, or in one in ill health, it would be wrong for a surgeon to expect, or to rely upon securing, a mode of repair which, in a younger or healthier subject, he might reasonably look for; people who are advanced in years, or who are feeble from frailty or disease, particularly visceral disease, have no or an insufficient capital at the bank of health to draw upon. Of all subjects for wounds, whether accidental or operative, the habitual drunkard is the worst. Defects in Treatment.—Of the causes of non-repair which are to he attrib- uted to treatment, a want of due care in maintaining the injured or wounded part in a state of rest, claims the first place, for in such a delicate process as is that of repair, it is plain that in any movement of the injured part, whether in the way of separation of surfaces or manipulation, the process may he inter- fered with or retarded, or the work already accomplished undone. Indeed, since it is certain that the best and most rapid repair of an injured part takes place when the wounded tissue is kept in an absolutely immovable position, and when the wounded surface is protected from all external influences that can possibly interfere with the physiological, reparative process, it clearly behooves the surgeon to have this great truth always before him, in order that he may adapt his treatment to the requirements of the case before him, and not have to blame himself—on account of some failure in the healing act—for a want of care in maintaining that absolute immobility of the wounded or cut part which is essential tor rapid or even good repair. In the treatment of fractures, the evil effects of want of rest and immobility of the broken hones are well exemplified, but it is to be remembered that the same want of rest and immobility is as pernicious in wounds of the soft as in those of the hard parts; in wounds of the surface as in those of the deeper structures. The term “ want of rest” is here used in its fullest sense, as want of that thorough immobility of tissue, which is all important for the rapid perfection of the physiological, reparative process. Again, if the edges of a wound are allowed either to gape, or to have too much tension upon them, repair will be interfered with—the parts, in both cases, from want of care in their adaptation, want of caution in not making due provision for the escape of the redundant fluids (drainage), or from some overaction (inflammation), not being allowed to remain at rest and undergo repair. Overaction in the vessels of a part which is undergoing repair—that is, inflammation—always has an evil influence. When it shows itself early in the case it prevents repair, and when manifested at a later period it retards the healing process, or even causes retrogression. Indeed, under all circum- stances, when the vascular action of a part which is undergoing repair ex- TREATMENT OF WOUNDS. 25 •ceeds what is essential for the steady perfection of the process, the repair of that part is interfered with. Inflammation (to repeat what has been already said) when it attacks a wound, at first checks repair, subsequently undoes it, and, at a still later period, brings about disorganizing changes. Inflamma- tion has, under all circumstances, a destructive tendency. The student, having learnt how wounded parts heal by nature’s processes, and more particularly how simple incised and open wounds are repaired; and having moreover learnt to recognize some of the most important influ- ences which retard, if they do not arrest, repair, will readily understand the more favorable conditions under which repair can be carried out, and, what is more, will at once appreciate the surgical requirements of the case he may have to treat, so that, as a surgeon, he may know when and where to apply his art, how he can help nature in her beneficent action, and how he can best guard against the intrusion of any outside influences that may tell against the steady progress of the reparative process. For it cannot be too strongly asserted, that the best surgeon is the one who best understands natural pro- cesses in the repair of parts, and who knows how to use them to the greatest advantage; who recognizes the fact that these natural processes are exact and, when applied to the healing of wounds, undeviating; who knows that if he is to utilize these natural processes to the full, he must bring up his art of curing to nature’s line, under the conviction that nature never systematically bends herself, or puts forth her hand, to help the curer; that she never de- viates from her path; that if, using Dr. B. W. Richardson’s words, “ we do not molest her, she goes on, as we say, naturally, towards a cure ; if we molest her a very little, she goes on, and the molestation is but little shown; if we molest her vehemently, she still goes on, showing molestation in proportion to disturbance, nature under all circumstances going her own way, caring just as little for ease as for pain, for life as for death.” When a bone is broken, nature will heal it quite irrespectively of the posi- tion in which it is placed; when a knuckle of bowel is strangulated, nature will cast it off quite regardless of the effects of such a sloughing act. But the surgeon who knows this, knows moreover that the same natural process will work on where the bone is “ set” in a right position, and maintained there by art; and that the sloughing may be avoided when the strangulated bowel is relieved by art from its false position, and placed where it can be best re- paired by nature’s means. Treatment of Wounds. In the treatment of a simple cut, or incised wound, in which there is no dirt or foreign matter to keep the edges of the wound apart, and to act as an irritant or exciter of overaction, and no hemorrhage beyond capillary or venous bleeding which can be arrested by elevation of the part, moderate pressure, or the application of a cold or hot sponge, the surgeon has simply to cleanse the wound, bringing its edges carefully together, and adopt means to keep them so, while at the same time he makes such provision for the protection of the part as may secure it from injury from without or within, and may allow the reparative process which has been described as taking place in primary union to be quietly perfected. In more severe wounds, a similar practice is to be advocated, though more care may he called for in cleansing the wound; more caution required in the arrest of bleeding; and more ingenuity demanded in bringing the edges of the wound together, as well as in so fixing the injured part in position that the patient may be com- fortable, while the wound is kept immobile and protected from such injuri- 26 avoitnds. ous outside influences as would interfere with the healing act. Provision moreover will have to be made for efficient drainage, that is, for the free exit of such sanguineous or serous fluids as are commonly exuded after severe wounds or operations, and the retention of which always proves injurious. Upon each and all of these points a few lines may not be without value. Cleansing Wounds.—After full examination of a wounded part, and clear knowledge as to tlie mode of its production, the extent of injury, and the requirements of the case for cure, the wound should he cleansed. This should he effected with all completeness and gentleness, since, on the one hand, every- thing like a foreign body between the lips of a wound would of necessity prevent quick or primary union, and would in all probability prove injurious to the subsequent progress of the case, while, on the other hand, anything like roughness would be detrimental to the already injured part. To effect this cleansing with gentleness, a stream of water, medicated with some anti- septic, is the best means for the surgeon to employ, and this stream may be brought to bear upon the part by using the irrigating bottle (Fig. 223), or the Fig. 223. Irrigating bottle. irrigating apparatus (Fig. 224). The stream of fluid washes away blood, with all light foreign matter, and what cannot be thus washed away may be removed with Angers or forceps. In gunshot wounds, special forceps and other instruments may be required. Those who believe atmospheric germs to be the chief cause of in- flammation and suppuration, or of most, if not all, the ills to which wounded flesh is heir, will employ the means that are supposed to be capable of destroying such malig- nant foreign visitors, and for this purpose will use the spray of carbolic acid, one part in forty, or other antiseptic, to kill the germs in the air as they approach the wound, and will dress the wound with the carbolic lotion, carbolic gauze, pro- tective, and waterproofing, accord- ing to the directions laid down in the Article on the “Antiseptic Method of Treating Wounds,” whereas those who disregard at- Fig. 224. Ward carriage with irrigating apparatus for cleansing wounds. ON THE QUESTION OF REPAIR BY PRIMARY OR SECONDARY ADHESION. 27 mospherie germs, and yet highly value means for purifying wound surfaces, will use antiseptic irrigation of the wound with a lotion of carbolic acid, 1 to 20; of thymol, 1 to 1000; of chloride of zinc, 20 grains to the ounce (originally used by Mr. C. de Morgan, many years ago); or of iodine, made by adding 20 drops of the tincture to the ounce of water. I have employed the iodine lotion for years, and prefer it to any other. It is always at hand, and is both simple and effectual as a wound cleanser. The lotion may be used warm, and it has the advantage of not only .cleansing the wound in the fullest sense of the term—for iodine is an antiseptic—but it has a marked tendency to arrest all capillary bleeding or oozing. I use it in about the proportions given above, but the best practical guide is to pour the tincture into a basin full of water, so as to make the latter of a light sherry color. Arrest of Bleeding.—It is well that all hemorrhage should be effectually arrested by some of the various means which the surgeon has at his com- mand, before the edges of a wound are brought together; and it is wise to have even capillary oozing stopped, when it is possible, for blood effused in even limited quantities between the surfaces of an incised wound is to be regarded much in the light of a foreign body, and as forming an obstacle to repair,, more particularly when primary union of the wound is to be sought for. Indeed, it was on this account that I was first led to employ, for cleans- ing wounds, the iodine water to which I have drawn attention, and which I cannot too strongly recommend for general adoption. A sponge wrung out of this lotion (made with hot water), and held to a wound for a minute,. completely checks all oozing of blood, and tends more than anything else,, except prolonged exposure to the atmosphere, to the formation of that glaze upon the surface of the wound, which so much conduces to satisfactory repair. On the Question of Repair by Primary or Secondary Adhesion. When the surgeon has cleansed the wound, removed what foreign bodies may have been present, and stopped all bleeding, he has to decide upon the means whereby the reparative process may be best helped, and, as a primary point, to determine either the feasibility or expediency of attempting to ob- tain quick or primary union of the cut parts, or the wisdom of looking to their repair by the slower open, granulating process. When the wound is of the incised kind, the question is not difficult to answer; for it may with confidence be asserted that, with but few exceptions, in all wounds of this description, whether superficial or deep, accidental, or the result of operation, repair by quick or primary union is to be desired, and, what is more, may be expected, if the subject of the wound be healthy, and not too old, and if nature’s reparative process be so aided by surgical art as to be allowed to take its course wdthout interference. The cleaner the cut is, the greater is the probability of its uniting by quick repair; the more ragged, contused, and lacerated the margins of the wound are, the less are the prospects of obtaining primary union, and the less the wisdom of making the attempt; between these two extremes are innumera- ble gradations. When there is a doubt about the wisdom of making the- attempt to secure primary union, in deep contused and lacerated wounds, let: the decision be against it, and when the doubt applies to the more superficial or hopeful class of wounds, let it be decided in its favor. Care must, however, be taken in these, as in all cases, to give up the at- tempt on the appearance of the slightest local or constitutional symptom, buggesting that, by the drawing together of the parts by sutures, etc., some 28 WOUNDS. retained blood, serum, or sloughing, injured tissue is keeping the part in a state of unrest by tending to separate the lips of the wound, and by exciting tension ; •or is undergoing chemical change and decomposition, thus threatening the production of some septicemic or pysemic blood-condition. For it must be recognized that, whilst in the cleanest incised wound there may be no death of the divided tissues, and consequently no animal matter to undergo chemi- cal change or putrefactive decomposition; in the contused and lacerated, there must of necessity be more or less destruction. When tissue dies, it must be shed or cast off from the living parts, before the physiological repa- rative or uniting process can take its course. When this dead tissue has been separated from the living, it ceases at once to be influenced by the vital processes by which it had been built up, kept alive, and eventually cast oft*; it consequently becomes subject to the physical laws of all dead matter, and undergoes chemical changes—which mean too often decomposition. The object of the surgeon, therefore, in the treatment of these cases of wound in which the death of tissue is to be expected, and cannot be pre- vented, is to neutralize as far as possible the evil influence of its death and probable decomposition; and this is to be achieved by so dealing with the injured part that the dead tissue may find a free outlet for its discharge, by rejecting all such applications or dressings as are likely to help putrefactive decomposition, and by employing such means and agents as are likely to neutralize its pernicious influence, and in a measure control the process of decay. With these views, therefore, the surgeon should close up such wounds alone as from their cleanness can be expected to heal by quick or primary union, and should leave open all such as from their raggedness and contusion are sure to be attended with more or less death of tissue, providing in these a free vent for all discharges of decomposed material, and employing antisep- tic and disinfecting local applications to neutralize the evils of the chemical -changes. Treatment to help Quick or Primary Union. To promote the primary union of a wound the surgeon has six indications to follow:— I. To cleanse the wound ; II. To arrest all bleeding; III. To effect coaptation of the two divided surfaces of the wound—the deep parts as well as the edges. IV. To maintain the wounded parts in a position of immobility, benefi- cial to the natural process of repair as well as comfortable to the patient. V. To secure drainage of the wound by providing for the escape of such dead tissue as may be thrown off, as well as of all fluids that are not required for repair. VI. To protect the external wound from all such outside influences as may be prejudicial. The first two indications have been already considered, viz., the cleansing of the wound and the arrest of bleeding. In all forms of wound, and for every form of healing, attention to these points is most important, hut when quick or primary union is to he expected, it is all essential. Coaptation of Wound.—The coaptation of the two divided surfaces of the wound (the third indication), may be efficiently carried out in superficial or not deep wounds by means of sutures and adhesive plaster separately or TREATMENT TO HELP QUICK OR PRIMARY UNION. 29 combined. When by the use of trustworthy adhesive plaster the object sought for can be obtained, sutures are not called for; and when sutures are used, the form of suture that carries out the object in view in the simplest way is the best. Interrupted Suture.—When the wound is superficial, the sutures need not be introduced deeply ; but when the wound is deep, the practice of bringing the edges of the wound and not the deeper parts together, is fraught with dan- ger, since the repair by primary union which is looked for cannot take place,, and between the separated surfaces of the deeper parts of the wound, blood,, serum, or inflammatory fluids will collect and give rise to trouble. Hence in deep wounds the sutures should either be all introduced deeply, or deep as well as superficial sutures should be employed. The interrupted is the most useful form of suture (Fig. 225), and it is applicable to superficial as well as to deep wounds. In the superficial, it should be in- serted with sufficient depth and closeness to bring the surfaces and edges of the part accurately and closely together, and it should be tied with enough force to carry out these objects, but not with more ; since to tie a suture as a surgeon would a ligature, is to do harm—the suture cutting rapidly through the strangulated tissues, and in so doing irritating the part instead of helping repair. In deep wounds the sutures must be inserted deeply, as in harelip operations, and introduced well away from the edges of the separated tissues, so that when they are tightened the deeper parts as well as the superficial will be brought effectually into apposition. In some cases deep and superficial sutures may be made to alternate. Superficial sutures should include neither muscle nor deep fascia. In the majority of cases in which sutures are employed, it is an excellent plan to alternate the sutures with the strapping; a narrow band of the latter, carefully adjusted between the stitches (as shown in Fig. 225), not only materially aiding the adaptation of the edges of the Avound, but, if well applied, tending towards the prevention of tension, and towards the immo- bility of the wounded part, while at the same time it gives important aid in the way of affording local pressure to the deeper portions of the wound. In operations on the breast, the advantages of this practice are well exemplified. [If wire is employed for the interrupted suture, the ends may be simply twisted, or may be passed through a Galli’s tube, or a perforated shot which is then clamped with strong forceps. This variety of the interrupted suture is known as the shot or shotted, suture.'] Continued Suture.—The uninterrupted,, con- tinued., or glover's suture (Fig. 226), is valu- able in cases of wound of the intestine, as well as in those of the eyelids and face gene- rally; indeed, a clean wound of these parts —superficial or deep—may be so accurately and well adjusted by means of a fine needle and thread as to leave but a minimum of scar. In operations about the lip, the same remarks are applicable, although, in these, care should be observed to introduce the sutures deeply, and well Fig. 225. Interrupted suture. Fig. 226. Continued suture. 30 WOUNDS. away from the margins of the wound. In operations for phimosis, in the adult, this form of suture is likewise of great value, not only expediting recovery, hut doing much to make the result of the operation more artistic. In these cases the fine carbolized gut suture may be used. Twisted or Harelip Suture.—The twisted suture (Fig. 227) is of value in cer- tain operations on the lips and cheeks, and in other parts where difficulty is experienced in bringing the tissues together, since by its use more force can be brought to bear upon the margins of the wound, and their adaptation can thus be rendered more perfect. This form of suture was in former times the one commonly employed in hare- lip operations, but it is not so now. I have discarded it in favor of the interrupted su- ture of silk, silkworm gut, or wire, and em- ploy it only in double harelip operations, or in cases in which exceptional difficulty is •experienced in bringing the parts together. [.India-rubber Suture.—This is a modification of the twisted suture, intro- duced by M. Rigal and formerly employed by the late W. L. Atlee, of Phila- delphia. An India-rubber ring is slipped over the ends of the pin, instead of the twisted ligature, and serves by its elasticity to lessen the risk of caus- ing undue tension.] Quilled Suture.—This form of suture (Figs. 228, 229) is applicable where deep wounds have to be well held together along their whole line, and more Fig. 227. Harelip or twisted suture. Fig. 228. Fig. 229. Quilled suture. particularly for a brief period, say two or three days. In ruptured perineum it is certainly of value, combined with superficial sutures (as shown in Fig. 229), but even in these cases the interrupted su- tures of silkworm gut, introduced well away from the margins of the wound, and inserted deeply, are probably to be preferred. Button Suture.—This (Fig. 230), which is a variety of the quilled suture, is useful in some amputations, as of the thigh, where the surgeon is desirous of keeping the bases of the flaps to- gether. It is useful likewise in harelip or other lip operations. Fig. 230. Button suture. 31 TREATMENT TO HELP QUICK OR PRIMARY UNION. Material for Sutures.—With respect to the material used for sutures—silk, wire, silkworm gut, prepared catgut, or horsehair—each is good in certain cases when rightly selected. Where there is little tension on the sutures, silk or wire may be indifferently employed, the amount of irritation excited by one or the other material depending more upon this point of tension, than on any other. I have long ago proved this to my own satisfaction, by testing both forms in the same subject, through a long series of cases. In plastic operations, silkworm gut, well softened in water before use, is to be recom- mended ; it holds well, and seems to irritate far less than any other material. In cases of ruptured perineum, and in operations for vaginal fistula and fissured palate, it should always be used. In the latter class of cases, when the soft palate alone is involved, horsehair is good, but it is not strong enough to resist much tension. In plastic operations in which some skill may be called for in adjusting the parts, wire sutures may be selected, since such sutures can be twisted and untwisted with facility, and the surgeon can con- sequently readjust the margins of the wound, as required, to his satisfaction. Catgut is not a reliable material for sutures, since it is uncertain as to its retaining power, and is apt, when sodden, to yield; it is, however, useful as a suture in holding parts together for a brief period, where there is no tension, and where there may be a difficulty in removing the stitches subse- quently. In operations on the penis, it is of special value. Pkessure.—The effectual carrymg-out of the third indication in the treat- ment of incised wounds, viz., the coaptation of the two divided surfaces of the wound—deep parts as well as edges—is not however always to be accom- plished by means of sutures and strapping, however well selected and applied these may be. Other means are constantly demanded, and of these, well directed pressure is the most important; indeed, the value of pressure in the treatment of all wounds is worthy of more consideration than it has received. By it the surfaces of divided parts are kept together, and particularly the deeper surfaces; mobility of the injured tissues is checked, if not prevented; the vessels of the wounded parts are supported; and the evil influence of blood stasis with its effect—effusion—is neutralized: under these circum- stances repair is helped, and nature’s processes are permitted to go on under more favorable conditions. With this view of the value of pressure, well- applied pads of lint, absorbent cotton-wool, gauze, or sponge saturated or not with some antiseptic drug, should be carefully adjusted over the flaps of all wounds, when such exist, and over the surfaces of others. These pads are kept in position by means of strapping or bandages, aided by splints when the extremities are involved. After the removal of a breast or tumor, the value of a well-adjusted pad, and more particularly of a sponge wrung out of iodine lotion or carbolized water, cannot be too highly praised. After an amputation, the use of a splint, adjusted to the stump, and pressure well applied to the bases of the flaps, not to their edges, should never be omitted. Immobility.—The maintenance of wounded parts in a position of immo- bility, beneficial to the natural process of repair as well as comfortable to the patient, is the fourth great indication in the treatment of incised wounds ; and to say the least, this is as important as the preceding, since, if neglected, the benefit that might be expected from efficiently meeting the third indica- tion could not be realized, and the process of repair in the wounded part would of necessity be checked, if not altogether prevented. To carry out this indication, immobility of the wounded part is of the first importance, and its position next: the position being always selected with the object of giving ease to the patient, and of preventing pain; of relaxing 32 WOUNDS. the wounded tissues, and so guarding against any tendency to bring about a separation of the edges of the wound, as in cut-throat cases ; and last, but not least, of encouraging the return of the venous blood from the wounded parts towards the heart. Thus in wounds of the trunk, the horizontal position is the right one to be maintained, and in those of the extremities, flexion and elevation of the limb ; in wounds of the lower extremity, the foot should be kept higher than the knee, and this than the hip ; and in those of the upper extremity, the same principles of practice should he followed, the elbow being generally flexed. Under all circumstances, wounded limbs should be fixed upon splints, with the view of immobilizing them, and, as a rule, the limbs should be swung; this practice adds greatly to the comfort of patients, by allowing them to move their trunks without their wounded extremities, and without therefore interfering with repair. It should be added, however, that this question of position ought always to be considered in reference to the fifth indication, namely the necessity of providing efficient means for the removal of the superfluous fluids of the part, and for the escape of disinte- grated dead tissue which may have to be discharged, or, in brief, for ‘ ‘ drainage.” Drainage.—Drainage, or the making of due provision for the escape from the wound of disintegrated dead tissue, with such fluids as are not required for repair, and which if left might prove injurious, is of primary importance in the treatment of all, and more particularly of deep wounds. It should never escape the attention of the surgeon. In scalp wounds, and those about the eyelids, though they may appear trivial, it is of as much importance as it is in the wounds that involve deeper parts and seem more severe; for in the- one case as in the other, pent-up fluids not only tend to separate tissues which are intended to unite, giving rise to pain by producing tension, and conse- quently causing constitutional irritation, but they are prone to excite inflam- mation in the part, and ultimately to undergo septic changes, which in their turn may give rise to blood-poisoning in the form of septicaemia or pyaemia. Ho other than trivial wounds consequently should be completely covered in, and deep ones very rarely. Some corner, and preferably that which is most dependent—some interval between the sutures or strips of plaster—should always be left open for the escape of disintegrated tissues, and of superfluous fluids, such as blood or serum; and where deeper structures are; involved,, some conducting material or “ drainage-tube” should be introduced. The best is a tube of India-rubber, perforated at intervals (as originally suggested by Chassaignac, in 1855), of a size varying with the cavity or wound to be drained; but in some cases a strand of carbolized catgut or horse-liair, a roll of gutta-percha skin, or a piece of lint saturated with carbolic or tere- bene oil, will do as well. In abdominal cases (as after ovariotomy), a per- forated glass tube is of great value, while under other circumstances an elastic catheter will answer the purpose. The particular mode of accomplishing the object is of little importance, as long a'S the object itself is secured. In using a drainage-tube, however, the surgeon must remember that it is not to be made a seton, and that the sole justification for its use is to secure the free evacuation of fluids from the deeper tissues. For this purpose, it is to be made to dip deeply enough into the wound, but no more ; it is not to be made an irritant. The size of the tube is to be regulated by the require- ments of the case; several short tubes are often better than a long one. Care is also to be taken that the outer ends of the tubes are left free; when covered, they should be covered but lightly, and then with some absorbent cotton, oakum, sponge, or gauze. As a rule, however, they should be left open. In using the tube, when the end is cut off level with the wound, the outer ex- TREATMENT TO HELP QUICK OR PRIMARY UNION. 33 tremity should be held by means of loops of carbolized silk, perforating its walls and secured externally by strapping or other means. The tubes should always be introduced at what will he the most dependent part of the wound, when the patient is in the recumbent position; and they should be taken away as soon as they have answered their purpose. When quick or primary union has taken place, they may safely be removed at the end of twenty-four or forty-eight hours; but when suppuration is present, they must be left longer, sometimes even till the cavity has closed. A drainage-tube should, however, be shortened as rapidly as the progress of the case will allow, the shortening of the tube and the closing of the cavity of the wound from below going on together. It is to be noted that, at the present day, the use of drainage, whether by tubes or other material, is suggested with the view of 'preventing suppuration in the treatment of deep wounds; whereas in former times, when Chassaig- nac introduced his tubes, it was for the treatment of wounds and cavities in which suppuration already existed. The value of the principle is, however, equally great in both classes of cases. When carbolic acid is used as a wound dressing, whether as a spray or as a lotion—or when chloride of zinc lotion is employed—the use of the drainage-tube is more necessary than it is when other forms of dressing are employed ; since under the stimulating influence of these drugs, there is, as Lister tells us, more effusion of plasma than is to be looked for under other circumstances. Whenever a wound is closed, with the view either of obtaining rapid or primary union, or of con- verting an open, as far as possible, into a subcutaneous wound, the most care- ful inspection is called for, to guard against and even to anticipate trouble. In these cases, the wound should be opened on the slightest approach of local tension or overaction, with elevation of temperature and traumatic fever, since this local and constitutional disturbance will probably be found to be due to the retention of some of the fluids of the part that are in excess of what is wanted for repair, and to be susceptible of relief only by the evacua- tion of such retained substances. Protection of Wound.—The protection of the external wound from all such outside influences as may be prejudicial to the progress of natural repair, is the sixth and last indication for the surgeon to follow ; and it is in itself as important as the live which have preceded it, since it includes the use of all means by which the wound can be protected from outside injury, as well as the dressing proper, or covering of the wound. For purposes of protection, most wounds require a covering, and, when they are on the extremities or other exposed parts, some cradle or other mechanical appliance, to keep oft* the weight of the bedclothes. In wounds of the face, however, coverings are rarely required, for all surgeons are familiar with the fact that there are no wounds, operative or accidental, that do as well as these, without any external application, provided that they have been carefully brought together and adjusted. Indeed, it is probably from a knowledge of these facts that the “ open method” of treating wounds has been advocated. This method cannot, however, be recommended, except for wounds of the face. For some years past I have been in the habit of dressing wounds with dry absorbent lint, or with lint soaked in a mixture of terebene, one part, and olive oil, three parts, and have every reason to be well satisfied with the practice. I simply cover the oiled lint with a second piece of dry lint, and fix the whole with some retentive bandage, room being left in all cases for drainage, either by loosely covering one corner of the wound, which is left open for drainage purposes, or by perforating the lint covering the wound, to allow of the protrusion of the end of the drainage-tube. Cotton-wool 34 WOUNDS. of the absorbent kind, is then arranged about the tube, to absorb all fluids that escape, but not in any way to arrest their flow ; since to insert a drainage- tube, and then to smother up its orifice, seems inconsistent practice. When the spray and gauze system (Listerism) is adopted, all the precautions essen- tial for security must be observed, the principle upon which this system is based being one of exclusion not only of air, but of all germs that may be floating in it, which germs are supposed to be the cause of suppuration and of the decomposition of organic fluids. Wet applications, and more particu- larly watery ones, are now seldom used, and cannot be recommended; since it is well known that by moisture, decomposition is encouraged. When they are employed they should be medicated; that is, they should contain some drug which has an influence in preventing or arresting decomposition, or in neutralizing the evil effects of the chemical changes which are sure to take place, either in the contused and devitalized injured tissues, or in the secreted or poured-out fluids, whether blood, serum, or pus. The best of these drugs are the chloride of zinc, carbolic acid, boracic acid, thymol, terebene, iodine, alcohol, the permanganate of potassium, and iodoform. On the Second Dressing of a Closed Wound. fixed period can be named when the first dressing should be removed from, and a second applied to, a wound which is being treated with the view of obtaining healing by quick or primary adhesion. But this is certain; that no interference should be allowed under a week, unless there is some in- dication, either in the form of local discomfort or pain, or of some constitu- tional symptoms, such as an increase of temperature with febrile disturbance, to justify the act. In truth, to use a legal phrase, the surgeon should, in all cases, show cause why he should interfere, before he does so, for it is not to be denied that even with the gentlest and most skilled manipulation, there must of necessity be some interference with the reparative process; some slight tearing away of the new reparative material; some taking away of support where support is essential; or removal of local pressure where such is needed; in fact, there must always be some injurious influence upon the healing part, which should not be permitted without a compensating good effect. A wound treated for repair by primary adhesion, if let alone, will prob- ably, under favorable circumstances, heal within the week; and a large wound, such as that made in ovariotomy, in excision of the breast, or in amputation, will heal within two weeks under the best conditions. If it does not, it is because there is something wrong with the patient’s general condition, or something wrong in the wound, or more particularly its treatment; for the primary dressing of the wound should have been such as to render early inter- ference with it unnecessary. To recapitulate, (1) the edges and surfaces of the wound should be carefully adjusted and fixed together; (2) complete immobility of the injured part should be guaranteed by the judicious application of splints, pads, and band- ages ; (3) the limb or wounded part should be placed in the most comfortable position for the patient, as well as in that which is most favorable for repair; (4) due provision should be made for the effectual drainage of the wound, and care should be taken that the effect of drainage is not neutralized by any external application or dressing; and lastly, (5) such dressings or external coverings should be employed as will protect the wound from external injury, and guard against or neutralize the decomposition of such fluids as may be poured out. A wound, however large, dressed effectually on these principles, will probably not require dressing for a week, or at least' not more than the OX THE SECOND DRESSING OF A CLOSED WOUND. 35 removal of the absorbent material which has been placed to catch the drained secretions of the wound; and will be found, when dressed, to be well, or nearly well. A wound, however small, dressed ineffectually, will probably he un healed and suppurating. The nearer the surgeon can approach perfection in his first dressing, the more successful will he he in his practice, and the larger will he his proportion of cures by primary adhesion. When a second dressing is called for, the surgeon should have at hand every- thing which may be required for the purpose: lint, prepared in size and shape, and steeped in whatever dressing he may have arranged to use ; scissors, for- ceps, bandages, strapping, absorbent cotton, trays, and irrigators, whether in the shape of a can or in that of a dressing bottle. When the wound is large, and water is to be used in quantity, he should have a piece of water-proofing to place beneath the part, and such assistants as may be required. He is then to remove the external dressings, and in doing this, as in every subsequent proceeding, he is to employ the utmost gentleness. lie should, however, be- forehand place his patient in the most comfortable position he can, and then place himself comfortably; for no surgeon can do his work well if he is in a constrained posture. In removing external dressings, some time is often re- quired, but it must be granted; for when dressings are glued to a wound by blood or secretion, they must be softened with water, or rather medicated water, before they can be taken away without doing harm. Having taken off the external dressings, sent them away, rolled them up, or thrown them into a basin of antiseptic Iluid, and having exposed the part with its sutures, and possibly the strapping which was applied for adjusting purposes, the surgeon is then to cleanse the part, and for this object he cannot do better than to use the absorbent cotton, either dry, or wet with the medicated lotion. The sutures should then be cut and withdrawn, care being observed not to drag a long loop of suture, covered with dry secretion, through the tissues, but to cut it oft' close to the skin through which it will have to pass. When the union of the wound appears weak, or when it is on an early day after the first dressing that the second is being made, support should be given to the tissues by the application of a piece of well-adjusted strapping, as each suture is taken away; a second and third, or more pieces, being successively applied as the dressing proceeds. If the sutures are not irritating, and the wound has not healed well, they should be let alone. In deep wounds, the surgeon should never be in a hurry to remove sutures, whether they are irritating or not, for if he remove them before good repair has taken place, the wound will gape, and under such circumstances the prospect of securing repair by primary ad- hesion will have disappeared; and even when the sutures are cutting through from overstretching of the part, it is, as a rule, well to let them alone as long as they have any influence in holding large flaps together, or in preventing wide separation. At the same time, all sutures should be removed as soon as they have answered the purpose for which they were introduced, or when all hope of their fulfilling it has passed away. The removal of a stitch from a wound which is suffering from the irritation caused by tension, and possibly from some collection of fluid, is always wise. When splints have been used to support and to insure the immobility of wounded parts, they should not be removed unless for some urgent cause. It is to be assumed that they were so applied at first as to allow the surgeon to remove, when necessary, the external dressings without interfering with them. With the same view, of preventing the necessity for its early removal, a splint should be covered with some protective such as gutta-percha, or oiled silk. To complete the second dressing, a fresh piece of lint soaked in the tere- bene and oil, or other selected application, is to be laid on the wound, and 36 WOUNDS. the parts covered as after the first dressing, the surgeon taking care to see that efficient means are employed for the external protection, immobility, and good drainage of the wound. Subsequent Dressings.—The third and later dressings of a wound must be governed by the same principles which have been laid down for the second ; and they are to be conducted in the same quiet, gentle, and yet decided man- ner. They are not likely to be very numerous, should primary adhesion be obtained, but when that hope has tied, they must be carried out daily, or pos- sibly more often: they will, however, then have to be conducted on very similar principles, although with different objects. Contused and Lacerated Wounds. These wounds, from a clinical point of view, should be classed together, since in both, the edges of the wound are as a rule so injured as to be irregu- lar and the seat of eccliymosis; and since in both, before repair can practically begin, death of some of the injured surface, or of some of the surrounding subcutaneous or other tissue—the margins or flaps of the wound—is to be ex- pected. In the contused wound, the breach of surface is brought about by a blunt instrument, moving with a greater or less velocity ; and the extent of bruising or contusion of the soft parts in the neighborhood of the wound, will be found to vary with the size of the instrument which inflicted the injury, and with the force of its impact. When the wounded body is large, the extent of injury will be proportionate; but when the velocity is great, the area of contusion around the edges of the wound will be lessened, as the extent of wound will be increased. The best examples of contused wounds of all kinds are met with in military surgery, as caused by the impact of spent balls or fragments of shell. Lacerated wounds are generally brought about by a tearing or biting process, and are characterized by great irregu- larity of the lacerated tissues from the skin downwards ; this irregularity de- pends much upon the different degrees of elasticity of the parts torn—skin, arteries, muscles, and tendons, all behaving differently when submitted to a lacerating force. In contused wounds, the area of injury generally extends far beyond the area of the breach of surface, and when death of tissue follows it may spread widely. In lacerated wounds, the area of injury is generally more localized ; though this remark is not applicable to wounds in which muscles and tendons are involved. When, for instance, a Anger or thumb is torn of, the tendons connected with the injured part may separate at their muscular origins in the forearm. Hemorrhage from Contused and Lacerated Wounds.—In both contused and lacerated wounds, there is less primary hemorrhage than there is in those of the incised variety; the contusing force so affects the vessels at the seat of injury, as to favor the coagulation of the blood about their open mouths, or so ruptures- the inner and middle coats of the bruised vessels as to mechanically interfere with the flow of blood, and thus encourage the formation of a clot by which the lumen of the injured artery may become occluded; while the lacerating force likewise irregularly divides the different coats of the vessel and its sheath—even in the case of a large artery—and thus favors the coagu- lation of the blood at the seat of laceration. This temporary plug of the vessel is generally sufficient to close the orifice until nature’s permanent haemostatic processes have had time to act and to seal the vessel. TREATMENT of contused, lacerated, and granulating wounds. 37 Secondary Hemorrhage.—In contused wounds there is, however, a far greater proneness to secondary hemorrhage than is met with in any other form of wound, the contusing force often primarily injuring an artery, but not opening it, yet so destroying the vitality of its coats as to set up an inflammatory, sloughing, or ulcerating process, which in its turn may be followed by the formation of an aneurism, a wound, or a rupture of the vessel, and, as a con- sequence, by secondary hemorrhage. Contused wounds are consequently of .a more dangerous character than lacerated wounds. Subcutaneous contused wounds, that is, severe contusions of soft parts from the impact of blunt instruments, the passage of a wheel over the part, or other force, without breach of surface or exposure of the injured tissue, are at times more grave than those in which a breach of surface exists. This is best seen by studying the effects of such kinds of injury upon the abdominal and pelvic viscera, an unbroken and apparently uninjured outside surface often •covering a fatal subcutaneous rupture of a solid viscus, or a laceration of a Follow one; but the same fact may be also well seen in severe injuries to ex- tremities, where from a contusing force an artery may be stretched, bruised, or lacerated, large veins may be torn across, nerves injured, and muscular and •other tissues irreparably damaged. The amount of harm which deep tissues may have sustained in any given injury, can therefore only be estimated by a correct appreciation of the force which has been applied, and of the position and condition of the injured part •at the time of its reception. It can never be made out by simple inspection of outside appearances. Such injuries always demand great care in their treatment. Treatment of Contused, Lacerated, and Open Wounds IIealing by Granulation, The principles upon which the treatment of contused, lacerated, or open wounds is based, are the same that have been laid down and explained in considering the treatment of incised wounds, though they may require some modifications in their application, on account of the altered circumstances in which they have to be carried out. For example, in a deep lacerated wound, the surgeon will have to cleanse it and arrest bleeding, as in an incised wound; but he will not have to adjust the divided surfaces and apply sutures, in the same careful way that he would be called upon to do if “quick union” was to be looked and worked for; and he will remember that this change of practice as demanded in contused and lacerated wounds, because there must of necessity be more or less sloughing or molecular disintegration of the lacerated tissue •and contused parts around, and that, as a consequence, it becomes a matter of primary importance to leave the wound open, for the free discharge of all such tissues as may have been destroyed, or may die, as well as for the evacu- ation of the fluids which must be poured out in the reparative process. He will, however, in this class of cases as in the former, secure immobility be of use. Thiersch moreover adds that in cases of compound fracture and gunshot injury—since the free escape of secretions is one of the most important points in their treatment—wounds may he enlarged by incisions, abscesses, opened, counter-openings made, and even free openings etfected into wounded joints, or resections practised. The conclusions of the Moscow committee are also favorable to the practice, and may he condensed as follows: The essential feature of treatment by aeration, as this committee calls it, consists in avoiding all local appliances for excluding air, and in placing wounds in conditions favorable for free and direct contact with the atmosphere. Lint and other such substances should never be used. Repair by primary union should always be sought when possible. Catgut ligatures and metallic sutures should he employed. The advocates of this system believe that the “Lister dressings” are injurious, but that the antiseptics employed counteract the baneful effects of the coverings. Summary.—The results of this open treatment are evidently satisfactory, and, judged by the essential points to which attention has been directed, the open treatment of wounds may he advocated ; for it includes careful adapta- tion of parts after arrest of all bleeding, and due provision for thorough 1 British Medical Journal, Oct. 27, 1860. 46 WOUNDS. drainage ; but, on the other hand, it takes little care to guard against mobility of the wounded part, and disregards antiseptic applications and precautions. This neglect is, however, probably due to the justifiable impression that if drain- age be provided for, there will be in the deeper parts no retained dead tissue or fluids to decompose or undergo chemical change, and that a free current of air upon the surface of the wound is the best guarantee against septic changes of its fluids. Indeed, Professor Humphry clearly indicated this when he tie- scribed how large open wounds, by this system, healed by scabbing more quickly than when the part was covered and kept moist. Some of the advo- cates of this system believe the open treatment to be more adapted to wounds in which union by secondary adhesion is to be expected, since they assert that, if an open wound be maintained in a condition of perfect freedom from all irritating causes, such as foreign bodies, dirt, and decomposing elements, granulations will form, and that suppuration is not an essential part of their formation. For my own part, after a careful review of the whole question, I must re- gard the open treatment of wounds as being far superior to any other in which due provision is not made for perfect drainage; but at the same time, I fail to see its advantages over some others, and more particularly over that which I adopt, in which all the advantages of the open system are secured, .and in which, in addition, the wounded part is effectually guarded against mobility and external injury, while, at the same time, due provision is made, by means of a light antiseptic dressing, against the possibility of any septic •changes taking place on the surface, as well as in the deeper portions of the wound. The recent investigations of Pasteur tend greatly to support the advocacy of this open dressing, since he claims to have proved that germ influence is weakened by contact with the oxygen of the air, and that “ it is the oxygen of the air which weakens or extinguishes germ virulence.”1 Treatment of Wounds by Irrigation.—This must he regarded as only a variety in form of the open method, since its essential advantage consists in the cleansing and thorough draining of the wound from all secretions and impurities. It is carried out by means of a can of water or medicated lotion, so placed above the part to be irrigated that the fluid can be conducted by a tube, as a gentle stream, or, what is better, by means of worsted threads, in rapidly falling drops, upon the exposed and wounded part, the limb being fixed upon a splint, with a pan beneath to catch the fluid as it drains away. In gunshot wounds of limbs, and in sloughing or unhealthy stumps, or wounds, this mode of treatment is very satisfactory. It has been employed in Guy’s Hospital for a quarter of a century, and can be recommended. Es- march speaks highly of it in military surgery. Treatment by Water-dressing, with and without Antiseptics in Solu- tion.—In 1825, the late Mr. Syme published a paper2 in which he pointed out the evils of such old methods of dressing wounds as those of mundify- ing, digesting, incarning, and cicatrizing, and recommended that wounds should he lightly dressed, after their edges had been adjusted and well brought together with stitches. To this surgeon, in connection with Mr. Liston, may he probably attributed the introduction into British surgery of the use of water-dressing for wounds generally. The practice was very rap- idly taken hold of and adopted, every thoughtful surgeon having recognized the evils that attended the methods in which wounds were smothered with masses 1 Remarks before the Academie de MAdecine, Lancet, Nov. 6, 1880. 2 Edinburgh Medical and Surgical Journal, vol. xxiv. p. 52, July, 1825. TREATMENT BY WATER-DRESSING. 47 or charpie,lint, or other material, and left to heal as best they could, under cover oi these masses of dressings saturated with blood, serum, or pus. The prac- tice, moreover, was simple and cleanly, and, when perfected, was comfortable to the patient to whom it was applied; that is, it became so, as soon as the value of a piece of oiled silk, or thin gutta-percha tissue, applied over the wet lint, was recognized, the wet lint before this improvement having soon become dry, and what might have been at first a wet dressing, having been thus converted into a dry one. The water-dressing likewise soon took the place of poultices, for by one, as by the other, warmth and moisture were applied to the wound. In 1835, M. Josse, a hospital surgeon of Amiens, published a book on the use of cold water in surgical dressings, and advocated its use, Jirst, as a trust- worthy and efficient means for the control of inflammation in parts not wounded; and secondly, as a dressing for wounds.1 If we had the choice, he says, referring to the treatment of the first class of cases, in which there is no wound, “ it might be established as a general principle that we ought to employ water by affusion with a continual stream, but the nature of the parts, or of the disease, may prevent this, and oblige us to recur to another method; thus, linen moistened with water, and renewed without ceasing, may to a certain degree prove a substitute for the affusions, but this mode requires much attention.” He subsequently describes his own method : “A vessel with a cock near its base is filled with water, and placed upon a narrow and high table, near the patient’s bed, in such a position that it shall be about a foot and a half above the diseased limb, beneath which a cerecloth is spread, intended to guard the bed, and facilitate the flow of the water, which is received in a bucket, placed near for that purpose, and into which the extremity of the cerecloth descends.” “ The diseased part should then be placed in the most convenient position ; it should be lightly covered with compresses ; an additional piece of linen should surround the cock by one of its extremities, while the other is ex- tended over the highest point of the apparatus. This is destined to prevent the water from falling with all its weight on the diseased part, and rather to disperse it over a larger surface.” I have described this method of using cold water fully, for it is one now recognized as the treatment by “ irrigationwhich, whether employed as cold affusion to check inflammation in injured parts, as in joints, or to keep wounds clean, is of great value. M. Josse likewise advocated the use of cold water as applied to gunshot or lacerated wounds generally, and in this received the support of the best mili- tary and civil surgeons. lie declared that— “ When cold water is applied directly after the injury, before reaction has taken place, and when it can be maintained with energy proportionate to the occasion, the phenomena of reaction will be prevented; heat, pain, and swelling will be subdued; and consequently sympathetic fever will not take place; but when the cold has not been applied before the development of the inflammatory symptoms, they will still be con- quered by its efficient use.” In these opinions most surgeons will agree, for at the present day the value of cold in checking and controlling inflammatory action is fully recognized; but cold is not now often employed in the manner described, the introduction into general use of ice and ice-bags having led to the adoption of simpler and more effective methods of application. The metallic coil of Leiter, of Vienna. 1 [“A great deal has been said,” says Liston, “about water-dressing, and the merit of intro- ducing it. Water has been applied to sores from time immemorial. The simple element, water, was supposed to he congenial to wounds and sores ; it was used to cool parts. The water-dress- ing has been used in my hospital and private practice for a long series of years, etc.” (Practical Surgery, p. 162. Philadelphia, 1838.)] 48 WOUNDS. is probably the best method of applying cold. I have used it freely and like it much. It seems to embody in itself all the advantages, without the dis- advantages, of all other known methods of refrigerating a part. However valuable cold-water compresses or bandages, hot fomentations, or a warm-water dressing, may be for application to parts that have been injured, bruised, or inflamed, they cannot be strongly recommended as dressings to parts in which wounds exist, for it is now a fairly well-recognized fact that water, per se, helps better than anything else to encourage in an injured or half-dying tissue, as well as in the secretions of a wounded part, chemical and fermentative changes, by means of which septic poisons are generated, or made to flourish, and from the absorption of which blood-poisoning is known to follow. Water, holding some antiseptic substance or salt in solu- tion, may, however, be used, the antiseptic preventing or neutralizing the' septic changes which the water by itself might encourage. In wounds,, therefore, that are much complicated with contusion and laceration of parts, and to which hot or cold fomentations seem applicable, these medicated water dressings may be employed; it being left to the fancy of the surgeon, whether he shall use carbolic acid, 1 in 20 of water; boracic acid, 1 in 50;, salicylic acid, 1 in 50; thymol, 1 in 1000 ; iodine tincture, 1 in 80; or per- manganate of potassium, 1 in 50. For my own part, I have for years given up using water as a dressing for wounds, whether with or without antiseptic substances, for I have found, that oily solutions of the same substances have- advantages over the watery preparations which render them far safer and more satisfactory. Oily antiseptic applications are without doubt the best dressings for wounds which we possess, and of these, one composed of terebene one part and olive oil three parts, deserves, as already mentioned, the prefer- ence. Dry Dressing of Wounds.—A dry dressing to a wound is to be preferred to one of which simple water forms a part, since with it the sanguineous or serous exudations are more or less absorbed and rendered inert, and the sur- face of the wound is kept quiet and protected, as by a scab, from outside in- jurious influences; whereas, with a water dressing, the injured surface of the wound and the wound-exudations are encouraged to undergo chemical and fermentative changes, by wdiich the risks of absorption of septic matter or poison are much increased, and the dangers of the simplest wound greatly enhanced. If the dry dressing be composed of some absorbent material, such as the absorbent cotton or lint, and impregnated with an antiseptic sub- stance, such, as boracic or salicylic acid, or iodoform, its eflicacy will be in- creased, since the dressing, under these circumstances, may be left untouched for some days, even for a week, and the healing of the part will not, there- fore, be interfered with. Repair, as a consequence, will go on with greater rapidity and certainty; the secondary wound dangers will be diminished, and the ultimate issue of the case will be rendered more satisfactory. When a wound is small, and the surgeon has no doubt as to the propriety of seeking to obtain its immediate union, the dry dressing can be recom- mended, for it, without doubt, helps better than any other to bring about the “quick union” which is sought. When the wound is large, or deep, the same recommendation cannot be made, and the dry dressings, if used, should only be so after every care has been taken to provide tor the free drainage of the part. They should, moreover, only be employed when there is a reasonable hope of the parts healing by primary union. When a wound is much lacerated or contused, dry dressings are not applicable, since in these no surgeon would entertain the thought of repair being brought about by rapid union, and where this hope cannot reasonably be entertained, the use of the ALCOHOLIC DRESSINGS. 49 dry dressings should be discarded. In brief, in all wounds, small or large, when repair by “ quick union” may reasonably be looked for, dry dressings are applicable, due provision having been made for efficient drainage. In all lacerated, contused, or deep wounds, in which repair by granulation is to be expected, these dressings are not to be recommended. Earth Dressings.—Earth, as a dressing for wounds, has doubtless been used by savage nations from an early period of the world’s history, but it was first brought before the notice of surgeons by Dr. Addinell Ilewson, of Philadel- phia, in 1872; and from his work upon the subject, it seems that he first re- sorted to this mode of treatment in 1869. Dr. Ilewson was first led to employ the earth as a deodorizer, in a bad example of compound fracture of the leg; and, as the results in this case were good in all respects, he began to employ it as a primary dressing to wounds. The earth used by Dr. Ilewson was dried, yellow, ferruginous clay, which had been well sifted through a fine flour sieve, and he claims for its use many advantages. He maintains that it is cool and pleasant to the patient as a local application, and that it has a marked influence in soothing pain. In burn cases and in those of carbuncle, this relief is very striking. Dr. Ilewson has satisfied himself that earth, besides being a deodorizer, has a marked influence in preventing putrefaction; that in no case does it provoke or aggravate inflammatory action in a wound, but that in many, it retards or arrests it; and, above all, that it promotes the healing process in wounds of every description, as well as in ulcers. The way in which the clay acts as a dressing may not be clear, but it seems reasonable, from the evidence adduced by Dr. Ilewson and others, to conclude that it has by its powers of absorbing gases, and more particularly oxygen and ammonia, a chemical action upon the part to which it is applied, and that by virtue of this action it is an efficient means of delaying decay and putrefaction, and of preventing fermentation in animal tissue. .Besides this, it excludes air from the wounded tissues, absorbs moisture and excess of discharges, and helps in a measure to give support to wounded parts. The dressing is applied directly to the wounded or ulcerated surface, by dusting over it the pulverized clay; or, in the case of a stump, by placing it upon a bed of dry clay, in a box extemporized of binder’s board, and by completely covering in the whole surface with some more clay. In some cases, when the clay becomes saturated with the discharges, the dressing has to be renewed daily; in others, it may be left for two or more days. Upon the whole, this mode of practice has not extended far beyond the sphere occupied by its originator, and it does not seem to possess any advan- tages over the more cleanly and simple processes which are now at the dis- posal of surgeons. Some years ago, when Dr. Ilewson was in London, I was tempted to give the method a trial; but I soon gave it up, as experience was not in its favor. The dirtiness of the dressing was not compensated for by any advantage. This, however, may have been because I was unable to obtain the right kind of ferruginous clay. Alcoholic Dressing of Wounds.—Hippocrates, Paracelsus, and others em- ployed wine as a dressing to wounds, and they did so under the idea that it dried the part, and in the belief that a dry condition was nearer a state of health, whilst humidity was nearer that of disease. Their followers used wine in which astringents were dissolved, such as gall-nuts, oak-bark, etc. All did so, moreover, with the view of arresting bleeding. In more recent times, the alcohol dressing has been made popular by Helaton, who used it largety, and found it of value. It may be applied in the form of simple alco- hol, or, which seems preferable, in that of the camphorated spirit of 50 WOUNDS. wine, as originally used by Dionis. The dressing is said to be a coagulant and astringent, and, with such properties, to favor primary adhesion. In open wounds, it is said to act as a healthy stimulant to the granulations, and as a disinfectant, thus helping repair, and guarding against septicsemic changes and other wound complications. Kelaton employed compresses saturated with alcohol, and he believed the camphorated spirit to be useful only in proportion to the alcohol it contained. M. Chedeverque asserts “that camphorated spirit of wine is without contra- diction the best disinfectant that can be found for the treatment of wounds and ulcers,” and he makes this statement after a careful investigation into the value of every known antiseptic, not excluding carbolic acid. The spirit is supposed to have the power of dissolving the pus cell, and of obviating its tendency to decompose, and of closing any open vessels. Maisonneuve bathes the raw surface of the wound with the spirit, and, having brought the divided edges together, and having adjusted them with sutures or adhesive plaster, so placed as to allow of the free escape of discharges, envelops the whole in a bandage steeped in tincture of arnica, and at times applies over the whole the apparatus for “pneumatic aspiration,” which will be again referred to. The disinfecting and cleansing power of the spirit, applied in this manner, probably helps the draining influence of the aspirator. Upon the whole, the alcohol dressing may be favorably regarded, whether simple alcohol or spirit of camphor be employed. It has, without doubt, a cleansing, and probably a disinfecting influence on a wounded surface, while, at the same time, it helps materially to arrest capillary bleeding and that serous oozing which is so detrimental to primary union. In its use, however, the surgeon should never be induced to forget the value of the other essential points of practice to which attention has been drawn, and particularly drain- age. Pneumatic Aspiration and Occlusion.—Maisonneuve’s method of “Pneu- matic Aspiration,” which he employed with some success before 1867, and J. Guerin’s plan of effecting “Pneumatic Occlusion,” promulgated in 1865, have already been described in the article on A mputations, Vol. I. page 601. It is essen- tial that the aperture of the India-rubber cap, in Maisonneuve’s apparatus, should tit the limb accurately, but the crown or lower part may hang some dis- tance from the wound. A few strokes of the piston, morning and evening, suf- fice to draw the discharges from the stump into the jar, where, in the absence of air, they accumulate without danger of decomposition ; while the healing of the wound is facilitated by the accurate and immovable adaptation of its sur- faces, and by the exclusion of air. This practice of Maisonneuve’s has three main objects in view, all of which are of importance: (1) to check the for- mation of matter; (2) to prevent its decomposition when formed; and (3) to prevent its poisonous action on the system by entrance into the circulation. It is essentially based upon the principle of drainage, and in that point of view is valuable. In exceptional cases, and particularly in certain cases of amputation, it may be employed, but as a general mode of treating stumps it does not appear to possess such advantages over simpler methods as to make up for the difficulties and expense of its employment. Antiseptic Irrigation of WoirNDS.1—The value of the antiseptic irrigation of wounds is not, at the present day, likely to be disputed by any surgeon, and a difference of opinion is only probable as to the antiseptic which shall 1 [The treatment of wounds by Prof. Lister’s “ Antiseptic Method” is described in a separate article, page 63.] 51 ANTISEPTIC IRRIGATION. be used, the mode of its application, and the character of the wound to which it is applicable. Every surgeon seeks to make and to keep his patients’ wounds as clean as possible, and by means of antiseptic solutions or applica- tions to destroy, neutralize, or guard against any and every outside or local influence that can possibly bring about or encourage chemical or fermentative changes in a wound. It is true that, within the last few years, a school of surgeons has been formed, the members of which talk of “Antiseptic Surgery,” and claim for themselves the title of “Antiseptic Surgeons,” as if it were applicable to them- selves alone, or rather to such of their body as have a belief in the germ theory as a cause of most, if not all, the surgical ills to which wounded flesh is heir; who assert, rather loudly and dogmatically, that “antiseptic surgery” must stand or fall with the theory upon which their practice is based; that no unbeliever in the theory is likely to carry out the practice with any probability of success, since it is only by a staunch believer in the theory that care and attention to every detail of treatment, suflicient to bring about a good result, are likely to be given. It is true, also, that the results claimed for this practice are great, very great, beyond all previous belief; that, according to these gentlemen, opera- tions which in former times were looked upon as dangerous, can now be undertaken with “certainty” of success; and that others which have hitherto been regarded as unjustifiable, are now legitimate and safe. In fact, the up- holders of this theory and adopters of this practice maintain that exploratory and operative measures, which have been regarded as being beyond the prov- ince of the surgeon, may now be calmly and quietly undertaken with a “moral certainty” of being followed by a good result. Thus it is that our sanguine confreres talk of cutting into healthy joints with the “ certainty” that no dan- ger will follow, and declare that great operations upon the bones of the knee may be undertaken with the feeling that in so doing we do not subject the patient “to any risk whatever.” That a wedge-shaped piece of bone may be taken from a deformed femur, with the confidence that such a produced com- pound fracture is “perfectly safe,” and “without risk;” and last, but not least, that the peritoneal cavity, under “antiseptic precautions,” may be opened “with impunity.” I need hardly say that much of this is bold assertion and nothing more, and that it is apparently due to the sanguine temperament which seems attached to those who pin their faith to a taking theory, and adopt the practice which is based upon it, in blind deference to the authority of its distinguished ori- ginator ; for facts, calmly looked at, neither by their number nor by their weight, justify these conclusions, but irresistibly suggest that an enormous superstructure has been raised by the ingenuity of its builders upon a narrow foundation, and that good results have been too hastily attributed to causes which have been but some of the factors of a work to which others equally potent for good have without doubt contributed. Facts, indeed, have been employed by our self-styled “antiseptic” friends, as legal advocates use small data which tell in their favor, to support the cause they have in hand;, but not as the judge who has to weigh evidence, and with an unbiased mind give judgment. It is only by this explanation that we can understand how the “antiseptic surgeon,” when he gets a good result, is so fond of asserting that such could not have been brought about by any other form of practice than that which he has adopted; and, when he is attempting an operation which may in all truth be called experimental, if not rash, maintains that he under- takes it “under the spray” with all confidence, and with a moral certainty of meeting with success. We must admit, however, that surgery is now much more successful than 52 WOUNDS. it was twenty years ago, and that of the many factors which have brought about this result, the employment of antiseptics stands foremost; and if we are not altogether indebted to Mr. Lister for their use, we are unquestionably indebted to him for the able and persistent manner in which he has both ad- vocated their employment and demonstrated their value. All honor, there- fore, to the name of Lister, for having helped, more than any one else, to establish the value of antiseptic drugs and antiseptic precautions in the practice of surgery, all over the world. Let those who smile at his theory, join with those who believe in it, in giving him this just meed of praise; and let those who do not believe in the efficacy of the spray, do their best to prove to those who do, that all the advantages of the “antiseptic system” can be obtained by simpler means than by its use. Amongst these means, what must be called the antiseptic irrigation of wounds, in my judgment, stands foremost. Antiseptic irrigation means the washing of a wound with an antiseptic solution, with the view of destroying any and every germ or element that might possibly set up chemical or fermen- tative changes in its secretions. It is as applicable to fresh wounds, acciden- tal or operative, as it is to the suppurative or foul, and it is as valuable as a preventive as it is as a curative means. In my own practice, the solution employed is, as has already been mentioned, iodine water—that is, a mixture of the tincture of iodine and water in the proportion of one part to thirty— and, after operations, this should be applied hot. It may be used by means of the irrigating bottle, described at page 26 (Fig. 223), or by means of sponging. When sponges are employed, they should be well soaked in this fluid, and subsequently, before the wound is dressed, should be used to absorb all excess; for this lotion, when applied warm, has more power than any other of which I know, to bring about that desirable “glazing” of a wounded surface which is so valuable as a first step towards quick or rapid repair, and to check capil- lary bleeding. In suppurating wounds, the same lotion cleanses better than anything else, and has the power of destroying germs of evil, as well as other more vaunted germicides. For the irrigation of a chronic abscess, or sinus, it is equally to be advocated; indeed, as a purifying and antiseptic lotion for all wounds of external parts, as well as for all suppurating cavities, it can be highly recommended. I have employed it for years past, as a purifying agent, but without germicidal intention, with excellent results; and although I have seen much of the spray and carbolic acid practice, I cannot yet see that its results are better than my own. Those who prefer carbolic acid as an anti- septic, can use it in the same way, in the strength of one in thirty or forty; and thymol, boracic acid, chloride of zinc, oil of eucalyptus, or any ftther known antiseptic, may be similarly employed. The essential parts of the practice consist in the thorough ablution of the wounded or diseased part with the antiseptic solution,after the arrest of all bleeding; the drying of the surface of the wound as far as possible with an antiseptic hot sponge, applied with moderate pressure; and subsequently the careful dressing of the wound with some antiseptic substance, in the way that was described on page 33. Subcutaneous Wounds. When John Hunter, in 1794, in describing injuries, divided them into those in which the injured parts did not communicate externally—as strains, bruises, simple fractures of hones, or divisions of tendons; and those which had an external communication—as compound fractures and wounds of all kinds; and laid it down, moreover, as a law, that the injuries of the first class seldom inflamed, whilst those of the second commonly both inflamed and suppurated; SUBCUTANEOUS WOUNDS. 53 lie established a principle of which “ indeed it seems hardly possible to exagge- rate the importance” (Paget), and laid the foundation of a branch of surgical practice now known as Subcutaneous Surgery. Why it is that extensive in- juries to soft parts, when covered with skin, should undergo quiet and thor- ough repair, with little or no constitutional disturbance, may not be clear; but daily experience teaches us that dislocations of large joints, fractures of bones, severe contusions and lacerations of soft parts, associated with copious local hemorrhages, and even crushes of all the subcutaneous tissues of a foot or hand, as a rule, do well, provided that they are not interfered with by meddlesome practice, but are placed in the most favorable position for natural repair to carry out its silent work. Whereas the same experience tells us, with no uncertain voice, that the presence of a wound, however small, may change matters all round, and turn an injury which, had it been subcutaneous, might have been regarded as trivial, into one of a serious and complicated kind; and this fact is well exemplitied in the different course usually taken by a simple and a compound dislocation or fracture. What there is in the air that makes this wide difference, is now, as it ever has been, open to argument; and whether it is the stimulating or chemical influence of the oxygen, the irritating influence of atmospheric germs, the length of time the part is ex- posed, rather than the mere fact of exposure, or some other cause, may be subject to dispute. In modern times, the germ theory has found much favor, and has been the fashion; and attempts have been made to assign to the presence of germs every evil influence, and to regard these as the cause of inflamma- tion and suppuration in every open wound. But this view can hardly be sustained, for, on the one hand, even in subcutaneous injuries, in which no air can get in, inflammation and suppuration may ensue; while, on the other hand, in even severe examples of fractured ribs, complicated with emphysema over the chest, body, head, and extremities—in cases in which the whole cel- lular tissue of the body seems infiltrated with unfiltered air under most unfa- vorable circumstances—it is quite exceptional for any inflammation of the Infiltrated parts to take place; indeed, I may say that I have never seen an instance in which it occurred. As corroborative evidence, I may refer to some observations made in 1857, by Malgaigne, who, to test this question, made animals emphysematous with common unfiltered air, and then fractured their bones, divided their tendons, and opened their joints, subcutaneously; though the parts operated upon were surrounded with air, no inflammation followed. For my own part, I am disposed to think that it is not the mere exposure •of a wounded part to the influence of air, that does the harm, but its pro- longed exposure; since it is certain that where wounds are sealed rapidly, after the receipt of an injury, and are thus placed much in the position of subcutaneous injuries, repair goes on silently and well. Even bad compound fractures, when sealed early from the influence of air, heal, as a rule, like sub- cutaneous injuries. Repair of Subcutaneous Wounds.—It may be accepted as a truth, that .subcutaneous wounds are repaired much in the same way as open wounds that heal by quick or primary union; that is, when the wounded parts are brought or kept in contact, they simply reunite; and this applies to hard as to soft tissues. The process of repair in both cases is a quick physiological one, not unlike that >of development and growth. The action that attends the process is just enough to bring about the required result, but no more; when it is excessive, inflamma- tion is said to exist, and this inflammation, in subcutaneous as in open wounds, always prevents, checks, arrests, or undoes the work of repair. In truth, the less there is of inflammation in a wounded part, subcutaneous or open, the more 54 WOUNDS. perfect and steady is the reparative process. Surgeons are well aware that when inflammation occurs in a part which has been the seat of some subcu- taneous operation, the process of repair is likely to be interfered with, if not arrested; for, as Paget observes, the more manifest are the signs of inflam- mation, the less is the quantity of the proper reparative material, and the slower in the end is the process of repair. When tendons are subcutaneously divided and drawn asunder, their repair takes place as follows:1— When such a tendon as the tend© Achillis is divided subcutaneously, the divided ends separate, in an infant for half an inch, and in an adult for from one to two inches, the degree depending much upon the healthy condition of the divided muscle, and the amount of movement subsequently permitted in the ankle-joint. The reparative pro- cess begins with increased vascularity in the sheath of the tendon, which is followed by the infiltration of a blastematous material into the meshes or spaces between its fibrous elements, exhibiting the development of innumerable small nuclei, a few cells of large size and irregular form, with granular contents, or, perhaps, with one or more nuclei, and studded with minute molecules of oil; a blastematous material, in which the cell forms do not develop beyond the stage of nuclei, appears to be the proper reparative material from which new tendon is developed. This nucleated blastema soon becomes vascular, capillary vessels having been seen in it on the eighteenth day; the nuclei assume an elongated, spindle, or oat-shaped form, and are seen after the addition of acetic acid to be arranged in parallel linear series. The tissue becomes gradually more fibrillated, and at last fibrous—a solid bond of union subsequently forming between the divided extremities of the tendon, which is tough to the touch, but to the eye presents, for at least three yeai’s, a grayish, translucent appearance, distinguishing it at once from the glistening old tendon. This newtissue remains during life as permanent, and has little tendency to contract subsequently. Adams’s observations rather lead him to the con- clusion, that the required portion of new tendon may be obtained during a lengthened period of formation, that is, about two or three weeks, under the ordinary conditions of health; but that in paralytic cases, or with patients of feeble health, this period may be doubled. Adams informs us, also, that the divided extremities of the old tendon take no active- part in the reparative process during its earlier stages, although the cut ends subsequently become rounded, and their structure softened. They become enlarged and exhibit a tendency to split, and thin streaks of new material, similar to that already described, are seen between the fibres ; the ends are joined by these means. At a later period, the bulbous enlargement gradually diminishes. When a tendon is divided a second time, there is but little separation of its ends, and this is probably due to adhesion of the new tendon to the neighboring fibro-cellular tissue, in which fact is found an expla- nation of the unsatisfactory results of second operations. There is no reason for believ- ing that, in the treatment of deformities by tenotomy, direct approximation and re-union of the divided extremities of the tendon must first be obtained, and that the required elongation is afterwards procured by gradual mechanical extension of the new connect- ing medium, as we would stretch a piece of India-rubber. When much blood is effused between the divided ends of the tendon, it has to be absorbed; it acts merely as a foreign body in the part, and retards repair. Treatment of Subcutaneous ‘Wounds.—When rightly treated, these wounds are generally repaired readily, and, as Hunter asserted, without inflammation; but when not rightly treated, “ the subcutaneous nature of a wound is not of itself a sufficient protection against inflammatory complications,” “and a clumsily performed subcutaneous operation may be as dangerous as an open wound; sometimes even more so” (Adams). In the treatment of these, as of 1 British surgeons are chiefly indebted, for their knowledge of the process of repair in subcu- taneous wounds, to the investigations of Sir James Paget and Mr. W. Adams, and the description in the text is mainly taken from the latter author’s work on the Reparative Process in Human. Tendons, etc. (London, 1860.) COMPLICATIONS OF WOUNDS. 55 open wounds, there are, consequently, essential points of practice to be ob- served, in order that good results may be obtained; and these are not unlike those which have been laid down for the treatment of open wounds. That is to say, the injured parts are to be placed as far as possible in a position of ease, and in one in which the contact of the divided tissues is assured, when contact is called for. The parts are, moreover, to be fixed by splints, band- ages, or other dressings, in a condition of absolute immobility. The seat of injury is to be protected from all outside injurious influences, and to be sup- ported by moderate pressure; and, what is more, is to be undisturbed, in order that neither by manipulation nor movement shall repair be retarded; for a subcutaneous wound is as susceptible to injury from mechanical interference as is an open wound. In treating the wounds made by the operations of subcutaneous surgery, the same principles of practice are applicable, and they are well summed up by Adams as follows:— “There are certain conditions which must coexist to render the subcutaneous opera- tions exempt from inflammation. These conditions are : 1st. That the knife used must be of small size. 2d. That the operation must be performed quickly and neatly, with decision rather than force, and with as little disturbance to the soft parts as possible. 3d. That the wound must be immediately closed, and a compress and bandage applied, so as to prevent effusion, and to support the part. 4th. That perfect quiescence to the part be insured for three or four days, and the dressing remain undisturbed. When all these conditions are strictly observed, it matters little whether large muscles, or ten- dons, or ligaments are divided; or even whether the large joints of the body are opened.” From all this, it is to be gathered that in the treatment of subcutaneous wounds, whether of accidental or operative origin, there are four essential requisites to be provided for, viz., Position, Immobility, Pressure to support the parts, and Time for repair to perfect itself. Complications of Wounds. On the well-fonndecl assumption that a wound, when made into healthy tissues in a healthy subject, will heal by natural processes if placed in the most favorable position for repair, and not interfered with, it cannot well be disputed, when a wound does not heal thus kindly, that there must be some obstacle or hindrance to its natural progress; and this will doubtless he found either in the nature of the wound itself, or the mode in which it has been treated, or in the peculiarities of the subject of the wound, or the surround- ings of the case. When the hindrance is due to the wound itself, or to its treatment, it may be that some foreign body has been left to irritate; that the hemorrhage which ensued primarily on its receipt has not been effectually arrested, and that a clot has formed between the edges of the wound; that a “recurring” bleed- ing has taken place within a day or so after the infliction of the wound and its first dressing, from some imperfection in the treatment of the bleeding vessels, or from excessive reaction; or that a collection of serum has been allowed to form in the depths of the injured tissues. In most of these cases, the causes of non-repair are clearly referable to a want of care or skill on the part of the surgeon who has had the early treatment of the case, and must be set down as preventable causes. By the same want of care, the edges of the wound may not have been properly adjusted or kept in apposition; the injured limb may not have been made immobile; and, as a result, spasmodic muscular movements and jumpings of the limb may have been excited ; 56 WOUNDS. no provision, or an insufficient provision may have been provided for drain- age, and, as a consequence, the wound may have been irritated by retained secretions, and possibly made to inflame by the tension which the retained secretions have produced. Harm may also have been brought about by the want of due attention to the dressing of the wound, and to its efficient protection from outside injurious influences. Other causes of non-repair may be the unsuitable character of the applications with which the wound is dressed, of the position in which it has been placed, etc. When the obstacle to natural repair exists in the subject of the wound, or in the surroundings of the case, it may be that it will be found in the age, tem- perament, or feebleness of the patient—as expressed by deficiency in the healing act, excess of pain, or inflammation of the wounded parts; in the unhealthy atmospheric condition of the chamber or residence in which the patient rests, as shown by unhealthy action in the wound, erysipelas, or septicaemia; in the unsuitable character of the patient’s food ; in want of proper nursing, etc. Under any circumstances, the obstacle to repair will be found in one or more of these causes, and it is for the watchful eye of the surgeon to discover the particular defect, in order that he may apply the proper rem- edy. It is well, however, for the student to recognize the fact that most of these causes are preventable, and that they are as a rule due to some want of care in the primary dressing of the wound ; let it be repeated, therefore, that in all cases, and under all circumstances, too much care cannot be bestowed upon the management of fresh or recent wounds, to carry out the essential points of treatment to which attention has been so often drawn. Consecutive Hemorrhage or Recurrent Bleeding.—This form of bleed- ing is that which takes place within twenty-four or forty-eight hours after the reception of the wound. When it occurs, it is of little consequence whether it is to be attributed to some imperfection of the means employed to check the primary hemorrhage, or to the re-opening, during the period of reaction, of a vessel which had been temporarily sealed by a clot at an earlier period of the case. It has to be dealt with, and with decision. When trifling in amount, it need not be regarded with anxiety, and more particularly when there is room for the blood to escape through the drainage opening or tube, although even then it will be well for the surgeon to see that the wounded part is elevated and watched. If the bleeding vessel be a small or cutaneous one, these means will probably be enough. If, however, the bleeding is persistent, or if the parts about the wound swell, and become tense and pain- ful, and more particularly if pallor of the skin, feebleness of pulse, restless- ness, and other signs of collapse furnish definite signs and symptoms of loss of blood, the wound must be re-opened, the clots turned out, the source of the bleeding looked for, and the vessel secured. At times the mere opening and exposure of the wound will arrest bleeding, and, under these circum- stances, when the bleeding vessel cannot be found, it is well to leave the parts exposed for a few hours, and either to bring them together again when they have glazed, and when most chances of bleeding have passed, or to leave them open to granulate. The wound should, however, be left open under only exceptional circumstances: when the hope of quick union is very small, or when such union is undesirable. When the bleeding vessel has been found, it is to be secured, and the wound treated as a fresh one, and reclosed. At times, where oozing of blood is per- sistent, moderate pressure upon a wound does much good; and this may be well applied by means of an ordinary, or a rubber bandage over a sponge or elastic antiseptic pad. Care must be taken, however, that the pressure be not too great. COMPLICATIONS OF WOUNDS. 57 Secondary Hemorrhage.—This is the form of bleeding which occurs after the lapse of two or three days. It may occasionally be due to the existence of the hemorrhagic diathesis; hut is more commonly owing to some ulcer- ation of the vessel in the line of ligation, before the vessel itself has been closed by natural processes; to some sloughing of the end of the divided artery or vein, with or without sloughing of the wound itself; to some im- perfection in the means employed for the arrest of the primary bleeding; or to the accidental separation of a ligature. When it takes place in a wound that appears to be healthy, and in which the reparative process seems to have progressed in a satisfactory manner, the hemorrhage will probably be found to have come from a vessel that has been imperfectly secured, or the end of which has been irreparably injured; and under these circumstances, if the bleeding be profuse, and evidently from a large artery, the wound must be re-opened, and the bleeding orifice sought for and dealt with as in the original wound. But if, on the other hand, the bleeding is not severe, and the probabilities of the case suggest that the vessel is not large, the injured limb should be raised, and moderate pressure applied ; for by such means there will be a good prospect of a successful issue being •obtained. Should a recurrence of the bleeding, however, occur, and the effects of loss of blood show‘themselves, the wound must be re-opened, and the bleeding vessel secured. When the bleeding conies from a vessel which has sloughed with the surrounding tissues, it is better practice to secure the vessel at a distance from the wound. When, however, the bleeding takes place in a case in which an artery has been tied in its continuity, the surgeon should delay re-opening the wound unless the evidence be strong that the blood comes from the supplying or afferent trunk ; since experience has fairly taught us that, in a large number of these cases, the blood comes from the lower or distal orifice of the ligatured vessel, and that, under such circum- stances, it may be readily arrested by the elevation of the limb and well applied pressure. In all cases, however, when the bleeding is recurrent and persistent, the wounded vessel should be looked for, and secured either at the seat of hleediug, or, when this is either difficult or dangerous, at a higher point. Pain.—There is no effect of a wound or operation which varies more in degree than pain. In one case the subject of a simple wound will suffer much pain, while another individual with a severe wound will experience but little. Persons vary greatly in regard to nervous susceptibility; never theless pain is under all circumstances a serious symptom, and a great evil; for it tends to depress the moral and physical forces of the strongest patient, and to exhaust even to death the feeble powers of the fragile. I am convinced that I have known pain to kill. In all wounds, therefore, operative or otherwise, it is important that pain •should be guarded against, and for this object surgeons can do much by care and forethought. The wounded parts should be well protected, and so placed as to give rise to the least inconvenience or distress; the dressings, likewise, should be so regulated as to give comfort. In most wounds, and after most operations, some pain will he necessarily experienced, but, as a general rule, it will subside in the course of one or two hours. To relieve this symptom, however, it is well to give opium in some of its forms, and for this purpose, after an operation in which an anaesthetic has been used, it is an excellent plan to introduce into the rectum, before the patient becomes conscious, a suppository containing from a third to half a grain of morphia. The anodyne begins to exercise its calming influence before the effects of the anaesthetic have quite passed off, and in some instances the action of the two 58 WOUNDS. drugs appears to be continuous. In other cases the subcutaneous injection of a small dose of morphia may be resorted to, or a full dose of the same drug may be given by the mouth. Under all circumstances, the early pain after a wound or operation is to be subdued. When the pain is persistent and continuous, after the healing process has progressed, or perfected itself, some nerve complication may be suspected: it may be that some nerve branch has been included in the ligature placed around a vessel; or some nerve trunk may be so involved in the cicatrix of the wound, or so bound to bone or fascia, as to be kept continually irritated, or even inflamed; or it may be that no definite cause for the pain can be made out—when the case, for want of better knowledge, is regarded as neu- ralgic. When the cause of the pain can be determined, this should be removed, and when no cause can be ascertained, the surgeon may be justified in cutting down on the affected nerve, and stretching it; or in subcutaneously dividing it, as suggested by Hancock. As constitutional remedies, narcotics may be given, with tonics such as quinine, iron, and arsenic. Muscular Spasms.—The muscular spasms or twitchings which follow wounds, and more particularly amputations, can generally be prevented by the careful application of splints and well-directed pressure; they should be put down as preventible sources of distress, and should be guarded against in the early dressing of the case. Well adjusted pressure, with rest of the injured part, is the one thing to be relied upon to prevent and relieve this symptom, and it rarely fails. The judicious use of narcotics should at the- same time not be neglected. Defects in the Healing Process, and Diseases of Granulations. Defects in the healing process may show themselves in either deficiency or excess of action, or in some morbid state of the granulating wound. Deficiency of Action.—In the old, and in the very feeble, whether from disease or otherwise, deficiency in the reparative power is to be expected since, for repair, a balance of reserved force at the hank of health is requisite,, and, where such a balance is absent, the extra force required for healing will be deficient. Wounds in subjects such as these, consequently, simply fail to heal, or heal slowly, or in the worst way—the failure resulting from a want of either the right quantity, or the right kind of nutritive supply and nerve force. In wounds in which quick union is aimed at, the parts which have been brought together will simply not unite; and they will remain together only as long as they are held in position by the mechanical means employed for the purpose. In the young and in the middle aged, the same failure in repair is likewise at times seen in cases of harelip or other plastic operations in which quick union is needed for success; the parts do not unite by primary adhesion, but gape, and granulate, and the operations consequently fail. In such patients, also, fractures sometimes fail to unite as they ought, or unite but slowly, and this may be the case even when no definite- cause for the deficiency in the reparative process can be detected. In all such instances, however, there is want of power from some general or local cause, which must be detected before treatment can be rationally or success- fully applied. In wounds in which union by primary adhesion is looked for, the failure may be partial or complete. When it is complete, the wound must be regarded and treated as an open one, and under these circumstances the sutures should defects in the healing process, and diseases of granulations. 59 be removed, and the surface cleansed and kept clean, and then stimulated by some stimulating dressing such as carbolized oil 1-40; terebene and oil 1-4; boracic acid lotion 1-10; boracic acid ointment 1-5 ; or chloral or chlorate of potassium lotion, ten grains to the ounce. At the same time, the- wounded part should be placed in the most comfortable position, and in that which will be most favorable for the process of repair. The constitutional treatment should likewise be of a tonic and stimulating character, with good, abundant, though simple, food, and with wine or spirits in sufficient quantity to aid its digestion, and to enable the feeble heart to send its contents to the nerve centres, so as to give them force, and to the digestive apparatus, so as to enable it to utilize the food and get rid of effete matter. The patient at the same time should be placed in the best hygienic surroundings. When, however, the failure in primary adhesion is not complete, but 'par- tial, and when there is the smallest foundation for the hope that by keeping the parts together the required repair may yet be secured, the sutures should be left in position, the wound cleansed with some medicated antiseptic lotion,, and, if necessary, either another suture introduced, or some other means em- ployed to bring and to keep the parts well together; even should failure fol- low the attempt to gain primary adhesion, success may follow another effort made to secure secondary adhesion of the granulating surfaces, or union by the third intention. Where the cause of non-union is local and only temporary, these measures will often succeed, and will turn what seemed to be a failure into a satisfactory result. In harelip and in most plastic operations, a rigid adherence to this surgery of hope and discretion is to be highly commended. Defects of the Healing Process from Excess of Action, or Inflammation. —When excess of action takes place in a wound in which repair by primary, adhesion is looked for, disappointment, in all probability, will be the result;, for whenever there is in a wounded part more vascular action than is required for the reparative process to perfect its work, repair is first interfered with, then stopped, and, finally, what might have been repair becomes dis-repair, and the wound, when not held together mechanically by sutures, strapping, or bandages, gapes or opens. When excess of action, or inflammation, attacks an open wound that is granulating and cicatrizing, repair likewise ceases, and becomes dis-repair; the granulations, instead of presenting a healthy, florid appearance, and secreting a bland, creamy pus, become cedematous or glazed; what has been a granulating surface becomes an ulcerating one; and the secretion from the wound changes from pus, to a thin, serous discharge, with more or less debris of tissue. The thin, red, marginal line, with its cicatrizing edge extending on to the granulating surface, presents a more or less extended area of vascular congestion; this being, when the action is sthenic, red to an extreme degree, but when asthenic, tending towards blue, the redness shad- ing off in intensity towards the blue lividity of congestion. The surround- ing parts, moreover, will, under these circumstances, be tense from inflamma- tory effusion, hot, and painful, when the inflammation is acute; but when this is of a lower type, they will be cedematous, boggy, less painful because less tense, and less hot. When the local inflammation is sthenic,the constitutional disturbance will coincide with it in type, and the symptoms will be those of inflammatory fever; when the local action is of a low and asthenic form, the constitutional symptoms will partake of the same nature, and will approach those of low fever. It is to be known also, and remembered, that the acute or sthenic form of inflammation, as a rule, attacks a wound when newly made, and is generally excited by some local cause; possibly from the original injury, more probably from some imperfection in the primary dressing, and most probably 60 WOUNDS. from the retention of some irritating fluid in the depths of the wound, from want of proper drainage. This is more likely to occur in wounds of certain parts or tissues—as in wounds of joints, wounds of large cavities, and deep, punctured wounds—than in lesions of another character. The asthenic form of inflammation, as a rule, attacks wounds at a more advanced period; when the first effort at natural repair has been made, and has more or less succeeded, and when it might seem as if the effort to repair the part, and the power to effect that repair, were not commensurate. At any rate, in the treatment of these two forms of inflammation, when attacking wounds, it will be safe to assume that such is the fact; for while in the acute or sthenic variety, a local cause for its production should be looked for, in order that it may be remedied—in the asthenic, or later kind, the recognition of the fact that the inflammation is due to a deficiency of general power, is all important. Treatment of Inflammation Affecting Wounds.—In the sthenic form of in- flammation, the local and general action is to be subdued by giving free vent to pent-up fluids; by the local employment of ice, or of some other means of applying cold; by the local abstraction of blood; and by free purgation. For the latter purpose, there is nothing better, after a good purge, than re- peated small doses of a saline cathartic, such as Epsom salts. When suppura- tion takes place, it must be actively dealt with. In the asthenic form, general tonics, with stimulants and nutritious food, are essential; and locally, absolute cleanliness, the free exposure of the wound for purpose of drainage, with, possibly, warm medicated irrigation, and the constant use of such stimulating antiseptic applications as the nature of the case may suggest. Cold, locally applied, is rarely beneficial. Diseases of Granulations.—When an open wound heals, or a cavity fills up with reparative material, it does so by a process of granulation; and when this process takes place in a healthy subject, and under favorable conditions, the granulations present certain appearances, and are known as healthy granu- lations. When, however, the same kind of repair is being effected in a feeble or diseased subject, or under circumstances which are not favorable for its progress, the granulations present different appearances, these being, as it were, pathological, in contradistinction to those which are seen when the ordinary physiological process of repair is being carried out; a process which is very closely allied to, if not identical with, that of development and growth. In a healthy granulating surface, the granulations appear as small, conical masses of granulation tissue, covered with a thin layer of pus cells. The granulations are of a bright, florid red color, and are fringed at their skin border with the well-known, thin, blue line which is so indicative of healthy “skinning” or cicatrization; and during the whole of the healing process, this appearance is maintained, the only visible change being the gradual diminu- tion of the granulating surface by the steady approach of the thin, blue line towards the centre. Some wounds undergo contraction at the rate of from one to one and a half inches a week. The skin around a healthy granulating surface'will be healthy. In these granulations, and in their different appearances under diverse cir- cumstances, the educated eye of the surgeon can rapidly read, not only every important change in the bodily condition of the patient, but almost every variation, from day to day, in the patient’s condition, for a granulating surface is, as I have been in the habit of describing it, a kind of weather glass or ba- rometer of health; the surgeon cannot only read in it, as long as it maintains its healthy aspect, that the man who bears it is healthy, and that his different systems—nervous, secretory, and excretory—are doing their duty in a normal DEFECTS IN THE HEALING PROCESS, AND DISEASES OF GRANULATIONS. 61 way; but he will be able to recognize in the changed appearance of the granulations themselves, and of the thin blue line of cicatrization, the slight- est deviation from the healthy type; for while it is true that, as long as a granulating surface is healing kindly, the inference is correct that the subject of the “sore” is healthy; it is equally certain, when the granulating surface has deviated from the healthy path, that there is something wrong, either in the patient, in the part itself, or in its treatment. Thus, in a patient who is amemic, the granulations will be pale and blood- less; and when this condition has been of long standing, they will lose their small conical form, and appear as coarse, watery elevations. When there is any interference with the return of the venous blood from the granulating part, from either heart disease, the dependent position of the limb, or the im- proper use or bad application of bandages or other mechanical appliances, the granulations will appear congested to variable degrees, and may even bleed;, they may be so congested and full of venous blood as to put on the purple - appearance which suggested to the old authors the name of the “juniper - ulcer,” the granulations being so full of venous blood as to appear as blue or black as a juniper; the sore is then, clinically, said to be congested. When it bleeds it is generally called hemorrhagic. When from some constitutional or local cause the reparative process is acting feebly, the deficiency of action may be seen in the granulations, or rather in the sore—for under these circumstances the surface of the sore will either present a few ill-formed and feeble granulating spots, or it will appear smooth and apparently deficient in granulations altogether, and will look to the eye not unlike the tense mucous surface of the pharynx. In other cases,. the reparative force may be too feeble to express itself in any granulating pro- • cess, and the sore may present a greenish, dirty-colored surface, discharging an acrid or putrid substance which is clearly blood and serum mixed with the decomposing elements of dead tissue, the ill-formed granulations or gran- ulation-tissue dying superficially, as soon as formed, for want of power to live and develop. In more extreme cases of deficiency of power, what may have been a reparative process not only ceases to be so, but becomes retro- grade ; what had been a constructive, changes into a destructive force, and the tissues that should have been repaired break down and undergo molecular disintegration, the sore, instead of healing, becoming an ulcer, and the new tissue dying from want of vitality. At times, when the reparative power is feeble, and yet granulations form, these will present a corresponding appear- ance; that is, they will have a pale, watery, oedematous character, and the discharge from them will not be normal pus, but a sero-purulent fluid ; the granulations that form are of a weak type, and the sore then constitutes a weak ulcer. On the other hand, excess of action may at times affect a granulating or healing sore, and, when it does so, it affects the granulating process as much as it has been shown to do a wound in which quick union or primary adhe- sion is sought for. In the stage of irritation, or that in which the granula- tion-tissue is simply over-stimulated, over-action shows itself in an excess of secretion from the granulating surface, in the shape of pus, and probably in some increase in the size and redness of the granulations themselves; and when this is other than a passing condition from some temporary cause, it will soon pass into one of inflammation. When inflammation attacks a granulating sore, changes will occur similar to those which have been described as taking place when it affects a healing wound. Physiologically, there will be an arrest of the healing process, an arrest of secretion from the granulations, and, if tb.e action. be. lasting, a. change from. 62 WOUNDS. what had been a healing process to one of ulceration. The ulceration will be more or less rapid, and associated with all the local and general phenomena of inflammation, such as redness and heat of the margins of the sore and the adjoining tissues, with pain and swelling. The degree and character of the inflammation regulate these appearances ; an inflamed sore or granulating surface presents as many different aspects as there are degrees or kinds of inflammation, for inflammation must be regarded as an accidental complica- tion of the sore, and it may attack it at any stage of its progress, or in any con- dition. At times, the granulating force may be in excess, and so act as to prevent repair. The granulations sprout above and beyond the margins in which the “ cutifying” action is carried out, and appear either as elevated, luxuriant granulations in the centre of a sore or at the orifice of a sinus, or as overhanging, florid granulations at the cicatrizing border. In these cases, there is simply an excess of granulating force, and this excess exhibits itself in fungous granulations. Again, a granulating Avound, when of long standing, may show on its sur- face, or in its surroundings, evidence of the existence of any constitutional or specific condition. That is to say, a chronic sore, in a patient who has a syphilitic taint, may present features by which the presence of the syphilitic poison can be recognized; and a chronic sore, in a scrofulous subject, will manifest conditions which, if not special, as in the syphilitic, will be clear enough to indicate sufficient feebleness and torpidity of action to suggest the existence of some general dyscrasia. THE ANTISEPTIC METHOD OF TREATING WOUNDS. BY W. WATSON CHEYNE, M.B., F.R.C.S. ASSISTANT SURGEON TO KING;S COLLEGE HOSPITAL AND DEMONSTRATOR OF SURGERY IN KING’S COLLEGE, LONDON. Okigin of the Antiseptic Method. The title of “ The Antiseptic Method” was given by Mr. Lister to a form of wound treatment founded on certain definite principles, and commenced by him in 1865. For several years previously lie had been impressed with the great evils which resulted from the putrefaction of discharges in wounds, and though he had succeeded in many ways in lessening the occurrence of putre- faction, yet it was not till after he had examined the results of Pasteur’s researches on spontaneous generation, and on the causes of fermentations, that he was able to systematize his work. Up to this time, scientific opinion, more especially in England, had been divided between two views with regard to the occurrence of fermentation, the one asserting that this process was due to the action of the gases of the air, and particularly of the oxygen, on the discharges, and the other asserting that fermentation was a spontaneous alteration, occurring in organic fluids after their exit from the tissues and vessels, and that it was a necessary consequence of loss of vitality. As long as these views were current, there was not much hope of entirely eradicating putrefaction in wounds, and its Consequent evils. The effort to exclude the gases of the air had been made by several surgeons, and had entirely failed to do any good. Most prominent among the surgeons who had used the so-called “ occlusion” method, with the view of arresting the putrefaction of the discharges of wounds by preventing the entrance of atmos- pheric gases, was Jules Guerin, of Paris. Starting with the good results which followed subcutaneous operations, he attributed these to the avoidance of putrefaction in the wound, or at least to the exclusion of the atmospheric gases from it. lie therefore carried on an elaborate series of experiments with the view of excluding the gases of the air from wounds, but without any good result. He sealed up wounds with various materials, especially with gold-beater’s skin, but the result was more frequently tension and inflamma- tion in the wound, than the absence of fermentation and a subcutaneous heal- ing. In later years, he tried other means, and at length introduced a special apparatus by means of which the air was pumped away from the vicinity of the wound. Nevertheless putrefaction and its consequences still occurred. Various other attempts have been made on the same principle, and these have in like manner failed. Thus the wound has been covered with collodion, so-called styptic colloid, etc. Leconte and Demarquay substituted other gases, more especially carbonic acid gas, for air, but their method was quite impracticable on a large scale, while it did not prevent fermentation. 63 64 THE ANTISEPTIC METHOD OF TREATING WOUNDS. While these attempts to prevent putrefaction by excluding the gases of the* air were being made, indeed before they had been thought of, it had been found that the addition of various substances to organic fluids, whether out- side the body or in wounds, had a marked effect in retarding or preventing fermentation, and notably in preventing smell. These substances therefore received the name of “antiseptics”—substances which prevented putrefaction, or, literally, which acted against the causes of putrefaction. These had been in use for a very long time, chiefly in the form of various balsams, ointments, or lotions. The most efficacious balsams contained various essential oils, which we now know to be powerful antiseptics, while the best lotions had, among other substances, alcohol as their chief component. The treatment of wounds with antiseptics had, however, been carried on in a very desultory maimer, and without any fixed guiding principle, till the publication, in 1859, of a paper by Corne and Demeaux on a paste containing coal tar. By means of this paper* the attention of French surgeons was at once attracted to the whole question of the use of antiseptics in the treatment of wounds, and for a year or two very fertile results were obtained. Lemaire more especially took the matter up, and after experimenting with an emulsion of coal tar, with very good results, he at length found that carbolic acid was the chief antiseptic constituent in coal tar, and accordingly introduced it into surgical practice. During the same time, various other antiseptics were brought forward, of which alcohol, in the practice of M. Xelaton, yielded the most important results. As the result of Lemaire’s writings, the use of carbolic acid spread very rapidly on the continent, and even in Great Britain a few surgeons (Spence, Wood, etc.) employed it somewhat extensively. Carbolic acid, as used in this way, has, however, many disadvantages, and hence many who had at first employed it largely, gave .it up almost entirely, and it seemed likely to fall into disuse, until it was again brought into notice by the writ- ings of Prof. Lister. All these attempts, however, with the exception to some extent of Le- maire’s, were merely empirical, or at least founded on no definite theory of the causes of fermentation. Consequently, the modes in which the antiseptics were used were very various, and as a rule very inefficient. What, perhaps, more than anything else, tended to confuse the minds of surgeons on this subject, was the success of what was apparently a very different method of treatment, and one opposed to any of the existing conceptions of the origin of fermentations. So contrary was it to the views of the majority of surgeons at that time, that great doubts arose in the minds of some whether, after all, putrefaction in wounds could be the evil which it had seemed to be. I refer, of course, to the open method of treating wounds. The Germ Theory. In the mean time, however, science was making rapid advances in this department, more especially by the labors of Schwann, Schroeder and Duscli, and Pasteur. The theory that fermentation was due to the gases of the air had become untenable. Organic fluids which had been sterilized by boiling, could be preserved for an indefinite time in the presence of air which had been previously heated (Schwann), which had been passed through sul- phuric acid (Schulze), which had been passed through water (Pouchet), which had been filtered through cotton-wool (Schroeder and Dusch), or which had simply been allowed to remain at rest for a sufficient time to permit the solid particles suspended in it to settle (Pasteur). It was also shown that no gas, per se, had any power of causing fermentation. Pure oxygen, nascent THE GERM THEORY. 65 oxygen, ozone, exhalations from putrefying materials, could be brought in contact with organic fluids and substances without setting up any fermenta- tive changes in them. The cause of fermentation was certainly not the gases of the air, and, in the case of boiled organic fluids and tissues, it was some- thing particulate; something floating in the air, but removable from it mechanically, by filtration, etc.; and destructible by various chemical agen- cies, such as sulphuric acid, heat, etc. It was thus evident that all attempts at excluding merely the gases of the air from wounds, could not but be abortive, for the gases were not the causes of the putrefaction in the discharges in wounds, and were not even an essential condition of that change; and that their exclusion, therefore, even if thoroughly effected, did not imply the exclusion of the causes of fermentation, or indeed its arrest in any way. The clinical experience of Guerin and others absolutely confirmed this conclusion. While it was thus established that the fermentation of boiled organic fluids and substances was due to the entrance of dust from the outer world, and not to the action of the gases of the air, or to any change inherent in the fluids or substances themselves, facts were being gradually accumulated which tended to show that unboiled organic materials, among which of course we reckon the discharges from wounds, obeyed the same law; and at the present time this view has been firmly established. One or two very simple facts will suffice to illustrate this point. Take Mr. Lister’s experiment with unboiled urine. The orifice of a flask is covered with a cap of cotton- wool, and the whole is placed in a suitable chamber, which is raised to a temperature of 300° F., and kept at that temperature for a sufficient length of time to destroy any living material in its interior (two to three hours). This heat acts on the air and the dust in the interior of the flask, in the same way that the air is acted on when passed through an iron tube heated to redness, as in Schwann’s experiment; the dust is ren- dered incapable of setting up fermentation. By means of the cotton-wool cap, the air which enters the flask during cooling is filtered of its dust, just as in Schroeder and Dusch’s experiments. The glans penis is then washed with 1-40 carbolic acid lotion, which acts in the same way on any causes of fermentation which may be present there. The cotton- wool cap being now rapidly removed, the glans penis is at once placed over the orifice of the flask, and urine is passed into the flask. As soon as the glans is removed, the cotton-wool cap is reapplied, and the flask containing unboiled urine in contact with filtered air is set aside in a warm place. This urinfi remains pure for an indefinite time, though, if dust be introduced into it, fermentation takes place rapidly. Here we have exactly the same law at work as in the case of boiled organic fluids; the gases of the air cannot cause fermentation ; fermentation is not a spontaneous change in the material experimented on; it only occurs when solid particles, removable by heat, fil- tration, etc., are admitted. I have been able to make out similar facts with regard to tissues removed from the bodies of healthy animals, facts which are further of import- ance in proving that the particles which cause putrefaction are not normally present in the healthy living body. Take a vessel, cover its orifice with cotton-wool and heat it as before described; then introduce into it some sterilized organic infusion, taking suf- ficient precautions to prevent the entrance of septic dust; lastly, with various precau- tions1 to render any air-dust innocuous, remove portions of the organs from the body of a healthy animal which has been just killed, and introduce them into one of these pre- pared vessels. The result is. if the experiment has been properly conducted, that many of the tissues of the body may be preserved unaltered for a long time, showing that there are no causes of fermentation present in them, and that they have no inherent tendency to undergo such a change. As soon as it was clear that fermentation was clue to the access to the fermentescible substances of particles from the outer world, and that these 1 For further details, see a paper “ On the relation of micro-organisms to antiseptic dressings,” in the Transactions of the Pathological Society of London, for 1879. 66 the antiseptic method of treating wounds. particles were destructible by heat and chemical agencies, a possibility of preventing fermentations in the discharges of wounds was opened up, and it was this idea which Professor Lister seized on, and the development of which has led to such fruitful results. A vast number of observations and experi- ments had shown that there was a very intimate relationship between fermen- tations in wounds and the constitutional disturbances so apt to follow them, a relation to some extent of cause and effect, and it was quite clear that if the occurrence of these changes could be prevented, a vast advance would be made towards the abolition of the so-called septic diseases. Mr. Lister’s aim has all along been to destroy the fermenting power of these particles before they reach the wound, and thus at once place the patient out of danger from any of the consequences which are supposed to be connected with a putrid or fermenting state of the discharges. Principles of the Antiseptic Method. While for the practice of the Listerian method it is only necessary to know that the causes of fermentation are particles, which reach the fermentescible substance from the outer world, and that these particles are destructible by various chemical means, yet it is of importance to ascertain more definitely what is the nature of these particles, and this knowledge will be found to open up a wider meaning of the term antiseptic surgery than is generally understood. It has been known for several years that in all fermenting fluids low forms of vegetable life are present, forms which are included in a class termed Schizomycetes, or more popularly known as Bacteria. It has also been amply demonstrated that these micro-organisms do not arise de novo in these materials, but that they are always derived from a parent. It has further been shown that they enter fluids and tissues from the outer world, being present as particles in suspension, in air, water, etc., or being deposited as dust on surrounding objects. It is also evident that as these bodies are living, they must acquire materials for their growth from the substances in which they grow; they must breathe, take in food to build up and renew their proto- plasm, and excrete waste products. It thus follows that the material which serves them for food must undergo a change as the result of their growth; and, since the result of the growth of individual cells in the complex animal organism is the formation from the blood of certain definite substances, there is nothing unreasonable in supposing that the result of the growth of cells floating free in a fluid, will be the formation of certain definite substances, varying according to the nature and function of the cell. In other words, the chemical substances forming the pabulum of these vegetable cells will undergo a constant and definite series of changes, which we know by the name of Fermentation. As we have already seen, fermentation is due to the entrance into the fer- mentescible material of particles from the outer world. The origin of micro- organisms in similar substances is also due to the access of particles from the outer world. Micro-organisms are always present in fermenting fluids. Micro- organisms must produce a change which comes within the definition of “ Fer- mentation,” as the result of their growth in these materials. The precautions which exclude micro-organisms from organic substances also exclude the par- ticles which cause fermentation. Where one set of particles is admitted, the other also enters; one cannot get fermentation without the presence of micro- organisms, nor the presence of micro-organisms without fermentation. The fermentations of which we speak are not instances of chemical decompo- sition; they do not correspond to the change produced by ptyalin, pepsin, 67 ANTISEPTIC AND ASEPTIC SURGERY. etc.; the ferment increases in quantity, and the fermentation takes a con- siderable time to be completed ; it is evidently a vital phenomenon. These facts of themselves would surely lead to the conclusion that the particles which give rise to micro-organisms, and those which cause fermentation, are one and the same; that in fact fermentation is the result of the growth of micro-organisms in fermentescible materials. Numerous facts show that this is so, but into the consideration of these I need not enter. It is now universally admitted that the alcoholic fermentation is due to the growth of the yeast-cell in the sugary solution, and that the formation of vinegar is due to the growth of the so-called “Vinegar plant.” Numerous simi- lar facts have been demonstrated with regard to other fermentations. The formation of numerous pigments on boiled potatoes and other suitable soil, is due to the growth of forms of micrococci and bacilli; and the same is true of blue milk, blue pus, etc. Pasteur has brought forward remarkably inte- resting facts with regard to the butyric fermentation. Mr. Lister has abso- lutely demonstrated that the lactic fermentation of milk is due to the growth of a special form of bacterium in the milk.1 Numerous experiments have also been performed which demonstrate that the 'putrefactive fermentation is no exception to the general law, and that it also is due to the growth of micro- organisms. Antiseptic and Aseptic Surgery. Since, then, the fermentation of the discharges of wounds is due to the growth in them of micro-organisms, which bodies come from the outer world, it is evident that surgery which acts against the causes of fermentation, that is, Antiseptic Surgery, may he carried out in various ways. It is not merely confined to the exclusion of organisms, but it may work by permitting their entrance, and neutralizing their power afterwards. This is the most common way in which antiseptics are employed at the present time. They are added to the discharge, and their usefulness depends on the extent to which they interfere with the growth and fermenting power of the micro-organisms which have entered the discharge, without at the same time being hurtful to the wound. The latter is an important point, and it is for this reason that car- bolic acid is one of the least satisfactory antiseptics when employed in this way. For it irritates the wound, thereby giving rise to increased discharge; while, on the other hand, it requires to be present in large amount, in albu- minous materials, in order to arrest or materially interfere with fermentation. The former effect of carbolic acid defeats the latter aim, and thus, where car- bolic acid has not been used aseptically, tnat is, with the view and with the result of excluding micro-organisms from wounds altogether, it has been found to be inefficient, and by no means a satisfactory application. The free drainage of wounds is also an antiseptic method, for by it the discharge is carried away from wounds before micro-organisms have time to develop in it, or to alter it to any extent. At the same time, it is a method liable to fail if anything interferes with the drainage, for as the causes of fermentation are constantly present, they develop, if for any reason the discharge collects in the wound. Among the most important antiseptic measures is treatment by irrigation, or by the water bath. In treatment by irrigation, the discharge is not merely permitted to flow away, but it is washed away as fast as it forms, and thus there is less chance of development of micro-organisms than where free drainage alone is employed. The antiseptic virtues of this method are much increased by using an antiseptic lotion for irrigation. Treatment by the water 1 Transactions of the Pathological Society of London, 1878. 68 THE ANTISEPTIC METHOD OF TREATING WOUNDS. bath can hardly be as effectual as by irrigation, for the discharge is not re- moved with the same certainty and rapidity. The open method of treatment must also be included among the antiseptic methods, though at first sight it might appear entirely opposed to them. The free exposure of the discharge to the air acts antiseptically in two ways. In the first place, it was pointed out by Pasteur long ago, with regard to the alcoholic fermentation, that the fermenting power of the yeast cells was much diminished if they were freely supplied with oxygen. On the other hand, if they had but little oxygen, they, according to his theory, took it from the sugar, and caused fermentation much more rapidly and thoroughly. Therefore, any micro-organisms requiring free oxygen for their growth, though they grow more rapidly, will produce less fermentation, if the dis- charge be well oxygenated, than if it be shut up under a mass of dressings. But Pasteur also showed, with regard to the butyric and putrefactive fermen- tations, that oxygen was directly noxious to the bacteria which caused them; that not only could these fermentations not occur if oxygen were freely ad- mitted, but that the bacteria were actually killed by this gas. Thus the free exposure of the discharge to oxygen diminishes the fermenting powers of those micro-organisms which grow in it, while it prevents the development of those which cause one of the most obnoxious fermentations—the putrefactive. In the second place, the open method acts antiseptically in another way. For by the free exposure of the discharge to the air, evaporation takes place, and the fiuid becomes more concentrated. How bacteria do not develop nearly so well in a concentrated as in a moderately dilute solution, and fluids may be made so concentrated that bacteria will not develop in them at all. This concentration of the fluids is carried to its most complete extent in the treat- ment by crust formation, and it acts to some slight extent in Alphonse Gue- rin’s cotton-wool dressing, though that hardly deserves to be included among antiseptic methods. A very different, but equally important principle is in- volved in the method of treatment by accurate approximation of cut surfaces, and the maintenance of perfect mechanical rest. It is well known that wounds of the face unite readily by first intention, without the occurrence of fermentation in the layer of lymph or blood-clot between the cut surfaces. This implies one of two things: either lymph is a medium in which micro- organisms can only develop with difliculty, or else the healthy living tissues have the power of preventing the development of micro-organisms in their substance and immediate vicinity. That the latter is the case, has now been amply demonstrated, and it is the chief agent, at work in getting this result. At the same time, lymph is not by any means the best pabulum for isolated bacteria. Aseptic Surgery and Listerism. It is, of course, at once evident that all these methods must stand far below the great principle which Mr. Lister was the first to enunciate, and to the application of which in surgical practice he has devoted so many years. When Mr. Lister first wrote on this subject, the confusion and uncertainty which existed in the minds of surgeons on this matter, was, as I have just indicated, very great, and the results obtained by him in all cases stood forward in glar- ing contrast to the results got at that time from the misdirected efforts of other surgeons. Since he wrote, however, and to a great extent by his own writings, interest has been excited in this department, and improvement has followed, not merely in the method of treatment which he devised with the view of excluding micro-organisms altogether from wounds, but also in the less perfect forms of antiseptic surgery to which I have referred in the preced- ASEPTIC SURGERY AND LISTERISM. 69 ing paragraph. Indeed, so good have the results become in ordinary cases treated antiseptically by one or other of the methods mentioned, though not aseptically (that is, on the Listerian principle),1 that some surgeons are in- inclined to the view that aseptic surgery is unnecessary in a great many cases, being only required for certain special operations. This view is, however, erroneous and mischievous, for by no method other than the aseptic method have infective diseases been entirely abolished; in cases treated by other forms of antiseptic surgery, they occur every now and then, and the surgeon cannot leave their possible occurrence out of account in determining the expediency of an operation. That certain operations are only j ustiliable when full precautions are taken to exclude micro-organisms, is now admitted by all. Such opera- tions are incisions into joints, opening of psoas abscesses, operations on healthy bones—as for ununited fracture, etc. That such operations are perfectly safe when done with proper aseptic precautions, is also abundantly proven. As the aseptic method can protect the patient under these circumstances, it can also protect him in ordinary cases, and, therefore, if one desires to be perfectly certain of avoiding infective disease in any given case, he must employ the aseptic method. But as it is the duty of the surgeon to prevent every pos- sible risk in every case, it is, therefore, his duty to employ aseptic treatment whenever he can. And even supposing that the other methods were perfectly reliable in ordinary cases for the purpose of saving life, there are other ad- vantages in the aseptic method which require its employment. By its use the patient is often saved a great amount of pain, and healing is very rapid and certain; while, on the other hand, patients treated in other ways, if they do recover, often do so only after a severe struggle for life. Many other advan- tages might be mentioned, but these I need not detail here.2 In speaking and thinking on this subject, great care must be taken to dis- tinguish between Asepticism and the Aseptic Method. Asepticism is synonymous with Listerism; it is the great principle, first enunciated by Mr. Lister, that the causes of fermentation in wounds are particles from the outer world, and that in order to abolish the risks due to fermentation in wounds, the proper method of treatment is to prevent the entrance of the liv- ing causes of fermentation into them. The aseptic method is synonymous with the Listerian method. It is the best way at present known of securing this result. When, as of late has happened, Mr. Lister gives expression to the view that perhaps the time is not far distant when some of the means at present employed in his method may be abandoned, the cry is raised that “Listerism is dead.” Such an idea rests on mis-appreciation of what Lister- ism is. Listerism or asepticism is a great principle which has triumphantly withstood the most searching tests, and which is now a law of the first importance to the practical surgeon. The Listerian or aseptic method is the best means at present known of carrying out that law in surgical practice, but the means have always been improving, and must always continue to improve. The time may indeed come when the method shall have under- gone an entire alteration, but, nevertheless, the principle underlying it will always remain the same. Whatever changes may occur in the present Listerian method, Listerism will always remain the most fundamental prin- 1 As will be evident from what has gone before, there are a variety of forms of antiseptic surgery, that is, of wound treatment directed against the causes of fermentation, and the method used by Mr. Lister for the total exclusion of micro-organisms, is only one form. To retain the term “ an- tiseptic surgery” for this method alone, is to introduce confusion, and it seems better, therefore, to abandon it, and to speak of Mr. Lister’s method as the aseptic method, for it aims at, and suc- ceeds in, excluding the causes of fermentation altogether from the wound ; that is, it renders the wound aseptic. 2 For full details on these and other points, see my work on “Antiseptic Surgery ; its Princi- ples, Practice, History, and Results.” London, 1881. 70 THE ANTISEPTIC METHOD OF TREATING WOUNDS. ciple of wound treatment, and the surgeon when he makes a wound will “lister” it in the fullest sense of that term. The same thing has occurred with all natural laws; when once discovered and firmly established they remain immutable, but the practical applications of them are constantly wide- ning and improving. As the other methods of antiseptic surgery have already been detailed in a preceding article, it only remains for me to describe the best means at present at our disposal for carrying into effect the great Listerian principle. At first the means employed were quite simple: some pure carbolic acid was poured into the wound, and, mixing with the blood, formed a crust; or the crust formation was assisted by the addition of lint; and under the protection of this crust the wound healed. Numerous disadvantages were found in this method, and many alterations and additions were made, till at length the present form was established, and has been employed satisfactorily for several years. The Aseptic Method. Iii order to have an aseptic state of a wound, a number of points must be attended to. In the first place, during the performance of an operation care must be taken to prevent the entrance of organisms. The skin of the patient is everywhere covered with dust which contains numerous active causes of fermentation. These must, therefore, be destroyed, as otherwise the operation would be entirely vitiated. On the hands of the surgeon and his assistants there are also numerous causes of fermentation, which must also be removed. The same is the case with all instruments, etc. Sponges must not be washed in water: indeed water contains perhaps more numerous causes of fermentation than ordinary air dust, and therefore it must not be employed at all. And the air itself, though in a much smaller degree than the deposited dust, con- tains some causes of fermentation which must also be guarded against. Then, after the operation has been performed, care must be taken to prevent the access of micro-organisms; this is done by the use of a suitable dressing, which imparts to the discharge, as it Hows out, sufficient of the antiseptic stored up in it to render the discharge an unfit soil for the growth of micro- organisms. After a time the antiseptic contained in the dressing becomes exhausted, and must be renewed. When this is done, the same care must be taken not to introduce any septic dust as during the operation. The antiseptic which has been chiefly employed up to this time, and which has proved most satisfactory, is carbolic acid. For the purification of the skin, either of the patient or of the operator, a watery solution, of the strength of one part of the pure acid to 20 parts of water, is employed. The skin over, and in the neighborhood of, the intended wound, is thoroughly washed with this solution, which must be allowed to act for some little time, because the antiseptic has to mix with the fatty matters, and to penetrate into the folds of the skin, while at the same time some of the micro-organisms may be peculiarly resistant, and may require a considerable time for complete destruction. In cases in which poultices have been employed, or in which there is an accumulation of putrid material on the skin, it is well, after washing the skin thoroughly with this lotion, to wrap a cloth soaked in it around the part, and leave it on for fully half an hour before the operation. For the purification of the hands of the surgeon and of his assistants, in the first, instance, if the operation be an important one, as, for example, on a i'oint, or opening an abscess, it is well to use the same strong solution of car- >olic acid, and care must be taken that the whole hand is thoroughly washed THE ASEPTIC METHOD. 71 with the solution. It is not sufficient merely to dip the tips of the fingers or even the whole hand in the solution; care must he taken that all the folds of skin, more especially about the nails, be acted on, and particularly that the solution pass up under the nails. In ordinary wounds, the 1-40 watery solu- tion of carbolic acid is sufficient, and it does not benumb the hand, as the stronger solution is apt to do. For the purification of the instruments, the 1-20 solution is employed. A large porcelain or tin trough is provided ; the instruments to be employed are laid in this, and then it is filled with 1-20 solution. In hospital practice, this is generally done from a half to one hour before the operation takes place. When toothed instruments, or instruments closing with catches, are used, it is best to separate the blades, so as to allow the lotion to get in between the teeth. It is well to immerse the whole of the instrument, for if oidy the point, for example the blade of a knife, is purified, the surgeon may inadvert- ently introduce the handle into the wound without washing it with the solu- tion, and he may thereby introduce septic dust. The sponges are washed in the 1-40 carbolic solution. After the opera- tion, they are rinsed in water, and then placed in a jar of 1-20 solution till required again; then the 1-20 solution is squeezed out, and the sponge, when washed in the 1-40 lotion, is ready for use. These sponges may be used for a long time, till, in fact, they wear out. In some cases they get clogged with fibrine. To get rid of this, the sponge is placed in a trough containing water, and left for some days. The fibrine putrefies, and can then be washed out readily. The sponge is then placed in a jar containing the 1-20 carbolic lotion, and is ready for use when required. The purification of the air is effected by means of a spray of carbolic acid. The spray is produced by driving a rapid current of air through the narrow orifice of a horizontal tube, which is placed over the orifice of a more or less- vertical one. The air rushing over the opening in the vertical tube, sucks the air out of that, and, if the lower end dips into a fluid, the fluid is sucked up and expelled from the narrow orifice in the form of finely divided particles, or spray (Fig. 231). At present, steam sprays are employed. They consist Fig. 231. Fig. 232. Diagram to show the principle of spray producers. Ordinary steam spray producer as at present employed by Mr. Lister. of three parts: a boiler, containing water; a lamp, placed beneath this boiler; and a retort, containing carbolic lotion. The steam generated in the boiler passes along a horizontal tube, sucks up the lotion through a vertical tube connected with the retort, and, mixing with it, forms the spray (Fig. 232). The fluid in the retort is the 1-20 watery solution of carbolic acid, and this* 72 THE ANTISEPTIC METHOD OF TREATING WOUNDS. mixing with the steam, forms a spray of the strength of about 1 part of car- bolic acid to 30 parts of water. The spray is employed during the whole operation; till in fact the dressing has been securely applied. With the view of excluding organisms after the operation, the material usually employed is the carbolic gauze. This is ordinary tarlatan, impregnated with a mixture of 1 part of carbolic acid, 4 parts of resin, and 4 parts of paraffin. If the cotton material were merely dipped in carbolic acid or car- bolic lotion, the antiseptic would very quickly volatilize, or be washed out by the discharge. It is necessary, therefore, to have the antiseptic stored up so that it may last for some time. This is the purpose of the resin. Resin and carbolic acid have a much greater affinity than water and carbolic acid. Water, therefore, may pass over a mixture of resin and carbolic acid for a considerable time, without washing out all the antiseptic. If the gauze were impregnated with resin and carbolic acid alone, it would be so sticky as to be useless, and therefore paraffine is added to it in sufficient quantities to do away with its stickiness. As the gauze at ordinary temperatures does not give off much carbolic acid, dust which falls on it is not deprived of its fermenting property, and, if a piece of gauze covered with dust is applied over the ori- fice of a drainage tube, this dust may pass into the wound, and entirely defeat the object of the whole treatment. On the other hand, the watery solution of carbolic acid acts very rapidly, and hence all that is necessary is to dip the layers of the gauze which go next the wound in the 1-40 lotion. Lest the carbolic acid should evaporate, the gauze, if it is to be kept for some time, is preserved in closely-shutting tin boxes. Carbolic acid is a powerful irritant, and, applied directly to a wound, it will retard or even prevent healing. With the view of overcoming this difficulty, Mr. Lister interposes a material, impervious to carbolic acid, between the wound and the gauze dressing. This material is termed the protective. It is ordinary oiled silk, coated on both sides with a thick layer of copal varnish. Outside this a solution of dextrine is brushed, because water runs off from the material without the dextrine, just as from a duck’s back, whereas the dextrine dissolves in the lotion, and the protective is equally and perfectly moistened. This protective is cut a little larger than the wound, dipped in the lotion, and applied over it. Outside the protective we have the wet gauze, larger than the protective and overlapping it in all directions, both together being called the deep dressing (Fig. 233). Fig. 233. Shows the mtthod of using the protective and deeper layer of the gauze. When used as a dressing, the carbolic gauze is packed into the hollows around the wound, and then a regular dressing is applied. This consists of the gauze folded in eight layers, beneath the outer layer of which is placed a piece THE ASEPTIC METHOD. 73 of mackintosh cloth, what is known as “ hat lining.” The object of this is to make the discharge traverse the whole of the dressing, and not pass directly through, as would be the case were the mackintosh absent. If there were no mackintosh, the discharge, always passing through one part, would wash out all the antiseptic in a very short time, and putrefaction would rapidly occur. To avoid this risk a large quantity of gauze would be necessary, and this would increase the expense of the treatment very much, whereas, by the use of the mackintosh, the discharge is made to pass from the centre to the edge of the dressing, that is, through a mass of gauze equal in thickness to the distance from the centre to the edge of the dressing. The same piece of mack- intosh may be used several times, till in fact it wears out. After the dressing has been removed, it is taken out, sponged with carbolic* lotion, and introduced into the new dressing. A patient is provided with two pieces at the com- mencement of the case, and these are generally sufficient, one being made up in a fresh dressing while the other is being used. Thus, though an expensive material, yet when divided over a number of dressings, its expense becomes very little. Expense is also saved by preserving the large pieces of gauze used in the dressings. They may be washed and recharged with the carbolic acid mixture. These dressings should be large,.and should overlap the wound for a considerable distance in every direction. The dressing is fastened on by a bandage. This may be made of carbolic gauze, which is light, cheap, and useful in many ways. But a cheaper band- age and one sufficiently convenient, indeed more convenient than the carbolic gauze bandage in many cases, may be made of thin muslin. As the dressing may not remain closely applied to the skin during all the movements of the patient, more especially in the neck, chest, or groin, there is a certain risk that air unacted on by the antiseptic may pass under the dressing and reach the wound, carrying active septic dust along with it. This danger is obviated by applying an elastic bandage along the edge of the dressing (Fig. 234). This Fig. 234. Dressing in a case of abscess of the hip-joint, showing the extent of the dressing and the arrangement of the elastic bandage around its edges. may be put sufficiently on the stretch to keep the edge of the dressing accu- rately in contact with the skin, without pressing injuriously, or interfering with the circulation in the part. Pins are put in along the edge of the dress- ing, fastening the dressing and the bandages together at the important points. Safety pins are the best for this purpose, as common pins are apt to get buried .and lost in the gauze. 74 THE ANTISEPTIC METHOD OF TREATING WOUNDS. Application of the Aseptic Method to Operations. Let ns now suppose that an operation is about to he performed with aseptic precautions. The following materials will be necessary :—- (1) One to twenty and one to forty watery solutions of carbolic acid ; (2) A trough containing the instruments, which are soaking in the 1-20 carbolic lotion ; (3) Sponges; (4) Basins containing 1-40 carbolic lotion in which to wash the sponges; (5) Vessel containing 1-40 carbolic lotion, for use during the operation, for the repuri- fication of hands or instruments ; (6) Towels soaked in 1-20 carbolic lotion. Mackintoshes. (7) A largish piece of muslin soaking in 1-40 carbolic lotion, and termed the “ guard (8) A basin containing 1-40 carbolic lotion, in which a piece of protective and loose gauze are soaking ; (9) A steam spray apparatus ; (10) A vessel containing 1-20 carbolic lotion, for the purification of the skin of the patient and of the operator ; (11) Catgut; (12) Drainage-tubes of various size ; (13) Horse-hair for drains and stitches ; (14) Carbolized silk for stitches ; (15) Silver wire for stitches ; (16) Lead buttons for “ button stitches;” (17) Loose gauze; (18) Gauze dressing; (19) Bandages, muslin, and gauze; (20) Elastic bandage; (21) Safety pins. .V. B—No water must be used. The patient having been placed on the table, mackintoshes are arranged so> as to prevent soiling of the clothes, and around the part to be operated on, and over the clothes and mackintoshes in the vicinity, towels soaked in 1-20 carbolic lotion are fixed. The object of these is that, should the surgeon lay down any instruments which he is using, he may lay them down on a pure basis, and may be sure that they will not take up any septic material from the place where they lie, while at the same time, should any of the clothes come in contact with the wound, it is protected from harm by having this pure layer interposed. The skin of the patient and that of the operator hav- ing been purified in the manner already described, a spray of carbolic acid is made to play on the part from a suitable distance (about six feet). If the spray be too near, it is unnecessarily wetting, while it is so narrow that the hand of the operator and his assistant will be constantly getting out of it. The spray is, on the other hand, perfectly efficient at a considerable distance; it is not wetting; and there is plenty of room for working in it. A basin containing 1-40 carbolic lotion is placed between the wound and the operator, and in this he can repurify his hands or his instruments should they have been contaminated with septic dust, either from the clothes, or by holding them outside the spray. All instruments, sponges, etc., must be handed into the spray, because every time that the operator has to reach his. hand out of the spray, it comes in contact with septic dust, and must be re- purified in the carbolic lotion before being introduced again into the wound. If the spray is to be used at all, these precautions are necessary. There can be no doubt that the spray is the least essential of all the details APPLICATION OF TIIE ASEPTIC METHOD TO OPERATIONS. 75 of the Listerian method. For, in ordinary air, there are comparatively few particles capable of causing fermentation. At the same time, there are par- ticles, and, as we cannot know where such particles are, if we are to take the precaution of purifying the air, it must be done thoroughly, as if the air were full of these particles ; and every time that the hands of the operator or his instruments have come in contact with unpurified air, that is, have been passed outside the spray, they must be repurified in carbolic lotion, before being reintroduced into the wound. The spray is a convenience, not a neces- sity. Aseptic treatment can be carried out without a spray; indeed for several years Mr. Lister did not use it. If, however, no spray is employed, we must not forget that septic particles are still present in the atmosphere, and must still be destroyed. This is done by washing out the wound every now and then during the course of the operation with carbolic lotion ; and, after stitching up the wound, it is well to syringe it out immediately before applying the dressing. Of course all the other precautions must be observed. In some cases, as in empyema, the spray is almost a necessity, and in all it is more convenient and more certain than the method of washing out the wound. The steam spray acts automatically. Once put in action, it goes on of itself. By its use there is no necessity for applying the irritating carbolic solution to the wound. To wash out the wound with carbolic acid, is to irritate it very much, and in some cases to interfere with the chance of primary union; at the same time, it causes an increased amount of serous oozing, which, of course, tries the antiseptic dressing very much, washing out the antiseptic, and increasing the risk of putrefaction during the after-treatment. It is, however, well to bear in mind that, where no spray is at hand, the aseptic method may still be carried out, and that the spray is the least essential part of the method as at present employed. The most essential part of the treatment is the thorough purification of everything (hands, instruments, etc.) which comes in contact with the wound. The introduction of an unpurfied instrument into a wound is a much worse error, and one far more likely to be followed by bad results, than the momentary deflection or cessation of the spray. When, for any reason, it is necessary to stop the spray for a time during an operation, the wound may be protected in the interval by throwing over it a piece of muslin soaked in carbolic lotion, and termed “ the guard.” The guard is also used in the case of a large wound where the spray does not quite cover the whole of the wound. In this instance, the guard is thrown over the part of the wound on which the surgeon is not working, and the spray is directed over the rest of it. The operation having been performed with the precautions detailed, the hemorrhage must be arrested. This is done by means of ligatures of carbolized catgut. There are two kinds of catgut which are at present employed: the carbolized catgut, which was that first introduced by Mr. Lister f and the chromic acid gut, which lasts longer in the tissues than the former, and is more rapidly and easily prepared.2 All bleeding points are tied, and the ligatures cut short. There is no excuse for leaving any bleeding vessel, as the ligatures cause no trouble afterwards. The drainage of wounds treated in this way is a most important point. It may be accomplished by means of drainage tubes, or by capillarity. The drainage tubes employed are made of vulcanized India-rubber (Fig. 235), and are of various sizes. They are introduced to the deepest part of the wound, and are cut flush with the surface at the outer end, obliquely if the tube be oblique, and transversely if the tube runs directly inwards. To permit the Lancet, April 3, 1869. 2 Lancet, February 5, 188] 76 THE ANTISEPTIC METHOD OF TREATING WOUNDS. discharge to escape from all parts of the wound, circular holes are cut in the sides of the tube, at intervals, the diameter of each hole being about one- third of the circumference of the tube. To prevent the orifice of the tube from becoming displaced, loops of carbolized silk, knotted at the end, are passed through the outer part of the tube, and the knots, lying between the skin and the dressing, prevent the orifice of the tube from becoming displaced. Should there be a great tendency for the tube to slip in, the loops of silk may be filled with wet carbolic gauze. The orifices of the tubes are generally placed at the most dependent part of the wound, but this is not essential. For as long as there is a free opening for the exit of the discharge, it may sim- ply be allowed to well out, because the discharge is unirritating, and, therefore, the quantity filling up the tube does no harm; at the same time, where possible, it is well to have a dependent opening. The chief point to be observed in determining the position of the orifice of the drainage tube, is to have it as far removed as possible from the edge of the dressing. Thus, in an operation for inguinal hernia, the orifice of the tube is not placed at the most dependent part, near the penis, because there would be very little space for overlapping of the dressing, but it is arranged at the uppermost angle of the wound, as far away as possible from sources of putrefaction. These drainage tubes are always kept ready for use, hi a vessel containing 1-20 carbolic lotion. When a drainage tube is removed finally from a wound, it is washed in carbolic lotion, placed in the jar with the other tubes, and is then ready for use when re- quired for another case. It is well to leave a tube undisturbed for three days after an operation. If it be taken out sooner, there will often be difficulty in reintroducing it, but bv the third day the tissues will have become condensed, and the tube will •be lying in a comparatively firm channel, which will not collapse when the tube is removed. When it is taken out, it is washed in the solution, and, if it projected from the wound, a piece corresponding in length to the projecting portion is clipped off from the inner end, and the tube is then reintroduced. Frequently, on the third day, a smaller and shorter tube may be used. Xo definite rule can be given as to the best time for dispensing with the tube altogether. When the discharge is very little, and when the channel is com- paratively straight, and not likely to become obstructed, the tube may be removed. This must, however, in the main be a matter of experience. Drainage by capillarity was first tried by Mr. John Chiene, of Edinburgh. He combines with it the principle of using absorbable drains. The material which he employs is catgut; several threads are brought out at a part of the wound, and the fluid flows out in the intervals between the threads. By using catgut he also avoids the necessity of removing the material em- ployed for drainage, because the catgut becomes absorbed in a few days. Mr. Chiene stitches the centre of a skein of catgut to the deepest part of the wound by means of a catgut stitch, so that the drain cannot become displaced. lie then breaks up the skein into bundles of six or eight threads each, and brings these out at various points along the line of incision. In a few days, the Fig. 235. Ordinary drainage tube. 77 APPLICATION OF THE ASEPTIC METHOD TO OPERATIONS. portions of the threads projecting from the wound fall off, and the point of exit cicatrizes. This method of drainage is very satisfactory in some cases, but the chief objection to it is that the catgut is apt to become absorbed too soon, before, indeed, a drain can be dispensed with. How far the new chro* mic acid catgut will obviate this difficulty remains to be seen. In some cases,. horsehair lias been employed instead of drainage tubes, and it answers very well where the discharge is purely serous. It has, however, the same objection as drainage tubes, that it requires to be removed ; and there is a further objec- tion, that it is not as easy to reintroduce it as it is to reinsert a drainage tube. In some instances, however, it affords the best means of drainage; for example, in situations where a tube might be liable to become compressed and obstructed, as in a joint. Dr. Neuber1 has quite recently applied Cliiene’s principle of absorbable drains to drainage tubes. lie decalcifies bones, drills a central hole in them, and cuts lateral holes just as in ordinary drainage tubes. These tubes, like Chiene’s catgut drains, become absorbed in a few days, and answer very well in some cases. The stitching of the wound is a matter of the greatest consequence with a view to rapid healing. In wounds treated antiseptically, provided that the Fig. 236. Button stitch. drainage be properly arranged, the edges of the skin may be brought very accurately together, even where a large piece of skin has been removed, and Fig. 237. Shows the three kinds ot stitches in a wound, and the arrangement of the drainage tube. where, therefore, there is considerable tension. To relieve the edges of the skin from this tension, and at the same time to allow them to be brought into accurate contact, lead buttons are employed in the following manner: A needle carrying a strong piece of wire, to the end of which a button is attached in 1 Archiv fur klinische Chirurgie, Band xxiv. 78 THE ANTISEPTIC METHOD OF TREATING WOUNDS. the way shown in Fig. 236, is introduced at some distance from the edge of the skin, carried through the wound, and brought out at a similar distance from the edge on the other side, where it is secured by a second button. Two or three pairs of these “button stitches’’ are inserted; these bear the strain, leaving the edges of the wound to be easily united by suitable stitches. In some cases, there is still a little difficulty in bringing the parts together, in which contingency thick silver wire stitches are inserted at intervals, taking a deep and broad hold of the tissues, and being termed “ stitches of relaxation and then the margins of the skin in the intervals between these are brought into exact apposition by stitches of carbolized silk, horsehair, or catgut. These latter stitches receive the name of “ stitches of coaptation.” (Fig. 237.) In this way union by first, intention may be got in cases where, at first sight, it seemed impossible, even by the most violent traction, to get the edges of the skin into apposition. The carbolized silk, which is used for stitches, is prepared by dipping ordinary ligature silk into a melted mixture consisting of nine parts of beeswax and one part of carbolic acid. The ligature is wound on pieces of lead, and kept in stoppered bottles. Having now completed the operation, the surgeon proceeds to apply the dressing. A piece of protective, of suitable size, is laid over the wound, and this is overlapped in all directions by a mass of gauze wet in carbolic lotion. This arrangement goes by the name of the “deep dressing.” In wounds close to the pubis, or the mouth, or, indeed, in any situation where there is but little room for the overlapping of the gauze dressing, it is well not to use the protective, because it prevents the carbolic acid in the gauze from reaching the discharge beneath it, and, therefore, if the gauze only extends a little beyond it, the discharge may not receive enough of the antiseptic to prevent it from putrefying. In any case, only as much protective as is necessary to protect the healing margin should be employed, and great care must be taken that it nowhere reaches to a point beyond the edge of the dressing, as the protective is only meant to protect the cut edges, and thus permit healing to occur; it is not used in cases of abscess, where there is only a drainage tube and no cut edge. All hollows are tilled up with loose gauze, and special masses of gauze are applied where most discharge is expected, and then the general gauze dressing is fastened on as before described. The dressing is always changed on the day following the operation, and afterwards the rule is that, if, at the hour of the ordinary visit, discharge is found at the edge of the dressing, it is changed ; if not, it is left till the next day, when the same rule is followed. The dressing is never left longer than a week unchanged. In changing the dressings, the spray is used. After removing the elastic and common bandages—during the time required for which the patient or an assistant places his hand on the dressing, over the wound, to prevent it from being accidentally exposed—the spray is turned on, and the edge of the dressing next the spray is lifted, so that the spray passes in between the dressing and the skin. There is no necessity for wash- ing the wound. A fresh piece of protective and wet gauze are at once applied, and then the skin all around is thoroughly washed with the lotion. Loose gauze and a fresh dressing are then arranged. The rules with regard to the drainage-tubes have been already indicated. The stitches are removed when the line of incision has healed, or sooner, if any of them are causing irritation. In removing the stitches, those of coaptation are first taken away ; then, a day or two later, the stitches of relaxation ; and lastly, when the parts are soundly united, the button-stitches. This, like the manipulation of the drainage-tubes, must be learned by experience. Where dressings are to be left on for several days, it is well to rub a little salicylic acid around the wound. This is most ASEPTIC METHOD APPLIED TO WOUNDS NOT MADE BY THE SURGEON. 79 conveniently done by using the acid mixed with carbolic glycerine, of the con- sistence of cream. This has the effect of preventing the troublesome eczema which sometimes occurs under dressings left on for some time. If the surgeon does not have a spray at hand for the purpose of changing the dressings, its use may be rendered unnecessary by the employment of catgut drains and catgut stitches, and by fixing down the deep dressing so that the wound is not exposed when the outer dressing is removed. This deep dressing is treated like a wound, is washed with the lotion and covered with a piece of wet gauze overlapping it in all directions, and a fresh dressing is applied. If it be necessary to expose the wound, it is well, by means of a syringe, to let a current of carbolic lotion flow over it when it is exposed. In some cases, especially in country practice, it is desirable to leave the dressing unchanged for some days. This may be done in various ways, but perhaps the best is by the application of large masses of carbolic, salicylic, or iodoform jute, as recommended recently by Dr. FTeuber. Wounds near the rectum may be treated aseptically, but here the carbolic gauze is not applicable. For this purpose carbolic acid and oil, or carbolic acid and glycerine, 1-10, is employed. This is especially useful in cases of abscess near the anus. The abscess is opened under the spray, and, instead of a drainage-tube, a narrow strip of lint dipped in 1-5 carbolic oil is intro- duced. Then, outside this, is applied a mass of lint dipped in the glycerine and carbolic acid, which is fastened by a T-bandage. For some days the patient’s bowels are kept at rest by opium, and afterwards, when he defecates, he holds the pad over the wound with his hand, defecates past it, washes the part with some 1-20 carbolic lotion, and pours fresh glycerine on the lint, or applies a new piece. The Aseptic Method applied to Wounds not made by the Surgeon. These wounds are essentially of two classes: those which come under treat- ment at once, or within a few hours; and those which are not seen for some •days after their infliction, till, in fact, fermentation has become firmly estab- lished. I. Wounds which come under Observation early.—Here the problem is different from that which we have been considering. .As yet we have merely had to exclude micro-organisms from wounds, but in these instances they have, in many cases, already entered, and we must extirpate them, and keep them out afterwards. To extirpate them, the wound is washed out with 1-20 carbolic lotion, or, in cases in which some hours have elapsed since the inflic- tion of the injury, with 1-5 solution of carbolic acid in rectified spirit. Let us take, for example, a case of compound fracture. Here we have a compli- cated wound ; air and dust may have been sucked into all its recesses, and have mixed with the blood-clot. The end of a gum-elastic catheter, connected with a syringe, is introduced into the wound, and the purifying solution is driven in through this. By means of the catheter, the carbolic lotion can be introduced into all the recesses of the wound. Care must be taken to leave the external wound freely open, so that the injected fluid may escape readily, for otherwise there would be a danger of the fluid penetrating among the layers of the cellular tissue, and causing inflammation, or even gangrene. It is well to squeeze out all the blood-clots. The drainage of the wound is next attended to, and, if necessary, the external opening is enlarged. The frag- ments are then brought into position, and the protective, wet gauze, and 80 THE ANTISEPTIC METHOD OF TREATING WOUNDS. gauze-dressing applied as usual. After a few days, the limb may be put up in plaster of Paris or other suitable material, a window being left for the daily application of fresh dressings. There are many other ways in which the limb may be fixed, space being provided for aseptic dressings ; but these must be left to the ingenuity of the surgeon. Some wounds may be stitched up, care being taken to provide for drain- age, but, unless in the case of clean, incised wounds, it is better to leave the whole wound open, for otherwise there is apt to be inflammation, or even sloughing of the edges of the wound, and thus the state of matters is by no- means improved. Lacerated wounds behave beautifully under this treatment. The wound is thoroughly purified b}7 scrubbing it well with carbolic acid, and then the salicylic cream, mentioned before, is applied in considerable quantity. Then a deep dressing is fixed on, and left undisturbed for some days. When the superficial dressing is changed, this deep dressing is treated like a wound, as described before. After a week or ten days, the deep dressing may be removed, and a fresh one applied. In this way a badly lacerated wound may heal without any suppuration or sloughing of the torn parts. Blood-clot fills up the wound, and remains there. In the deeper part of this clot, and in the deeper parts of the dead tissues, organization occurs by infiltration of young cells, and cicatrization takes place under the superficial layer of the clot, so- that frequently, after a time, a superficial layer of blood-clot may be peeled oft' from above, and a cicatrix be found beneath. Gunshot wounds may also be treated aseptically, and often with great suc- cess.1 Reyher’s experience in the recent Russo-Turkish war led him to the conclusion that the aseptic treatment of these wounds might be carried out in two ways, according to the state of the wound and the nature of the injury. If the wound was gaping, or if there was any reason to suspect that the bul- let, in its course, had carried along with it portions of clothing or other extra- neous material into the interior, it was necessary to wash out the wound with carbolic lotion after the manner described under compound fractures. When possible, the bullet was extracted. The skin around the wound was also purified with the 1-20 lotion, and a large antiseptic dressing of carbolic- gauze or salicylic wool applied. This treatment was also necessary in all wounds caused by a ball or shell, which were of course lacerated wounds. In cases where there was no reason to suppose that the bullet had carried in any foreign matter along with it, and where the edges of the wound were lying in contact, this treatment was unnecessary, and it was sufficient to disinfect merely the orifice of the wound and the surrounding skin, and to apply a suit- able antiseptic dressing. In carrying out this treatment, the spray is not necessary, but, if it is at hand, it is a great convenience, and renders the result more certain. Burns may also be treated in some cases aseptically. AVliere the burnt surface is not extensive, an attempt should be made to purify it by washing it with 1-20 carbolic lotion. Then, if it be small, full strength boracic ointment of the following composition may be employed. (Make a basis of 2 parts of paraffine and 1 part of vaseline. Take of this 5 parts, and of boracic acid crystals 1 part. Mix.) Outside the ointment, which is spread on a piece of linen, several layers of boracic lint are applied. Where the burn is more 1 See Reyher on “Die antiseptisclie Wundbehandlung in der Kriegschirnrgie.” Volkmann’s Raininliing kliniscker Yortrage, Nos. 142 und 143, 1878. ASEPTIC METHOD APPLIED TO WOUNDS NOT MADE BY THE SURGEON. 81 extensive, and in cases in which, as a consequence, the use of carbolic acid would be dangerous, wet boracic lint dressing, that is, boracic lint used as water-dressing, is employed. Carbolic oil may be used in some cases, but, if the burnt surface is large, there is apt to be a fatal absorption of carbolic acid. Afterwards, the same dressing is used as in the case of ulcers, which will be presently alluded to. II. Wounds in which Fermentation already exists.—Wounds and sinuses which have not been treated aseptically, and in which fermentation therefore exists, often come under observation. Here an attempt may be made to destroy the causes of fermentation which already exist in these wounds, and these attempts are sometimes successful. In these cases, the micro-organisms not only exist in the discharges which flow from the wounds, but they are also present in the granulation-tissue lining them. It is therefore necessary not merely to disinfect these discharges, but also to destroy or disinfect the lining membrane of the wounds. For this purpose, the layer of granulations is scraped away by means of an instrument termed a “ sharp spoon,” introduced by Yon Bruns for scraping away carious bone, and first used by Volkmann for the purpose under consideration. (Figs. 238, 239.) The whole procedure is Fig. 238. Fig. 239. Volkmann’s sharp spoons. as follows: A spray being employed, the skin surrounding the sinus is thor- oughly washed with 1-20 carbolic lotion, and then the layer of granulations lining the wound is scraped out with a sharp spoon. After this is done, the wound is thoroughly swabbed out with a watery solution of chloride of zinc (40 grs. to the ounce of water). It is well, where possible, to arrest the cir- culation by means of a tourniquet, so as to allow the chloride of zinc to act thoroughly. Then gauze, wet in carbolic lotion, and a carbolic gauze-dressing are applied as usual. Where superficial ulcers have to be dealt with, it is not necessary to scrape the surface of the sore, and the spray is not employed. The surface of the sore is washed with the solution of chloride of zine, or iodoform powder is freely sprinkled on it, and the surrounding skin is washed with 1-20 carbolic lotion. A piece of protective a little larger than the sore is then applied over it, and outside this, one or more layers of boracic lint, overlapping the protective well in all directions. The boracic lint is prepared by immersing ordinary lint in a saturated, boiling solution of boracic acid, and then hanging it up to dry. In the after-treatment, boracic lotion is employed instead of carbolic lotion. This is simply a cold, saturated solution of boracic acid in water. The lint and protective are removed, the sore is washed with the lotion, and a fresh dressing is applied. The spray is unnecessary. When the discharge diminishes, these dressings may be left unchanged for two or three days. As a rule, one application of the iodoform or chloride of zinc solution is sufficient, but if putridity still exists, they may be employed a VOL. II.—6 82 THE ANTISEPTIC METHOD OF TREATING WOUNDS. second time. Sores treated in this way heal very rapidly if proper attention be also paid to position and rest; they heal more rapidly than by any other method of treatment. Various modifications of the Listerian method have been proposed, but they have seldom been satisfactory, as they have generally failed to fulfil the requirements of the aseptic principle. In the foregoing description, various modifications have been hinted at which may be followed out where better means are not at hand, and which will be efficient as long as the}7 are used in strict accordance with the Listerian law. Other antiseptics have been sug- gested instead of carbolic acid, but none of them have as yet been generally adopted. Perhaps the best substitute is eucalyptus oil. This has of late been used extensively by Mr. Lister in the form of eucalyptus gauze, and ii acts very well. It is of great value in those rare cases in which patients suffer from carbolic poisoning. Eucalyptus gauze may be used in these instances without interfering with the aseptic principle. I would be passing the space at my disposal were I to enter into the discussion of the various materials and modifications which have been proposed. The foregoing description indicates sufficiently the best mode as yet known of applying the principle, and it will be evident that other antiseptics and antiseptic materials may be employed, and that the use of the spray may be avoided, where necessary, without in any way interfering with Listerism, which is a principle which must in the future always form the basis of any method of wound treat- ment. When properly applied, it reduces all wounds to the level of subcu- taneous injuries. [Corrosive-sublimate Dressing. The antiseptic substance which at present seems to obtain most favor is the bichloride of mercury, which enters into the “ sal-alembroth ” dressings now employed by Professor Lister. The exact composition of the “ sal alem- broth ” in its modern form does not appear to have been published,1 but a short account is appended of the dressings used at the Pennsylvania Hospital, Philadelphia, where the corrosive sublimate is largely employed, and almost to the exclusion of other antiseptic agents. Before an operation the part is shaved, and rubbed with oil of turpentine or ether, then with soap, and finally with a 1-1000 solution of the bichloride. A piece of oilcloth, wet with the solution, is laid beneath, and towels dipped in the same are placed around the part to be operated on. Instruments are boiled and immersed in a three per cent, solution of carbolic acid, and needles, pins, etc., are kept in a similar solution made with glycerine. Sponges are used but once; they are carefully cleansed and bleached, and then stored in a 1-1000 solution of corrosive sublimate. Both ligatures and sutures are made of catgut, prepared with oil of juniper and alcohol, or carbolic and chromic acids, according to the length of time which it is desired that they should hold their position. The spray is not used—and indeed very few surgeons still employ it—but the wound is frequently irrigated during the operation with a sublimate solution of the strength of 1-2000. Drainage is secured by the use of strands of catgut, or of india-rubber tubes, etc., the wound before closure being [* In Milne’s catalogue of antiseptic dressings it is said to consist of corrosive sublimate and sal ammoniac in combination ; according to Dunglison, the “ sal alembroth ” of the alchymists was a product resulting from the sublimation of a mixture of these substances.] 83 CORROSIVE-SUBLIMATE DRESSING. thoroughly washed with the solution, and then closely sutured. A thin strip of Lister’s “ protective ” is next adjusted, and the part is wrapped in a dressing of carbolic gauze, prepared as described on page 72, wrung out of a 1-1000 bichloride solution, and thickly dusted on its inner surface with iodoform. A pad of bichloride absorbent cotton (1-1000) is superimposed, and the whole is secured with a gauze bandage. Unless indicated by pro- longed elevation of temperature, by excessive pain, or by the appearance of discharge, the dressing is not disturbed for a period varying from one to several weeks, when it is either removed, or replaced by a simple dressing of boracic-acid ointment.] POISONED WOUNDS. BY JOHN H. PACKARD, M.D., ■SURGEON TO THE PENNSYLVANIA HOSPITAL AND TO ST. JOSEPH’S HOSPITAL, PHILADELPHIA. Under ordinary circumstances, if a healthy person sustains a wound of the skin, whether incised, lacerated, punctured, or gunshot, the tendency is toward repair of the local damage, without any other constitutional disturbance than may be due to the severity of the injury. By the older writers this was at- tributed to what they called the vis medicatrix natures, or healing power of nature, an expression which was objectionable, as implying an external force, ft is more philosophical to say that healthy action is the law of being of living organisms, and of all their parts; and that they tend to return to this, if disturbed by any cause, as soon as that cause ceases to act. But if, either at the time of infliction of the wound, or at some later date, before the healing has occurred, a poison is applied to the abnormally ex- posed tissues, there is superadded to the violence sustained, an irritation, which may not only change the local condition, but affect more or less pro- foundly the whole organism. The poisons which so act, and with which we are now concerned, are almost without exception of animal origin, and some of them would seem to be actually organized. Of their real nature, however, very little is known as yet, and the mode in which they produce their effects cannot be clearly explained. We can only describe the symptoms to which they give rise, and suggest theories as to the pathological conditions involved. There are three ways in which poison applied to a wound (either at the time •of its infliction or subsequently) may be supposed to affect the system at large: (1) Through the nervous system; (2) By absorption into the lymph current; (3) By absorption into the venous blood current. Very probably these are often combined in the same case; and it may be that in no single instance does even the slightest poisoned wound occur—such, for example, as a mos- quito sting—without an irritation of the nerves of the part, and the taking up of an amount, infinitesimal as it may be, of the poison, not only by the lymphatics but also by the veins. Perhaps it should be stated that the evi- dence as regards venous absorption is less positive than that of absorption by the lymphatics, since the cases in which the former seems to have taken place are in many instances open to another explanation, viz., that the poison was conveyed into the venous system through the lymph-channels. Thus there are many cases in which the extension of inflammation along the lines of the lymphatics is quite clear; there are none in which equally distinct proof is afforded that the veins alone are so affected. But these points will be fur- ther referred to. Certain conditions of system seem to favor the occurrence of poisoning in wounds. Such are depression, from fatigue or exposure ; previous disease; 85 86 POISONED WOUNDS. the effects of extremes of heat or cold, and perhaps of other states of the atmosphere, electrical or hygrometric. These influences are more clearly traceable in the graver cases, but are probably not without effect even in the more trifling. And we shall have to note, on the other hand, some singular instances of tolerance, or rather of insusceptibility, induced by habit. I shall take up in succession: dissection-wounds, and certain allied lesions; insect- stings; snake-bites; and bites of animals.1 Hissection-W ounds. Under this head are included, not only wounds or poisonings contracted in the dissection of dead bodies, hut an allied class of injuries sometimes- sustained by surgeons in operating on the living, as well as under other cir- cumstances, to he presently mentioned. While in the very great majority of cases the poison finds an entrance through some crack, fissure, or puncture in the skin, there seems to he evi- dence that it may sometimes be absorbed through the sound tissues. Thus, Sir James Paget, in his most interesting account of his own case, says, “ I had no wound or crack of any kind."2 Wiart,3 after describing a poisoning in his own person in 1862, from making an autopsy in a case of erysipelas, says,. “ I have always been convinced that I had not been wounded at all, that I had, neither on my fingers nor on my hand, any erosion to serve as a place of entry for the virus.”4 But even when there is no actual wound, if the cuticle is so cracked, as for instance, along the edge of the nail, as to give the poison access to the true skin, it may be taken up by the absorbents and produce mischief. However the harmful material enters, there must be, as it seems from known facts, a certain condition of the system (perhaps various conditions) rendering it susceptible to injury. Those who are constantly dissecting may acquire, as Sir James Paget points out in the paper referred to, a marked degree of im- munity, so that no bad consequences ensue upon the cuts and scratches which they are very apt, to sustain. Yet this cannot be counted on, and those who are depressed by fatigue or other causes, as students often are after a winter’s work, may be specially liable to this form of disorder. The period which elapses between the reception of the poison and the occurrence of trouble from it may vary greatly; sometimes inflammation is set up at once, or in the course of a few hours, while it occasionally seems as if there were a pro- cess of incubation, as in hydrophobia or in the eruptive diseases. Cases are upon record in which no symptoms have ensued for several days; but here there may have been some new influence affecting the system, without which the poison would have remained inactive. In former times, before it was the practice to use antiseptic injections, such 1 It may be said here, that while it might he strictly proper to include tetanus, hydrophobia, and pyaemia in the present subject, there is in each of these diseases so new and formidable a chain of symptoms developed, in comparison with which the original wound ceases to have any importance, that they are generally accorded separate consideration. 2 Clinical Lectures and Essays, p. 322. 3 Gazette M6dicale, July 23, 1881. 4 In the American Journal of the Medical Sciences, for August, 1838, p. 396, there is an account of a typical case of diffuse cellular inflammation, ascribed by the reporter, Dr. J. M. B. Harden, of Georgia, to the violent motion of the arm during a long ride on horseback. The case was a fatal one, and at the autopsy Dr. H. contracted blood-poisoning through ah existing wound in the finger. During his illness he was attended upon by his father-in-law, who dressed the abscesses, introduced tents, etc. This gentleman became ill after sudden and great exertion in putting out a fire, dif- fuse cellular inflammation manifesting itself, and terminating fatally. No wound is mentioned in his case, but only contact with pus. Another slighter case is said to have occurred in the person of another attendant upon Dr. H. during his sickness. DISSECTION-WOUNDS. 87 as chloride of zinc solution, in preparing bodies for the dissecting-room, dis- section-wounds, or serious symptoms following upon them, were much more common than now. The danger is incurred in dealing with the tissues of the recently dead rather than with those in a state of advanced putrefaction, and it is well known that post-mortem examinations of those who have died of certain diseases—especially of puerperal fever, erysipelas, or pyaemia—are attended with peculiar hazard. It would seem as if the earliest changes undergone after the occurrence of death were those which developed the poison. Very possibly the ptomaines, or cadaveric alkaloids, substances allied to the vegetable alkaloids, recently studied by Brouardel and Boutmy, Selmi, and other European observers, may be found to play an important part in the causation of the mischief. With regard to these substances very little is as yet known, but it is stated1 that they are supposed to be analogous to a con- stant ingredient of saliva, which, in a concentrated form, is the active con- stituent of the venom of snakes. M. Brouardel is quoted in the same connection as of opinion that the ptomaines may be formed during life. One point should be especially noted, viz., that the amount of poison absorbed in a case of dissection-wound (using this term in its general sense) makes no difference in the effect. The minutest portion seems to act as a ferment, and to change the condition of the whole mass of circulating blood. In this re- spect, the analogy between the dissection-poison and snake-venom seems to fail, since the effect of the latter is clearly proportionate to the amount and concentration of the dose received into the system, as in the case of mineral or vegetable substances taken by the stomach or rectum. Symptoms of Dissection-Wounds.—In the slightest form, the effects of this species of poison seem to be purely local. Thus if the dissector has a prick or scratch on his hand, it may become the seat of slight inflammation, and in a day or two discharge a small quantity (perhaps only a drop or two) of pus. But the cuticle around generally dies and peels off, just as in the case of a boil, and the redness and swelling disappear somewhat slowly. Sometimes, especially after the fingers have been for some time in contact with purulent liquids, and more particularly in abdominal abscesses, the poi- son may affect a chain of points on the backs of the hands. Thus in 1862, after making a post-mortem examination in a case of peritoneal inflammation, with suppuration, from an intestinal concretion in the vermiform appendix, I had four or five small abscesses on the back of each hand. In these cases, there seems to be no further action of the poison, although the local conditions are analogous to those present when inflammation extends upward along the course of the lymphatics. Occasionally there occurs enlargement of the lym- phatic glands in the axilla, either without any notable lesion of the hand, or, if such should exist, without any traceable affection of the vessels. This, I think, is not apt to be from the ordinary dissection-poison, but may be met with where injected bodies are used for purposes of study; it seems to bo from the irritant effect of the chloride of zinc or other chemical antiseptic employed. The swelling of the glands is chronic in its character, not painful, nor very tender, and has not in my experience run into suppuration, but has gradually subsided, under the local use of tincture of iodine. Agnew describes2 a peculiar form of irritable sloughing ulcer of the hand, attended with marked constitutional disturbance, as a result of dissection-wounds. This I have never seen, although it has sometimes happened to me to note the very slow healing of severe cuts received in making autopsies; one in my own person,, 1 Gaz. Med. de Paris, July 30, 1881. 2 Principles and Practice of Surgery, vol. i. p. 210. 88 POISONED WOUNDS. in 1860, remained open for seven months. Bryant,1 under the name of Ver- ruca necrogenica, proposed by Dr. Wilks, mentions a warty condition occa- sionally seen on the posterior aspect of the lingers, or on the knuckles, in those engaged in dissecting fresh bodies. This lesion, called also “ anatomi- cal tubercle,” seems to consist of an inflammatory hypertrophy of the cuticle, and to some extent of the true derm. It is slow and obstinate in its course, unattended with any constitutional symptoms, and yields to local treatment by iodine and caustics. In a severer grade of dissection-wounds, there is, in addition to the local irritation, a line of redness (sometimes several), extending up the forearm, and marking the course of one or more inflamed lymphatics. There may also be more or less general swelling of the member, with tenderness and stiffness, and some degree of fever. A not infrequent termination of a case of this kind is by swelling of a lymphatic gland, either on the front of the forearm, just above the elbow, or in the axilla. When suppuration of the gland takes place, the poison seems to be discharged, and all the symptoms subside; hut I have seen such a gland remain swollen and tender for some time after its healing had seemed complete. The condition just referred to is very similar to what may be observed in many cases of injury to the foot, even in the apparently robust. It not very unfrequently happens after the fracture of a toe, or even a slighter hurt, in laboring men, that a “ bubo” is formed in the upper part of the thigh ; and the same may occur in healthy and well-nourished children, even in the better classes. Still another class of cases may be mentioned, in which the local trouble consists in the development of a carbuncular swelling somewhere on the hand or forearm, or in a crop of boils in the same region ; in the latter case there is apt to be one large one surrounded by a number of small ones. The con- stitutional symptoms, with fever and depression, may be quite marked during the height of the local irritation. Sometimes the local disturbance is more violent, and a cellulitis of the finger ensues, with suppuration, tending to follow up the sheaths of the tendons; this may occur without involvement of more central parts, but the constitu- tional symptoms are apt to be marked. In the majority of instances, the whole limb is more or less concerned, and the cases would then come under the class next to be described. With any of these forms of dissection-wound, except the anatomical tubercle, there is very apt to be a more or less extensive area of erythematous redness in the neighborhood of the lesion. n the severest grade of these cases, the constitutional symptoms are very decided, and the local inflammation runs very high, extending rapidly toward the more central parts of the body. At a variable period after the poison has been received, there is pain, itching, and burning at the spot, and a gen- eral sense of malaise and depression. This is soon succeeded by headache, nausea, chilliness, and aching in the back and limbs. The pain runs up the arm, and the whole member becomes swollen and tender, especially along the anterior and inner aspects. Intense fever comes on, especially at night, and the patient is either sleepless, or disturbed by frightful or harassing dreams. On the occurrence of suppuration, which may involve a large extent of the areolar tissue of the arm or side,2 there are general rigors, and a further increase of fever. Low muttering delirium is early developed, with great 1 Manual for the Practice of Surgery, 3d Am. ed., p. 66. 2 At a recent meeting of the Clinical Society of London (Lancet, Feb. 19, 1881), Messrs. Heath and Cripps reported cases of gangrene of the arm from poisoned wounds. In Mr. Heath’s case amputation was successfully performed ; hut in the other it was postponed until too late, and the patient died. Sloughing of the cellular tissue, as already said, is very generally resent in these cases ; but gangrene of the limb is very rare. DISSECTION-WOUNDS. 89 prostration of strength, ancl profuse and fetid sweating. The tongue, at first •coated with a dirty fur, becomes dry and brown, and the teeth are covered with sordes. During the accessions of fever, the temperature runs very high, mid the pulse is extremely rapid. Sometimes the patient seems to succumb to the general systemic poisoning before there is time for definite lesions of internal organs to occur; but if the progress is less hurried, there may be a -supervention of pleurisy or pneumonia of a low type, readily running into suppuration. Death may result either from prostration by the poison; or from deterioration in the quality of the blood, affecting the brain-functions ; or from intercurrent inflammation of the lungs or pleurae, or perhaps of the heart; or from secondary exhaustion. When recovery takes place, it is very .slow, and resembles that from typhoid or other low fevers, being apt to be retarded by abscesses and other local disorders. Moreover, there is often •stiffening and contraction of the finger which was the seat of the primary inflammation. For a time there may be also, when sloughing has been exten- sive, some impairment of motion in the parts concerned; but this is gradu- ally done away with by time and the stretching incident to exercise. From this brief sketch, it may be seen that the graver cases of this sort can scarcely be excelled in severity by those of any other known disease. And the analogy which they present to eases of phlegmonous erysipelas, as well as of pyaemia and septicaemia, is obvious. At the present day, the recognition of the fact that the condition is one requiring, not depletion, but the most active and energetic supporting measures, has led to a more judicious treatment, and it is only in extremely rare cases that the symptoms are not arrested before they assume the threatening character above described. But still, whether from previously-existing disease, as, for example, of the kidneys, or from fatigue or exposure, at the time or subsequently, the onset of the disorder is occasionally very violent, and the most prompt, energetic, and skilful inter- ference may be of little avail. For obvious reasons, the post-mortem investigation of disease of this kind is both, difficult and dangerous; and we have but little knowledge of its pathology. The tissues of the limb affected are apt to be disorganized by diffuse suppuration, veins and lymphatics being alike involved, while the internal organs present inflammations of varying extent and intensity; but the sequence of the morbid conditions, even in the light of the most careful •observation during life, cannot be unravelled. That the lymphatic system plays an important part seems unquestionable. Allusion has already been made to the occurrence of poisoning of this kind from other causes than dissections. Thus surgeons sometimes sustain injury by scratching or pricking their fingers in the performance of operations, and symptoms analogous to those already described may ensue. Perhaps the most frequent source of injury of this kind is contact with rough points or edges of dead bone, as well as with pus, especially of an unhealthy or foul charac- ter. Carelessness in cleaning and handling instruments may also give rise to poisoned wounds. But in all these cases, the matters which act as poisons are practically dead. I saw, in 1865, a child aged 22 months, who had been vaccinated by a woman living in the neighborhood, and who had diffuse suppuration, with sloughing of the areolar •tissue, from beneath the scapula to the crista ilii. Death ensued in a day or two, and an autopsy was made; but the disorganization was so great that the exact sequence of lesions could not be determined. I believe, however, that this case was one of blood- poisoning by the use of a dirty lancet. Another case of blood-poisoning by vaccination came under my notice in 1869, in which the disease assumed the form of erythema fugax. The vaccination had been per* 90 POISONED WOUNDS. formed by a most careful physician, of high standing, and the child’s parents were people- of the best class; so that it was difficult to account for the origin of the poison, which proved fatal. It will be sufficient merely to mention here the liability of surgeons to syphilitic infection, from absorption of the discharge from sores of that cha- racter, in the course of their professional duties. Fortunately this is rare. It has been stated on a previous page that poisoning is more apt to occur from bodies recently dead (that is, in which the post-mortem changes are in their early stage), than in those which are already putrid. Yet animal sub- stances in the latter state may be productive of injury in the same way. Thus Heath1 speaks of the digital cellulitis known as whitlow, as sometimes caused in cooks and others by the handling of game which is “ high.” And a notice recently appeared2 of the poisoning of the Medical Officer for Health for Rother- hithe, near London, by a wound of the hand received in making a micro- scopic examination of some pork. It is said that “ the meat was so putrid that he was compelled to use disinfectants, which obscured the minute struc- tures ; but he satisfied himself that the animals had been the subjects of, if they had not died of, pig-typhus; and he believes also that they were trichi- nised.” The report goes on to say that he had “ narrowly escaped permanent maiming.” Treatment of Dissection-Wounds.—The treatment of all these cases must be: to subdue the local inflammations, and to support the strength. Wherever there is heat and swelling, with pain, either at the part injured or at points nearer the body, hot fomentations, hot poultices, hot lead-water and laudanum, and like dressings, will be found to give comfort. It should be mentioned that any wound received, or any puncture or cut becoming irri- tated, during a dissection or operation, ought to be at once washed clean, thoroughly sucked, and protected. I have myself great faith in thorough cauterization with nitrate of silver, or with a white-hot needle, if done at once. The best protective application afterwards is a strip of clean rag or lint thickly spread with any simple unguent, as cosmoline, carbolized cerate, or mutton- tallow. A clean cut may be closed with a strip of plaster, which should how - ever be at once removed if pain or swelling come on. As soon as suppuration occurs, the part should be freely laid open, and poultices applied. Should the inflammation extend up the arm, it has been recommended to place a cordon sanitaire around the member, by painting it with tincture of iodine or with a very strong solution of nitrate of silver. Either of these may be used, a band about an inch wide, encircling the limb,, being applied above the higher limit of the area of inflammation. This sometimes seems to be of benefit in arresting the disorder, just as in erysipe- las ; but it cannot be relied on. Dlistering lias been used in the same way, and is recommended by AgnewA Tonics, such as iron, quinine, the mineral acids, and concentrated food,, should be given from the vevy first; in as large doses as the stomach will bear. Carbonate of ammonium is a valuable adjunct in combating prostra- tion. Stimulants are often imperatively called for, given either separately or along with the food. Dry champagne is well borne, and lias the advantage of allaying the gastric irritability which is often a marked feature of these cases. When the fever runs very high, the ordinary febrifuges may be em- ployed, and sponging with hot w hiskey or bay rum and water. Anodynes 1 Medical Times and Gazette, June 18, 1881. 3 Op. cit., vol. i. p. 212. 2 Ibid., Aug. 31, 1881. OTHER FORMS OF INJURY ANALOGOUS TO DISSECTION-WOUNDS. 91 are sometimes demanded by the severity of the pain, and must be given. Opiates need not be withheld unless there is a strong tendency to cerebral congestion; they may be combined with the quinine, and the iron given separately. The bromides and chloral-hydrate, in mild cases, answer a good purpose ; but the stomach may not always bear them well. By way of prophylaxis, some dissectors are in the habit of smearing the hands, previous to beginning an autopsy, with cerate, either plain or carbol- ized ; others use caoutchouc gloves or finger-stalls. But in neither case is the protection at all perfect. The cerates are soon removed by contact with the tissues, and the thin sheet of rubber is readily penetrated by a knife-point, a tenaculum, or a spiculum of bone. Other Forms of Injury analogous to Dissection-Wounds. There are certain other cases which may he most appropriately mentioned here, as they are closely analogous to those just spoken of. Fish-Wounds.—Some fishes have sharp fins or spines, which inflict severe and “ poisonous” wounds. An instance in point is reported by Murray:—1 A young man on the Irish coast was wounded by a fish called a “ stang,” a sort of herring, with hard scales and a sharp dorsal fin, well known to fishermen on account of the danger of its sting. The wound was in the ball of the thumb ; the man sucked it, but he had pain up the arm as far as the axilla, and next day the whole limb was swol- len, a bubo had formed in the armpit, and there was marked fever and headache. Pulse 98, temp. 100.5°. An incision was made, laying the wound open ; poultices, and sub- sequently dry cotton, were used, and the arm was dusted over with dry bicarbonate of sodium. A purge was also given. The man made a rapid recovery. In the Mediterranean, and in some Eastern seas, there are other fish which have dorsal spines capable of poisoning the wounds inflicted by them. Some again have the poison-spines connected with the gill-covers. One species is mentioned by Hielly,2 as found at Panama, having four spines, two dorsal,, and one attached to each gill-cover; each of these spines is said to be traversed by a canal leading to a sac full of liquid venom. The Acanthurus, met with in the waters about the Antilles, has its spines, which are mobile, on either side of the tail. The skate, or ray, is often called “sting-ray” or “stingaree,” from its long, sharp, caudal spine, wounds from which are troublesome but not dangerous. Bathers along the Atlantic coast are often stung by the jelly- fish, or Acalephce, found in the water especially after storms; the injury seems to be due to an irritating secretion ejected through the tentacles, and induces symptoms resembling those of urticaria, with occasionally a decidedly ery- thematous tendency. Oyster-Shells sometimes seem to have a poisonous effect, producing great irritation if the hands are scratched with them; in this respect they re- semble the sequestra of dead hone, before mentioned. Animal Typhus.—I am tempted to refer here to a ease reported by Pichon, and quoted by Dr. Jamieson, of Shanghai, China.3 It was that of M. Char- rier, a veterinary surgeon, who was examining a cow suffering from typhus, when the animal coughed up a quantity of foul discharge, part of which 1 Lancet, Jan. 3, 1880. 2 Elements de Pathelogie Exotique. Paris, 1881. 3 Medical Times and Gazette, July 23, 1881. 92 POISONED WOUNDS. entered his mouth. lie became very ill, with such local symptoms—diph- theritic stomatitis, with a strong gangrenous tendency—as seemed very like those of a poisoned wound. From the chronic septic poisoning which ensued, *deatli resulted in about six months. Poisonous Effluvia.—One other form of poisoning by animal secretions ought not to be passed over—that by inhalation of effluvia. The reader will find this fully discussed in a most interesting paper by Dr. William Hunt.1 Except in the mode of its origin, and in the absence of primary local symp- toms, it does not differ materially from the disorder already described. Mr. II. E. Cauty2 reports a case of poisoning of a sewing-woman from handling “ Imitation Moleskin.” He says that, although there does not •seem to be anything peculiar in the material, the women employed have to be very careful, as nasty sores are sure to be produced if they have any fis- sures or abrasions on the hands. This woman had on her hands nodules (seven on the right, five on the left) about the size of marbles, bright red, and very painful. These nodules suppurated in about a week ; on the left hand there was some burrowing of pus, and on the 12th day some sloughing took place. Thirteen days after she was seen, two more nodules formed on the right hand; red lines extended up the forearm, there was glandular irrita- tion at the elbow, and tenderness in the axilla. The skin exfoliated over the •affected parts. Complete recovery ensued under the use of wine, cod-liver oil, and full diet. "Wool-Sorter’s Disease.—Within the last year or two, attention has been called anew to a disorder known as “ wool-sorter’s disease,” or “ antlirax-fever.” It seems to he analogous to the forms of toxaemia described in the fore- going pages, and perhaps to be a sort of connecting link between them and “ malignant pustule.” The following description of it is condensed from various articles in recent English journals, it having prevailed so extensively in and about the manufacturing town of Bradford, as to call for investigation and report. The wool and hair of sheep and goats, imported for various purposes, was found to produce unequivocal attacks of anthrax, or “ murrain,” in sheep and •cattle. Upon the persons employed in sorting and cleaning it, it produced •effects classified as follows: (1) A purely local irritation at the seat of inocu- lation ; (2) constitutional symptoms; (3) local manifestations followed by secondary localization of a constitutional infection; (4) a papule or pustule, not hitherto ascribed to specific infection, but not uncommon among wool- sorters, and those who make post-mortems in cases of anthrax. The stage of incubation is said to last from a few days to long periods. In the pro- dromal stage, there are chilliness, weariness and depression, sweats, flushing, and sleeplessness; a sense of constriction of the chest, sighing, yawning, ach- ing in the limbs, cramps, headache, pain in the neck, dizziness, nausea, and vomiting. In the stage of full development, there are prostration, restless- ness, quickened respiration and pulse, high temperature, with irregular remis- sions,, pulmonary congestion, haemoptysis, gastro-intestinal distress, diarrhoea, and jaundice in some cases. Twice tetanus was developed; once cerebral hemorrhage occurred. Recovery sometimes took place, without immunity from a second attack. The pathological anatomy of the disease is thus described.3 Early decom- * A Contribution to tbe History of Toxaemia. Pennsylvania Hospital Reports, 1868, p. 310. '•* Lancet, July 23, 1881. 3 J. Spear, Report to Local Government Board, etc. INSECT-STINGS. 93 position; petechire. Heart flabby, hemorrhages in its walls; endocardium blood-stained ; often pericardial effusion ; blood fluid. Lungs hypenemic ; small scattered hemorrhages in them ; oedema, true pneumonia, or metastatic abscesses, or sometimes hemorrhagic infarcts. (The smaller hemorrhages, were due to emboli formed of bacilli, the larger to acute nutrient disturbances of walls of bloodvessels or tissues.) Bronchial glands swollen, soft, or purple and blackish ; bronchial mucous membrane reddened, with hemorrhagic extra- vasations; pharynx and trachea hypenemic. Abdominal organs congested, with various hemorrhages. Spleen large and soft; kidneys congested, and the seat of cloudy swelling. Often acute intestinal catarrh, and swollen mesenteric glands. Sometimes albuminuric hemorrhages in the brain. Serous or serous- arid bloody, jelly-like infiltrations in the connective tissues, especially in the neck and mediastinum, in the sub-pleural and peri-renal tissue. Bacilli were usually detected in the blood and extra-vascular fluids. A curious fact was- noticed—that this disease was apt to be developed by the eating of vegetable food, and thus to occur after the Sunday indulgence in this diet, usual with the wool-sorters. Insect-Stings. Very few insects can properly be said to bite, as they have not the appa- ratus for so doing; they insert a terebra or aeuleus, and then suck, by means- of a haustellum or sucker. In this act, they inject at the same time an irri- tating secretion of a peculiar kind for each species, but always acid. Most of them, in inflicting the injuries they do upon man, are simply obtaining nourishment, not attacking him; but there are some, as the bees and wasp3, which are provided with poison-glands and stings as weapons of offence and defence. Of some varieties, as for example the mosquito, it is the female only that stings; the males do not leave their breeding places. There are such differences between the effects of the stings of various in- sects, as would seem to indicate the possession of a specific character by each. Thus the bedbug causes a white wheal, surrounded by an area of redness, with intense burning itching, which, however, very soon disappears, and finally. When the bug is a very small young one, the wheals produced by it are correspondingly small, although they may itch intensely. Usually there are a number of punctures near together, marking the course of the insect as it crawls over the skin, each one being the centre of a separate wheal. For a few hours, the irritation may be re-developed by scratching. When in the eyelids, the swelling that ensues may be so great as to temporarily close them. The mosquito induces a red swelling, somewhat conical, persistent, the irri- tation of which recurs occasionally, with or without apparent cause, for days. There is a different variety of mosquito, which comes with the first warm days of spring, and gives rise to a wheal like that from the bedbug, after- wards assuming the characters of the ordinary mosquito-bite. Two cases of severe mosquito-bite are thought worthy of special record by Mr. G. Thin.1 A medical man is said to have been “ so cruelly bitten on the face and head, that he was much disfigured.” In the case of a young lady, residing in the same hotel, “ the bites were chiefly on the nose and upper parts of the cheek, and were seen as large, raised, flattened vesicles—not unlike a vaccine pustule, with a central de- pressed dark point, which corresponded to the point bitten. These vesicles had been confluent over the nose, and produced an appearance of impetiginous eczema, with well 1 Lancet, Aug. 27, 1881. 94 POISONED WOUNDS. defined borders. The discharge had, on some parts of the cheeks and chin, which had not been bitten, produced, secondarily, bullae of what is often called impetigo contagiosa.” The sting of tho flea produces a larger, very red and angry, flattened, long ovoidal swelling, or welt, with a peculiar velvety feel; it is very persistent. The louse simply inserts its sucker into a follicle of the skin in search of nourishment, and the rupture of one or more small vessels is apt to occur. The ensuing inflammation is due more to the scratching than to the intensity of the poison. Certain midges are sometimes met with in swarms at the seashore, and are very annoying by the sharp but very transient irritation caused by their suckers. Among flies, the large “green-head,” found on the Jersey coast in the late summer, and the “ black fly” of June, in the northern woods, may, perhaps, be considered as the most troublesome species. The former produces a very severe irritation if allowed to penetrate the skin, as it often does in children. Some of the Ixodes or ticks are very poisonous to man. There is a very small variety met with in dry, sandy woods in New Jersey, and perhaps else- where, which buries itself in the skin. I have known of two or three in- stances of children being nearly covered with them, especially in the legs and about the scrotum ; the itching induced was intolerable, especially at night, totally preventing sleep. But in tropical climates, and occasionally in this latitude, the larger species are sometimes encountered. I saw a gentleman in 1881, who had had the horny head of a large Ixodes buried in the skin of his chest for several years, occasionally to his great annoyance. Mr. R. R. Allen writes, from Natal, S. Africa, to the Lancet, Aug. 27, 1881, an ac- count of the Ixodes reticulatus, or ox-tick, which buries its sucker in the skin, and when filled with blood, is half an inch long. He says : “On June 28th, I was bitten by one of these little animals in the right axilla. When caught, it was deeply buried in the flesh and ‘ full-blown.’ I had to use force to extract it. The next, and four following days, I was very unwell, with severe frontal headache, which continued for three days, nervous depression, loss of appetite, thirst, pain, swelling, and stiffness of the muscles of my right arm and axilla. The axillary glands became hard, enlarged, and most painful, .but did not suppurate. The punctures made by the tick became a pustule with a dark inflamed areola, which burst and dried up. The feverishness was considerable, and I suffered greatly from nausea, insomnia, and towards the end diarrhoea. I am now con- valescent (July 4). Perhaps I got the tick from my horse, which was suffering from mange at the time.” The scorpion is very seldom met with, except in tropical countries, and there its sting, although very irritating, is seldom fatal. Swelling of the tongue is said by some writers to be a constant symptom in these cases, and sometimes a singular loss of power in the cervical muscles lias been observed, as if the poison, when absorbed, acted in a special degree upon certain por- tions of the nerve-centres. Spiders have a bad reputation, but the cases are certainly very rare in which dangerous injury is inflicted by any of the species known to us. Yet Stahl1 reported a case in which the sting of a “ black spider” on the elbow produced a condition of alarming collapse; and Hulse,2 one in which like symptoms followed a hurt of the same kind on the penis. (In both these cases the old- fashioned antiphlogistic system, including copious venesection, calomel, and tartar emetic, with active purgation, was adopted. Ilulse states that his patient took, within four hours, four ounces of laudanum and an equal quan- tity of aqua ammonise.) 1 American Journal of the Medical Sciences, Aug. 1838. * Ibid., May, 1839. 95 INSECT-STINGS. Centipedes (Scolopendridce) can bite or nip with their mandibles, and some inflammation is apt to follow; a fatal case of this kind, in a child, has been re- ported by Dr. Linceicum, of Texas.1 In this case the little irritated holes made in the skin by the feet of the insect were also noted, and any one who has happened to touch one of our common centipedes will be likely to have felt a peculiar slight thrill in the Angers, lasting for some time. But the amount of poison contained in these small animals is of course vastly less than in one such as Dr. L. describes—eight inches long and nearly an inch broad. Xielly2 quotes from Moquin-Tandon an account of an officer at Cayenne, in 1828, who by accident swallowed a centipede in some water. Enormous swelling of the neck, profound nervous symptoms, and death, speedily ensued. Attention may here be again called to the fact that in these poisonings by insects (and the same is true in the case of snake-bite, to be presently dis- cussed) the quantity of venom taken into the system determines the severity ■of the symptoms induced. In this respect the disorder, for it seems to be one and the same, no matter what the source is, differs from that induced by dissection-wounds, in which the smallest dose of the morbific agent may de- velop the gravest possible constitutional condition. It is but rarely that any serious general disturbance follows upon insect-stings, although, when in large numbers, they may produce feverishness and languor. Travellers who are subjected to the attacks of bugs and fleas sometimes experience this, but the loss of sleep may have something to do with it. And cases are upon record in which death has resulted from bee-stings and other injuries of this kind. In some of these instances men, and even horses or other animals, have been attacked by swarms of bees, wasps, or hornets, and have sustained so much injury as to destroy life almost at once. Xo very careful investigation •of these cases has ever been made, and the circumstances have generally been such that even a skilled scientific observer would have found it difficult to note the phenomena accurately; but it would seem that so large a dose of insect-poison acted very much like snake-venom, and that the main cause of death was the shock to the nervous system. Of fatal results following single stings, Dr. James Mease3 has recorded a number of instances, and refers to •others. Dr. J. A. Lidell,4 in an article on Injuries of the Scalp, refers to poisoned wounds of this region as especially dangerous, and gives accounts of and references to several cases of the kind now under consideration. Dr. A. L. Gihon, U. S. X., reports5 a case of fatal poisoning occurring on board ship, at Xagasaki, Japan, by the sting of an unknown insect; the part attacked was a middle finger, and the symptoms resembled those of sedative narcotic poison. Four days elapsed in this instance between the onset of the disorder and its fatal termination; an unusually long period. Treatment.—The treatment of all these cases is, in its general principles, the same; local irritation is to be soothed, and if constitutional symptoms ■occur, they are to be combated by appropriate remedies. Alkalies, as dilute aqua ammonite or solution of carbonate or bicarbonate of sodium, seem to neutralize the poison. Every boy knows the comfort given by a clay poul- tice to a bee- or wasp-sting. Ordinary poultices, or lead-water and laudanum, may be applied if there is much inflammation. 1 American Journal of the Medical Sciences, Oct. 1866. * Op. cit. 8 American Journal of the Medical Sciences, Nov. 1836, p. 265. 1 Ibid., April, 1879, p. 336. 5 Ibid., April, 1869. 96 POISONED WOUNDS. Snake-Bites. As is well known, there are many genera of snakes which are destitute of poison-apparatus, and wholly harmless to man. Life may indeed be destroyed by the boas or pythons, the constricting snakes, which enfold and crush ani- mals, and occasionally human beings, before swallowing them as food. But it is with venomous snakes, strictly speaking, that we are now concerned. All kinds of reptiles are much more numerous in hot than in cold climates,, and in hot weather they are more active, and the danger from those which are venomous is greater. The principal poison-snake of North America is the rattlesnake, or Crotalus horridus ; there is also the moccasin, the copperhead, or Trigonocephalus, the cotton-mouth (perhaps only a variety of the last-named), and a species of Maps, of which the popular name is, I believe, the “ harlequin.” In India, the Cobra, the Naia or Naja, the Daboia, and the Trimerisurus, are, according to Fayrer,1 those which are most frequently met with, and most hurtful to man. Among African snakes, the Cerastes cornutus, or horned snake, and the Naja haje, or asp, seem to be the best known. The Jararaca, a Crotaline species, is the chief pest of this kind found in Brazil and Central America. The only snake known in Europe is the viper. All these are land snakes, although they swim freely on occasion. Fayrer2 describes and figures a large number of Hydro- phidae or sea snakes, which are very poisonous; they are found in the Indian and Pacific Oceans, and in the seas between Southern China and Australia. All fresh-water snakes are harmless, except perhaps the cotton-mouth. It w'ould be a waste of time to quote descriptions of these serpents, further than to say that the hooded snakes are peculiar to India, and the rattlesnake to America, one only among Indian snakes, the Ilalys Himalayana, belong- ing to the Crotaline or rattlesnake group ; in it the rattle is represented by a caudal spine. The poison apparatus of snakes may, however, be briefly referred to. Poison-Apparatus.—All venomous snakes have at either side of the ante- rior part of the upper jaw, two long recurved fangs, movable3 by means of a joint between the maxillary bone and the ecto-pterygoid. The poison is secreted in sacs lying behind and below the eyes; from each sac it is con- veyed by a duct to a tube or canal in the corresponding fang, terminating at or near the tip of the latter. Thus the same action strikes the fang into the victim and injects the poison into the wound as it is made. Behind each fang lie others partly developed, ready to grow into its place should it be broken or extracted. This apparatus, as well as the poison itself and its mode of action, lias been, in the case of the rattlesnake, carefully studied and admirably described by Dr. S. W. Mitchell.4 It appears to present itself with but slight modifica- tions in all the venomous snakes. The fang is said by Holbrook to be, in the Maps of our southern States, permanently erect, and not jointed as above described. 1 The Thanatopliidia of India. London, 1872. 2 Op cit. 3 Fayrer (op. cit.) says that in the Hydropliidse the fangs are small, and differ very little from the other maxillary teeth. They have also only a groove, and not a tube, for the transmission of their poison. 4 Researches upon the Venom of the Rattlesnake : with an Investigation of the Anatomy and Physiology of the Organs concerned. Smithsonian Contributions to Knowledge. 1860. See also a paper by the same author, “On the Treatment of Rattlesnake Bites,” etc. North American Medico-Chirurgical Review, March, 1861. SNAKE-BITES. 97 The venom is a glutinous, albuminoid liquid, varying in color, but gene- rally yellowish or greenish, acid in reaction, without taste or smell. Neither heat nor cold, acids nor alkalies, long keeping, nor even decomposi- tion, would seem to affect its activity as a poison. \\rhen taken into the stomach, it is wholly harmless, as indeed it is everywhere except in the circu- lating blood. It has been said to be hurtful to vegetable life ; but this is dis- proved by experiments. This description of the rattlesnake poison, given by Mitchell, corresponds remarkably with Fayrer’s account of the venom of the Cobra. No thorough chemical analysis of this substance has ever been made, although Dumas1 is said to have found the composition of the Cobra venom to be analogous to that of yeast. At a recent meeting of the Academie de Medecine, in Paris, M. A. Gautier detailed some experiments upon poisons, and said that one curious result he had arrived at was “ that poisons owed their deleterious action to the presence of a neutral and not albuminoid sub- stance, and to that of another alkaloid substance, comparable to the cadaveric alkaloids—the ptomaines—concerning which there has been of late so much discussion, and which exist in variable proportions in the saliva of all animals; in birds, for example, this alkaloid is found in a state of dilution seven or eight thousand times more marked than in the poison of snakes.”2 These statements cannot be accepted without further inquiry, but they deserve consideration, and may lead to a more fruitful study of the subject. Mort ality from Snake-Bites.—Snake-bites are generally very much dreaded, and the popular opinion is that they are almost inevitably fatal. Fayrer says that, in India, the number of deaths per annum from this cause is “per- fectly appalling.” It would appear from the official returns,3 that 10,064 persons were said to have thus lost their lives in Bengal, in 1880; but some doubt is thrown on this estimate by the statement that an immense propor- tion of these cases were really suicides, falsely reported as snake-bites by their friends, “ to save the honor of their families.” Mitchell, in the paper before referred to,4 shows very clearly how it is that many rattlesnake-bites fail of fatal effect, and deduces from an analysis of cases, that recovery occurs in at least seven-eighths of tire whole number. Perhaps the greater abundance and activity of the snakes in India, as well as the swarming population, their habits of life and dress, and their inferior powers of resistance, may account for the fatality of these injuries in that country. It is probable that the poi- son-apparatus is used by snakes against man in self-defence only, as when they are trodden upon or irritated, or startled by a sudden approach. Symptoms op Snake-Bites.—As to tlie effects of the venom, it has been said, on a previous page, that the dose—the amount received into the system—has much to do with their severity. It is probable, also, that if the poison is discharged into the subcutaneous areolar tissue only, it may induce only local irritation ;6 while if it enters a vein, and thus goes directly into the circulation, the results are much more serious. The part bitten immediately swells and becomes intensely painful, both swelling and pain extending up toward the body. Along with this there is intense congestion, and ecchy- 1 Philadelphia Medical and Surgical Reporter, 1873, p. 216. 2 Gazette Medicale de Paris, Juillet 30, 1881. 3 British Medical Journal, Nov. 12, 1881. 4 North American Medico-Chirurgical Review, March, 1861. 6 As in many other forms of poisoning, the symptoms are sometimes anomalous ; for instance, a case is reported (Lancet, July 9, 1881, p. 75) by an East Indian surgeon, whose name is not given, in which, two hours after the receipt of a snake-bite in the right foot, pain extended up to the groin ; next day it reached the right axilla, and the left forearm and elbow were painful and greatly swollen. Under the use of hot fomentations the man was well in a few days. 98 POISONED WOUNDS. motic spots appear. Very marked symptoms of shock are soon manifested; fainting, giddiness, vertigo, loss of speech,1 dimness of sight, with clammy sweats and great terror; nausea, vomiting, intense weakness; rapid, feeble pulse and labored respiration. Death may occur in a very short time—less than half an hour in one case on record, forty minutes in another2—but oftener in the course of from live to forty-eight hours. When the struggle is pro- longed beyond this period, the symptoms just spoken of give way to those of the more ordinary forms of septic poisoning or septicaemia, and death takes place by exhaustion or failure of nerve-power. In these cases, it would seem that the venom, unlike the other animal poisons before considered, gained access to the system through the veins, and not by way of the lym- phatics, since the latter do not show any sign of special involvement; and the rapid onset of general symptoms would indicate that the whole mass of the blood was affected at once. * But, as has been before said, in many instances the threatening symptoms either do not come on at all, or subside in the course of a few hours, some- times even without active treatment, at least of a scientific kind. Such is the case almost always in viper-bites; thus an account is given3 of a gentle- man, M. Dumeril, being bitten five times in the arms and hands |jy a very large viper; he fainted twice, and was very ill for twenty-four hours, but recovered perfectly. Dr. T. S. Savage relates4 two cases of the bite of the Cerastes cornutus (or nasieornis), a snake very much dreaded by the natives of South Africa, neither of which was fatal. And, from inertness of the venom, the small amount injected, or the failure of one or both fangs to pene- trate the skin, even the rattlesnake-bite is often sustained without causing death. Hence, as Mitchell5 points out, remedies are often vaunted which really have but little to do with the patient’s recovery. In some instances, as in one of viper-bite reported from Cyprus,6 the symp- toms induced by snake-venom strongly resemble those of phlegmonous ery- sipelas from more ordinary causes. Pathology and Morbid Anatomy.—As to the pathology of snake-poisoning, we have not many positive facts. One thing seems to be well established, viz., that the venom acts as a septic ferment upon the blood, breaking down its coagulating power, and disintegrating the red corpuscles. Whether the effect of the poison on the nerve-centres is direct, as Fayrer asserts,7 or whether it is a secondary result of the vitiation of the blood circulating through them, does not seem to be clearly determined. The post-mortem appearances may be briefly stated to be:—in the neighborhood of the bite, extravasations of blood, and softening of all the tissues; in the internal organs (the brain, spinal cord, and kidneys especially), more or less intense congestion, with ecchymoses in the subperitoneal areolar tissue, and fluidity of the blood mass. Dr. Lacerda Filho is said8 to have published, in a Brazilian medical periodical, the following conclusions, based upon experiment: “ (1) The poi- son of the Crotalus horridus acts upon the blood by destroying the red blood- corpuscles, and by changing the physical and chemical quality of the plasma; (2) the poison contains some mobile bodies similar to the micrococcys of pu- trefaction ; (3) the blood of an animal killed by a snake’s bite, when inocu- 1 W. Ogle, St. George’s Hospital Reports, 1868. 2 Shapleigh, American Journal of the Medical Sciences, April, 1869. 3 American Journal of the Medical Sciences, July, 1852. 4 Ibid., Jan. 1849. 6 Op. cit. ' 6 Heidenstam, Lancet, Feb. 19, 1881. i Indian Annals of Medical Science, quoted in American Journal of the Medical Sciences, April, 1871. 8 British Medical Journal, Nov. 12, 1881. SNAKE-BITES. 99 lated in another animal of the same size and species, causes the death of the latter within a few hours, under the same symptoms and with the same changes of the blood; (4) the poison can be dried and preserved for a long time without losing its specific quality; (5) alcohol is the best antidote as yet discovered for this poison.” This writer further claims to have ascer- tained that the venom of the Hachesis rliambeata possesses the power of di- gesting albuminous substances, and emulsifying fats, and infers that the local effects of its inoculation may perhaps be regarded as in effect a digestion of the living tissues. He thinks that it may serve, not only as a means of attack or defence, but may aid in the digestion of the victim. M. Couty, comment- ing on these statements, points out that “ the venom of snakes is not a simple poison, but a pathogenic agent, capable of selecting certain organs and tissues.” On its intravenous injection, there always ensue hemorrhages in the lungs, in the endocardium of the left side of the heart and not in that of the right, in the meninges and not in the nerve tissues, less commonly in the stomach, intestines, and kidneys. Different animals show very different degrees of susceptibility; thus, the monkey is said to be about a thousand times as sus- ceptible as the frog. “ Many of these poisons, after keeping, contain various bacteria, which can be cultivated, and the culture-liquid, or the fluids from an inflammation due to the poison, cause symptoms different from those of the poison itself, and comparable to simple septicaemia. The venom is thus not an organized virus.” While the foregoing statements may be taken as true, or at least as em- bodying the general results of observation on snake-poisoning, it is by no means impossible that further study may show that differences exist between the venom of one species and that of another, or, it may even be, between different samples of venom. Fayrer thinks that the poison of the Naja does not destroy the coagulability of the blood, while that of the Daboia makes it perfectly and permanently fluid. Halford1 described certain cells developed in the blood of animals, killed by snake-poison, which he thought might prove to be a means of diagnosis in doubtful cases ; but Mitchell2 asserts that these are not new organisms, but only leucocytes, confirming his view by microscopical observations made by Dr. J. G. Richardson. Hodgkinson3 says that the bites of the Australian snakes have less local effect, and exert their influence more upon the general nervous system, than those of the snakes of other countries. Treatment of Snake-Bites.—With regard to the treatment of snake-poison- ing, the remedies that have been proposed, and even those that have been declared to be infallible, can scarcely be counted, and it would be simply a waste of time to enumerate them. A few, however, which have been brought forward upon plausible grounds by scientific men, may be mentioned. Bi- bron’s antidote enjoyed a wide reputation for some years; it consists of iodide of potassium, gr. iv; bromine, 13v; corrosive chloride of mercury, gr. ij :— 10 drops at a dose. Ammonia has been advocated by various authors for the last seventy years,4 notably of late by Halford. Shortt is said5 to regard po- tassa as a reliable antidote, neutralizing the venom. Iodine has been depended upon by others. Dr. Anderson, of Wilmington,.North Carolina,6 has recorded two cases of rattlesnake-bite successfully treated by means of bromide of po- 1 British Medical Journal, Dec. 21, 1867. 2 American Journal of the Medical Sciences, April, 1870. * Ibid., April, 1845. 4 First by Mangili, in 1813. 5 Letter from Madras, in Medical Times and Gazette, Aug. 23, 1873. 6 American Journal of the Medical Sciences, April, 1872. 100 POISONED WOUNDS. tassium, and recommends its further trial; he used stimulants also. But the fact seems to be established by the intelligent observations and experiments of Mitchell, Fayrer, and others, that there is no known antidote by which the venom can be neutralized,1 nor any prophylactic against it. Hence, medi- cation with this view is to be avoided altogether, and the aim of treatment should be to prevent the poison from gaining access to the general circulation, and to obviate its prostrating effects if its entrance has already taken place. As soon as practicable after the receipt of the wound, a broad ligature should be tied, so tightly as to check the circulation, around the limb above the upper limit of any swelling which may have appeared, and the wound itself should be thoroughly sucked; the poison is harmless when taken into the mouth. Another plan is to apply cupping-glasses over the wound ; this mode of treatment was, at one time, strongly advocated, and seemed to pro- duce good results.2 Mitchell,3 however, doubts whether sucking can remove any of the poison through the narrow fang-track, and thinks that cupping only delays the poison for the time in the neighborhood of the part bitten. Some- times the site of the wound is not such as to admit of either of these measures; thus inonefatal case it wason the bridge of the nose. Very prompt cauterization, either with a hot iron or coal, or with the potential cautery—bromine or iodine, solid or in strong tincture—may coagulate the tissues, so as at least in some measure to hinder absorption ; the hot iron will actually destroy the venom. Instant excision has seemed, in some cases, to prevent ill effects,4 or, in the case of a finger, amputation may be resorted to, as more likely to remove the entire dose of the poison. A plan which has apparently much in its favor, is to slacken the ligature somewhat at intervals, say for five minutes at a time, so as to allow the poison to be admitted little by little, and thus to be dissipated. By slightly shifting the constricting band, so as to change the part of the limb pressed upon, some advantage will be gained. It must be remembered that the continuous application of a tight ligature for twenty-four hours, or even less, would greatly endanger the life of the constricted limb, and, al- though this would be a less evil than the death of the patient, it is one to be avoided if possible. Fomentations or poultices (a poultice of tobacco-leaves is a favorite Southern and Western remedy) are the best local applications. With these it will, of course, be proper to combine anodynes. The constitutional treatment in these cases is of the utmost importance, but is founded upon the very simple principle of sustaining the strength until the poison shall have been eliminated. To this end, stimulants are given as freely as the patient can bear them. Ammonia is valuable in this way, especially, perhaps, in the earliest stages, where its diffusibility renders its action very speedy. Along with it, and at a later period, whiskey seems to be the most reliable of our resources. Very large quantities have been taken under these circumstances without intoxication being induced. The object is not at all to bring about this condition, which would even favor the injurious effect of the poison, but simply to keep the vascular and nervous system stimulated to the activity required to effect elimination. Should life be maintained, the patient does not for some time feel the need of food ; but the addition of ' The latest claim of this kind is made in a letter to the Medical Times and Gazette, Aug. 27, 1881. The writer says that Dr. Lacerda Fillio asserts that the permanganate of potassium is in- fallible ; neither the dose nor the mode of administration is mentioned. Mr. Vincent Richards (quoted in the British Medical Journal, Dec. 31, 1881, from the Indian Medical Gazette), is said to have found this remedy effectual in neutralizing the cobra-poison. These statements certainly need confirmation. 2 See Pennock, American Journal of the Medical Sciences, May, 1828 ; and Rodrigue, ibid., Aug. 1828. 3 Op. cit. 4 Agnew, op. cit., vol. i. p. 229. BITES OF OTHER ANIMALS. 101 an egg to the whiskey (the two being beaten up together) every two, three, or four hours, would probably prove judicious. The after-treatment of cases of this kind will suggest itself: a condition of debility often ensues, requiring the free use of the ordinary tonics, quinine, iron, strychnia, and, perhaps, the mineral acids. But, as has been already said, there is sometimes a remarkably rapid return to health upon the elimi- nation of the poison, in which case no after-treatment will be required. Bites of Other Animals. The peculiar symptoms often induced by the bites of rabid dogs, cats, and other animals of allied tribes, constituting the disease known as hydrophobia, have been made the subject of a special article (vol. i. p. 215). In most cases of this kind, opportunity is atforded to determine, either by previous knowl- edge or by subsequent observation, whether the animal which inflicted the bite had or had not been hydrophobic. But symptoms, either of this or of other forms of poisoning, to be presently mentioned, occasionally arise from bites inflicted by wild animals, or animals of which nothing is known. Thus a case is reported by Acting-Assistant Surgeon Wolfe, U. S. A.,1 of a boy, aged 12, who was attacked with a fatal disease, resembling in all respects hydro- phobia as ordinarily met with, three weeks after receiving two bites from a skunk. Other such cases have been placed on record, and the name “rabies mephitica” has been given to the malady. Now it can scarcely be sup- posed that hydrophobia could prevail among wild beasts, especially as travel- lers inform us that the disease is wholly unknown among the half-savage dogs which swarm about Constantinople and other eastern cities. Were it otherwise, the propagation of the poison would be so rapid, in the constant lighting of these animals, as to exterminate them in no long time. Hence we must infer, if the facts are known and justly interpreted, either that spo- radic cases of hydrophobia do occur among animals, either domesticated or wild, or that the disease may be developed in man by the bite of an animal which is itself healthy. The bites of cats, although sometimes very severe, do not seem to have any special effect in the way of causing blood-poisoning. I have seen one case in which a sick cat bit a servant-girl on the thumb, tearing the tissues deeply for over an inch ; the wound was cauterized, and healed kindly, and the pa- tient continued well, to my knowdedge, for several years. Injuries inflicted by the larger felines, as by lions, tigers, etc., are sometimes met with among the employes of menageries; several such instances have occurred in this city within the last twenty years. A good deal of shock seems to attend these cases, and in one of lion-bite, reported by Dr. John Ash- hurst, Jr.,2 the rapid occurrence of traumatic or spreading gangrene was a noticeable feature, the patient dying in forty-eight hours. No evidence, however, exists to show that there is any actual blood-poisoning, any more than in injuries of like gravity sustained in railroad or other accidents. The same may be said of the shark-bites occasionally observed along the sea- shore, or in bathers in large rivers near the ocean. Such cases are not un- common in India, and several have occurred in New York within a year or two. One case of apparent blood-poisoning from the bite of a rat has come under my own observation,3 and seems of sufficient interest to be detailed here:— 1 American Journal of the Medical Sciences, Oct. 1875, p. 567. 2 See vol. i. p. 567. 8 It was published in the Philadelphia Medical Times, August 1, 1872. 102 POISONED WOUNDS. W. T., aged 7, a very stout and healthy boy, was bitten severely in the left forefinger, between the knuckle and the first joint, by a rat which he had caught. Fearing pun- ishment for playing in the street, he concealed the real nature of the injury for two weeks, when I was called to see him. The soft parts about the phalanx were now (June 11) enormously swollen, purplish red, and shining, the hand was somewhat putfy, and a gland as large as a chestnut was felt in the anterior fold of the axilla. The boy had some fever, especially at night, and was listless, and without appetite. Next day I made a free incision into his swollen finger, but very little pus escaped. He was put on the use of the muriated tincture of iron, with a febrifuge at night, and poultices were applied locally. The symptoms all subsided; but on June 18, I was again called to see the patient, as he had a chain of small glandular enlargements all the way up the forearm and arm, while the swollen gland in the axilla had increased to the size of a w'alnut. By the third day, under hot sponging, all the lumps had gone ; but on June 27, he pre- sented a most curious phenomenon ; patches, as if the skin had been bruised, very slightly raised, of a pale-purplish, brown, mottled color, extended up the radial side of the forearm, and around the front of the arm to the axilla, up in front of the shoulder, and on the side of the neck to the head. One separate patch existed on the middle of the forearm, and another near the anterior axillary fold. A large patch occupied the axilla. Many similar but less vivid patches existed on the body, and even down on the legs. Each patch had a red rim, clearly marking the line between it and the healthy skin. The only tender patch was that on the left side of the neck ; but the boy com- plained somewhat of soreness, apparently muscular, all over his body. There was no- stiffening of the jaws, nor other sign of tetanus. For several nights there was high fever.. Under the steady use of the iron, with hot sponging, all these symptoms abated, and on July 2,1 ceased attendance. On July 15,1 saw the patient again, and found that he occasionally had a re-appearance of the patches, but very faint, and with no constitutional symptoms. The phenomena here, as in most cases of poisoning by the bites of animals (excepting always the specific ones before referred to), seem to have been those of lymphangeitis, with, in this instance, a very mild attack of septicae- mia supervening. But they may assume a far graver type; thus Ivocher reports a case of acute sepsis, with embolic pyaemia proving fatal in forty- eight hours, which followed the application of a leech to the gum.1 With regard to the treatment of all these cases, it can only be said that it must be based on general principles. Local inflammation is to be combated, and the strength of the patient maintained; the special means of effecting these objects have been elsewhere detailed, and need not be repeated here- 1 British Medical Journal, Oct. 16, 1880, p. 633. SABRE AND BAYONET WOUNDS; ARROW WOUNDS. BY J. H. BILL, M.D., SURGEON AND BREVET LIEUTENANT-COLONEL, UNITED STATES ARMY. Sabre and Bayonet Wounds. Whilst the injuries inflicted by the sabre may be classed among incised wounds, yet they differ among themselves in point of cleanness of cut, according to the sharpness of the weapon and the way in which it is handled. As ordinarily used in war, the sabre has a dull edge, like the hack of a table knife ; rarely are the sabres ground. Such a weapon, then, makes a wound by the weight of the blow, not by the velocity of the cut, and the wound which it makes must be more or less contused. Nevertheless, these wounds heal as readily as incised wounds made with keen-edged wea- pons, although they are more apt than the latter to be followed by noticeable scars. Sabre-wounds, and with these I include all sword-wounds, for thrusts with the sword are very rare, are of infrequent occurrence in modern war- fare, owing to reduction in the cavalry arm, and to the changes which of late have befallen its functions. The bayonet makes a punctured wound, and, this weapon being more or less blunt, its wound is apt to be a good deal contused. The weapon is triangular in section, and makes a wound with three radiating branches. The spade or trowel bayonet, if it ever wounds at all, will make a wound like any other spade. Like all other punctured wounds in cellular and mus- cular tissues, the gravity of a bayonet wound depends upon its depth; at the moment of making the wound, the several tissues through which the weapon, passes are in different states of tension, and, as soon as the weapon is with- drawn, the several tissues resume their natural state, and thus cause an interruption in the continuity of the wound, Or, in mining phrase, produce “ faults” in it. If the parts heal by first intention, as they usually do, no harm is done by these “ faults,” but if pus forms, it will not be able to find its. way to the surface by the wound, and hence burrowing and abscesses. These wounds, like sab re-wounds, are of very infrequent occurrence. The soldier as a rule dislikes to use his bayonet. I was told by an officer engaged in the Mexican war, in 1846, that, at the capture of the city of Mexico, he saw soldiers firing their muskets into the bodies of certain of the enemy, to- whom quarter had been refused, with the bayonets actually resting against the persons of the slain. Both sabre and bayonet wounds are quite as often received in private quarrels and disturbances as in battle. Statistics of Sabre and Bayonet "Wounds.—In the British army in the Crimea, about 11,900 wounded men were received into hospital. There were only 76 cases of bayonet wound, with 7 deaths, and 87 of sword wound, with 103 104 SABRE AND BAYONET WOUNDS—ARROW WOUNDS. one death. In the same war there were 2700 killed in action, and, if the same proportion should hold for these, the total number of cases of bayonet wound would be 93, with 24 deaths, and of cases of sword wound 107, with 21 deaths. The records of the Mexican war of 1846 make no distinction between gunshot and sword and bayonet wounds, nor can I find any statistics •of the relative frequency of these two classes of wounds in the Franco- German war of 1870. In the late War of the Rebellion, out of a total of 400,000 wounds, there were 22,700 incised and 5900 punctured wounds.' But few of these, however, were inflicted with sabre or bayonet. If a man cut his finger while “ whittling,” and was taken on sick report, he constituted one of the 22,000 subjects of incised wounds. The punctured wounds were usually of the same trivial character. Ho data exist ffiom which a correct and exact statement can be made of the relative frequency of gunshot wounds and sabre or bayonet wounds during this war. In the Medical and Surgical History of the War of the Rebellion, 481 cases of sabre wound, with 18 deaths, and 188 cases of bayonet wound, with 19 deaths, are noticed, and are explicitly attributed to the weapons named. How many more of the 400,000 wounds were bayonet or sabre wounds cannot now be deter- mined. The fact that these wounds are of very infrequent occurrence, is so well known to military men that it has been proposed by more than one officer to discard both weapons; and, indeed, one of the strongest arguments for the substitution of the trowel-bayonet for the weapon of the old pat- tern was the fact that the offensive powers of the latter were of so little importance. Sabre Wounds of the Head.—Of the 282 cases of sabre wound of the scalp, recorded in the Medical and Surgical History of the War, 263 ended in complete recovery, while 11 patients were disabled, 3 died from inter- current disease, and 3 died of the injury. There were 49 cases of wound of the cranium, of which 13 terminated fatally, mostly from encephalitis. In some cases the sabre will completely detach a circular plate of bone, and leave it hanging by the scalp. The proper treatment of such a case is not settled. The temptation, of course, would be to put bone, scalp, and all, back into place, and let them unite, if they would. But it seems to me that the probabilities of non-union, and the risks of necrosis, suppuration, and encephalitis, would greatly outweigh the advantages of having a bony cover for the wound. My own practice would be therefore that recom- mended by the Historian of the War of the Rebellion, to dissect out the bone, saving the pericranium if possible, and then to hold the soft parts in their place by a sufficiency of antiseptic catgut stitches. In cases of sabre wound of Steno’s duct, the experience of our war was that spontaneous healing might be counted on. I myself saw such an event happen, during the war, in a base of gunshot wound of the duct in question, [and an equally fortunate result was obtained, a few years since, in a case of salivary fistula resulting from gunshot wound involving this duct, under the care of the Editor.] Sabre Wounds of the Abdomen.—Sabre wounds of the abdomen are rare, for the dull sabre is incapable of cutting the soft, yielding, abdominal tissues, protected as these are by folds of cloth, and sword stabs are not very common. Our soldiers, contrary to the theoretical teachings which they receive, use the edge of the sword rather than its point. Sabre Wounds of Forearm.—Formerly, when duels with swords were more common than at present, the object being to disable rather than to kill an antagonist, wounds of the flexor muscles and tendons of the sword fore- ARROW WOUNDS. 105 •arm were frequent. These were inflicted by a draw cut of the hack of the sabre, which was kept as sharp as a razor for this purpose. Such a wound should be treated, after the arteries are secured, by placing the limb on a splint so arranged as to flex both the fingers and the hand, and by adopting a strictly antiseptic dressing. Bayonet Wounds.—Bayonet wounds penetrating the skull were in our late war generally fatal—four deaths having occurred in five cases. The penetrating bayonet wounds of the chest seem to have been equally fatal, whilst of eleven patients who received bayonet wounds of the abdomen—in some of the cases the bowel was transfixed—eight recovered. The cardinal point in the treatment of bayonet wounds is to secure rest. If a limb is hurt, it should be put on a splint, and a bandage applied to keep the muscles quiet, and the patient should be required to keep the horizontal position. If the lung is wounded, opium should be given to secure rest, and Guthrie’s rule, to lie upon the wounded side, might be enjoined. If the abdomen has been penetrated, opium must be given in very large doses, or rather very decided -effects must be produced by the opium, and the patient’s diet must be most strictly guarded. The patient must of course be kept in bed until all risk of peritonitis has passed by. Arrow Wounds. History op Arrow Wounds.—The arrow is a weapon of the greatest anti- quity. Hot only can we infer its possession by primitive man, from its use at the present day by the most savage tribes, but the earliest writings and the oldest sculptures, and the treasures of the caves, all testify that from its infancy the human race has drawn the bow. Accordingly we find that the arrow was of particular interest to the surgeons of antiquity, who discussed at length ■the wounds which it caused, giving specific rules for the treatment of the wounded, and inventing instruments for the removal of the missile. Homer, in the Iliad, tells us at length of the wounding of Macliaon by the arrow of Paris, and in another place is described some bad surgery of Machaon’s, in which Menelaus, wounded by an arrow, was the sufferer. The Father of Medicine devoted a book, but unfortunately one of the lost books, to missiles and the wounds made by them. Celsus gives a chapter to arrow wounds, and from him we know pretty much all that is known of these lesions as they were seen in his day. Celsus lays down some excellent rules for the treatment of these wounds: thus he advises free dilatation with the knife, do allow perfect exploration by the finger, and teaches that an arrow may be removed as well and very often better by pushing it forward to emergence, than by pulling it back over the course already taken.1 Paulus HCgineta2 merely reiterates the teachings of Celsus, as does Albucasis.3 The ancients surpassed our Indians in the destructiveness of their inven- tion, for they contrived arrow heads with barbs pointing forwards as well as backwards, and attached scraps of metal, which might be unwittingly left behind by the surgeon, if he should be so skilful as to extract a doubly- barbed arrow. They had, besides, a crescentiform arrow head with a keen ■edge, with which instrument a man could almost be decapitated. Pare gives considerable space to arrow and spear wounds. In his day, the arrow was fastened to the shaft in two different ways. Most commonly, the arrow head at its base terminated in a spike, which was driven into the 1 Medicinse, lib. vii. cap. v. 2 Lib. vi. cap. lxxxviii. 3 Chirurgia, lib. ii. 106 SABRE AND BAYONET WOUNDS—ARROW WOUNDS. wooden shaft, but other heads had thimble-shaped sockets, into which the wooden shaft was driven. Some of these last described were composed of several parts, one arrow head being nested over another, frequently to the number of five. Fare’s forceps for extracting these arrow heads was shaped like a glove-stretcher. Its beak entered the socket, and, on pressing the handles together, made sufficient outward pressure to hold the foreign body during its extraction.1 Grose2 says that the English arrow was from twenty- seven to forty inches long, that its range was from 120 to 360 yards, and that English archers could easily shoot through an inch plank. Archers consti- tuted a part of the English army as late as the time of the Great Rebellion, and several important battles were decided by the bow and arrow, the battle of Hastings being the most important of all; nor is it impossible that the bow and arrow may again become a military weapon, and a very formidable one, in the hands of cavalry.2 Arrow of the North American Indian.—The arrow of the North American Indian usually consists of three parts: a head, a shaft, and a hand that binds head and shaft together. The head is made of bone, of iron, of one of the silicious minerals, or even of glass. The stone or glass arrow head is made by trimming a fragment of agate, flint, obsidian, or bottle glass, into a cuneiform shape. This is done by holding the fragment in the left hand, and breaking oft' its edges, bit by bit, by means of a bone having a shallow groove cut around one of its ends. The edge of the glass is caught in this groove, and the thumb is used as a fulcrum.4 These arrow heads have no neck ; they are about an inch long, and a third of an inch wide. They are fastened by gum into a notch, which is cut in a rod of wood eight inches long, and this again is fastened by gum into a reed thirty inches long;, but so frail is the connection between head and shaft, that the Indian is obliged to take extraordinary care that they do not become separated in the quiver.5 These heads are of course brittle, and if they strike a bone, they are sure to break. Mr. V., a paymaster and clerk, was thus ■wounded in the arm by an Apache arrow. The glass head struck the humerus, and broke into many fragments, which were a long time in coming away.6 The metallic head is usually made from soft hoop-iron, by aid of a sandstone hone. This head is from half an inch to an inch broad, and from one to three inches long, and of the well-known shape ; its edges are dull-sharp, like those of an oyster knife, and it has at its base a small quadrangular stem or neck for attachment to the shaft. Usually it is not barbed. The shaft of the arrow is made from the sapling of the willow or dogwood tree. A bundle of these saplings is thrown into a warm pool, and soaked until the bark can be easily peeled off. ' Each sapling is then straightened in this way : Pieces of wood are first firmly lashed to the ends of the sap- lings, crosswise; one of these crosspieces is held between the feet, and the other is held in the hand; a to-and-fro, semi-rotary motion, as in trephining, is given to the crosspiece in the hand. Thus the fibres of the stick become 1 (Euvres completes d’Ambroise Par6, ed. par J. F. Malgaigne, tome ii. p. 183. Consult also Daniel, Historie de la Milice Franqaise, tome i. p. 303. Amsterdam, 1724. 2 Military Antiquities respecting a History of the F.nglish Army, etc., p. 268, 1801. 3 On the shapes and sizes of the arrows of the Middle Ages, consult Hewitt, Ancient Armor and Weapons in Europe, etc., vol. i. pp. 23-65, 1865 ; also Matthew Paris, Historia Major, pp. 1090-1091. Paris, 1644. 4 Consult Report of Explorations for a Route for the Pacific Railroad, on the trail of the 41st parallel, North Latitude. Senate Document, 33d Congress, p. 43. 5 Consult Notes on Arrow Wounds, hy Elliot Coues, Assistant Surgeon, U. S. Army. Medical and Surgical Reporter, April, 1866. 6 Unpublished Notes of Cases in the Office of the Surgeon-General, U. S. Army. ARROW WOUNDS. 107 untwisted, and it is easily made straight. It is then confined in this straight condition on a flat rock, by superimposed weights, until it becomes dry, when it remains straight. It is next cut to the length approved by the archer who has fashioned it, a length ranging from twenty-six to thirty-four inches. A slit is made at one end to hold the neck of the iron head, a notch at the other to receive the bow-string and the feathering that is to steady its course, and the shaft is done. The third part of the arrow is the damp that binds head and shaft together. This is a flat piece of sinew, or tendinous ribband. The neck of the arrow- head having been pushed into its place in the slit of the shaft, the well-soaked sinew is tightly wrapped around the joint. As it dries, it contracts, and so pinches together the sides of the cleft. Thus by its embrace, a bit of iron and an innocent stick are transformed into an inflexible, dangerous weapon, for, as will appear, much of the danger of arrow wounds depends upon this peculiarity of construction. Bird Arrow.—The bird arrow, consisting of a simple shaft, its end pointed and hardened by fire, is sometimes used in war. Thus Mr. Evans was wounded in the top of his left lung by a bird arrow, which he plucked away at once- He died two weeks afterwards.1 Range and Penetration of Arrows.—Although the distance at which arrow fire is effective, is not great—being less than 100 yards—the penetra- tiveness of the missile itself, even at far range, is surprising. I have seen an arrow, discharged from the distance of an hundred yards, so deeply imbedded in an oak plank that it could not be removed by any force directly applied. I have often had occasion to notice the tightness with which an arrow-head is held, when it has penetrated a bone. It is usually impossible to remove it by direct traction. The Indian highly prizes this power of penetration, and increases it by skill and practice. An arrow" which has been shot in the chase through the body of a buffalo, is carefully treasured and decorated, and, when worn on festal days, marks its owner as a man of the most worshipful skill. There are numerous specimens in the Army Medical Museum proving the Fig. 240. Fig. 241. Fig. 242. Penetration of superciliary ridge and brain by an arrow. (A. M. M., Sect. I. Spec. 5644.) Ribs of buffalo transfixed by arrows. (A. M. M.,. Sect. I. Spec. 4735, 4736.) penetrativeness of the arrow. Among these, I have selected three, repre- sented in Figs. 240, 241, and 242. In "the former, an arrow has gone through the thickest part of the superciliary ridge, and then four inches into the brain. Figs. 241 and 242 show ribs of the butfalo transfixed by arrow heads. 1 Unpublished. Notes on Arrow Wounds in the Office of the Surgeon-General, U. S. Army. 108 SABRE AND BAYONET WOUNDS—ARROW AVOUNDS. Correctness of Aim and Rapidity of Discharge.—The arrow can be aimed at fifty yards’as correctly as the revolver, and can be shot nearly as fast. At close quarters, and in a melee, it is a weapon more to be trusted than the pistol. It is not common to find a man killed who presents hut one arrow wound: usually he will have received three or four; I have counted thirteen in one corpse. In 1872, two Indian scouts were found dead near Fort Rice, the two having been pierced by thirty arrows.1 An expert archer will easily deliver six arrows in a minute, for he does not aim with the eye, drawing the string to the shoulder, but simply points the arrow, both arms being extended, and the hand which holds the bow grasping at the same time a .sheaf of arrows. These are not shot away wantonly, for their manufacture costs the lazy Indian too much work, but in the frenzy of the fray ; just as a dog, when excited, will rend the victim which he ordinarily loathes. Poisoned Arrows.—After a residence among a number of our Indian tribes, and careful reference to authorities, I am satisfied that the North American Indian does not use poison on his arrow, at least not designedly. It is probable that in those cases in which poison seemed to have been carried by an arrow, it has infected the arrow accidentally, as may easily occur in view of the squalor and disregard of sanitary'requirements in which the Indian lives. Alien arrows are prepared for war by dipping them in blood, ■etc., I believe that this is clone from superstitious motives—a baptism of fetich, as it were. But a consideration of the subject, as already set forth, and as will be further developed, will show that poison is not needed to make the arrow a most effective weapon ; its silence, its penetrativeness, the diffi- culty with which it is removed, the rapidity with which it is discharged, and its correctness of flight, all confer upon it the highest deadliness. While this more particularly concerns the soldier, we shall find much in the character and treatment of arrow wounds to interest the surgeon. Appearance of Arrow Wounds.—The arrow makes a wound which is at the same time punctured and incised. Thus, while on the one hand, owing to its high velocity, it rarely tails to lay open any viscus or to divide any vessel which it touches, it makes, on the other hand, a well-like wound, like that inflicted by the bayonet. But owing to its high velocity, the wounds made by an arrow oftener preserve their continuity (like gunshot wounds received at close range) than do bayonet wounds, which, as already pointed out, by becoming discontinuous, prevent the outward flow of discharges, and so give rise to abscesses. The cleanness of cut which characterizes arrow wounds also renders them less apt to suppurate than other punctured wounds. If an arrow has passed completely through a fleshy part, we And the two oriflces differing in appearance. The wound of entrance looks like that made by a small pistol ball, a slit being found in the skin, which may be darkened and bruised, and slightly depressed. The wound of exit is a simple slit. When only one wound is found, the shaft having been plucked away, a ques- tion may arise as to whether the injury has been caused by an arrow or by a bullet. After the attack by Navajoe Indians on Fort Defiance, in 1860, a soldier was found dead with a small wound just below the left nipple. The external wound looked like that made by a small conical ball, and it was thought that the man had met his death in a gambling quarrel at the hands of his comrades. But an examination of the in- terior of the chest showed that the vena cava was pinned to a rib by an arrow bead, which had also passed through the heart. In all probability, the shaft had been removed by the archer. 1 Unpublished Memoranda in Office of Surgeon-General, U. S. Army. ARROW WOUNDS. 109 An arrow may make a simple incised wound, several inches in length. Thus, if an arrow head strikes the skin obliquely, particularly at some spot where it is closely drawn over bone—as over the ulna, the tibia, or the cra- nium—a long cut with clear edges will result. Parts Oftenest Wounded.—In the annexed table is shown the liability of the several regions of the body to be wounded, and the relative fatality of these wounds:— Head or spinal column. Neck and trunk. Thorax. Heart. Abdomen. Upper extrem- ities. Lower extrem- ities. Total. Contents wounded Contents not wounded Lung wounded Lung not wounded Cavity pene- trated. Cavity not pene- trated. Recovered . Died . . . . 2 7 4 12 1 5 13 10 2 2 18 11 3 44 2 17 1 107 47 Cases. . . . 9 4 13 18 10 2 20 14 46 18 154 The above table is founded upon some seventy cases of arrow wound which fell under the notice of the writer in 1860, and an account of which was published in the American Journal of the Medical Sciences for October, 1862, together with other cases which have occurred since—some reported to the Surgeon-General of the United States Army, and published in Circular No. 3, S. G. O., 1871; others as yet unpublished; and five reported in the Philadelphia Medical and Surgical Reporter for January, 1864, by Assistant- Surgeon Elliot Coues, U. S. Army. The upper extremity is oftenest wounded, not only because it is most ex- posed, but also because an arrow can be seen as it advances, and the arm, being instinctively raised to ward off the missile, thus receives its point. Wounds which penetrate the abdominal cavity, and injure its vessels or vis- cera, are the most fatal. Knowing this, the Indian, if he has time to de- liberate, points his arrow and lance at the abdomen, while the Mexican protects this part with special care, by covering it with many folds of a blanket. As already stated, multiple arrow wounds are the rule. In the above table, in each case in which there were multiple arrow wounds, the most serious, or the fatal wound, only is recorded. Causes of Death.—The following table exhibits the causes of death in thirty-nine cases of arrow wound, in which this was ascertained:— Cause of death. Immediate hemor- rhage. Peritonitis Compres- sion of brain. Encepha- litis. Empyema. Tetanus. Pneumo- nia. Paralysis from wound of cord. Wound of heart. (Shock ?) Number ) of cases $ 10 16 4 3 1 1 i 1 2 Prognosis.—The prognosis in a case of arrow wound depends on several circumstances. It is influenced, in the first place, by the nature of the parts wounded. Vessels and intestines are not pushed aside, as they frequently are by bullets, but are laid open; fecal matter may be thus thrown into the peritoneum, or a hemorrhage, sufficient to determine the fatal issue, may take place before the case is seen by the surgeon. Hot only have we to consider the blood already lost, but that which is likely to be lost in extracting the 110 SABRE AND BAYONET WOUNDS—ARROW WOUNDS. missile, or in securing the wounded vessel. The first of the preceding tables shows, however, that arrow wounds of the abdominal cavity are not invari- ably mortal. Secondly, ;n considering the prognosis, we should regard the chances of extricating the arrow head,, if this has lodged. If the shaft remains attached to the head, the operation will probably be successful; but if the head is lost in the soft tissues, or is left in the chest or abdomen, its removal will be difficult and perhaps impossible. If, however, the foreign body be not ex- tracted, it will sooner or later bring about the death of the patient, for, unlike a smooth ball, the arrow head—long, sharp on the edges, angular, perhaps serrated—will not become encysted. Other considerations, too, not pecu- liar to arrow wounds, affect the prognosis; such as the health of the patient, the immediate importance of the wounded parts to life, the liability to inflammation, and especially the courage or mental serenity of the sufferer. The presence of shock shows that an organ essential to life, or highly inner- vated from the sympathetic system, has been seriously hurt, for ordinarly there is no shock at all. Wounds of the joints generally do well, and de- structive inflammation of the synovial membranes is not likely to occur. Treatment of Arrow Wounds in General.—If an arrow has struck a fleshy part, such as the outer side of the thigh, and has p>assed completely out, but little need he done. The wound should be encouraged to heal by first intention, and to this end perfect rest, both general and local, should be en- forced. If a limb is hurt, it is well to place it on a light splint, and to apply a bandage firmly, so as to quiet muscular action. On the high, dry table- lands of Colorado and Hew Mexico, these ■wounds will often heal in two or three days. 1 kematomata may form, but, even under these circumstances, we may frequently get absorption without the formation of pus. If an abscess has formed, it should be opened according to general rules. If the whole arrow—head and shaft still bound together—has lodged, we must first determine whether or not the head is impacted in the bone. This can be ascertained by gently twirling the shaft between the finger and thumb, or by trying to push it a little forwards—never by pulling it back. The slightest mobility settles the question, and the greatest care must be taken not to separate the head and shaft in the examination. If the head is not fixed in the bone, we next consider whether the missile shall be pulled, out over the course it has already taken, or whether it shall be pushed out through the tissues which it would have traversed, had its progress not been arrested. This will depend upon how deeply the missile has penetrated, and upon what tissues it must encounter in a forward course. If it is decided to push out an arrow, we oil the shaft, and make firm pressure on its end. When the head is felt under the skin, it should be released by a touch of the knife. The head and tendinous ribband are then removed, when the shaft is with- drawn with a gentle rotary motion. In this case too, where we artificially make the arrow do what it would have done had its progress not been stayed, we get a cure without suppuration. But if the ribband of tendon lias been left in the wound, or if, for any reason, such as inability to secure rest for the parts, we expect suppuration, then, before withdrawing the shaft, it is well to fasten to this a drainage-tube, and to drag the latter into the wound as the former is plucked out. Some carbolized oil may be injected into the tube, which should be left in place until suppuration commences; then the tube with a pledget of lint may be drawn through the wound, and the miss- ing tendinous ribband be thus brought away. Further search for this will usually be inexpedient. If it is not feasible to push the arrow out, we must pluck it out, and, to do this, the head itself must be seized. But the shaft is so tightly grasped by ARROW WOUNDS. 111 the skin and other tissues that not even a probe, much less the finger or forceps, can be carried down to the head. A deep incision, using the arrow shaft as a guide, must therefore first be made with a probe-pointed bistoury, sufficiently free to permit the finger to pass down and touch the arrow head. After the position of the latter has been ascertained by the finger, a pair of long dressing forceps, applied to the flat sides of the head, will suffice for its removal. I would urge that this should be done with the greatest care, lest the head should be separated from the shaft. So easily may this accident occur, and so unfortunate are its results, that this manoeuvre with the forceps must always be a matter of anxiety to the surgeon. If the arrow head is deeply lodged, or if it has penetrated the chest or abdomen, some other instrument than a dressing forceps will be necessary. If the arrow forceps, to be presently described, is not at hand, a loop one- quarter of an inch in diameter should be made on a stout wire, and this loop, having been bent at right angles to the body of the wire, should be carried down beyond the point of the arrow head, and so manipulated as to snare the latter. In doing this, a forked probe, like that used in the operation for vaginal fistuke, or the old fashioned porte-meche (Fig. 40, Vol. I. p. 487) will be of the greatest assistance. Fig. 243 shows the application of the loop to Fig. 243. Wire loop applied to arrow head. the arrow head. When the loop has embraced the head with a very gentle pressure, the wire should he firmly lashed to the shaft of the arrow, and then gentle traction should be applied to this, the finger being kept as deeply in the wound as possible. It is best not to pull directly on the wire itself, but to use this only as a kind of clamp, to make the arrow head fast to the shaft, making traction on the latter. In -this way, if any tissue which it is desirable not to cut, should be pinched between the wire and the edges of the arrow head, it will be less likely to be wounded. As soon as the head is drawn within reach of the finger, the dressing forceps should be applied. The loop should be used for arrow heads not lodged in bone, only to draw the missile within reach. In making the incision with the bistoury, it is better to make it too large than too small. It must allow perfect freedom for the manipulation of any instrument, and especially for that best of instruments, the index-finger. If the arrow head has lodged in a bone, and the arrow forceps is not at hand, the wire loop must be applied in a different way, and considerable force may be required to unseat the foreign body. The shaft in this case should be cut oft* with pliers, the wound well dilated, and, if possible, the position of the arrow head ascertained with the finger. Then a loop of stout but flexible wire—the ends being threaded into a Coghill’s suture twister—is slipped over the remnant of the shaft, and, by means of the twister and a porte-meche, is pushed down until it has passed over the arrow head, which it is made to encircle loosely. The wires are then drawn tight and fastened to the handles of the twister, and the latter having been rotated once or twice, the loop will be firmly attached to the head, from which it cannot slip owing to the wedge shape of the latter. Figure 244 shows the application of the twister and loop. The arrow shaft and the twister having been lashed together, the two may be gently twisted or rocked from side to side as one system, whilst trac- tion is made by the handles of the twister. If force enough be used, and if the wire do not break, the arrow head will come out. If the wire should 112 SABRE AND BAYONET WOUNDS ARROW WOUNDS. appear too weak, and likely to break, a second loop should be cast around the head by means of another twister, before traction is made. Any amount of force may be applied by fastening both twisters to an inflexible rod, one end of which rests upon a block placed upon the patient’s body, and then using this rod as a lever of the second order. Force is thus applied evenly and Fig. 244. Application of wire loop to arrow head embedded in bone ; the loop is adjusted by aid of the wire twister and porte-m&che. without jerking. The ecraseur and wire cable used for crushing piles, or two catheters soldered together, may be used instead of the twister, though this can be made by any blacksmith. I think, however, that the forceps which I have devised for extracting arrows, will be found more convenient in all cases than any arrangement of loops. The instrument is represented in Fig. 245. The jaws are flat, and are Fig. 245. Strong forceps for extraction of arrows. bent at right angles to the handle, and they form, when closed, an elliptical loop adapted to embrace the head as a dagger is embraced by its sheath. For convenience and certainty of passing these forceps down to the arrow head, the face of the jaws, close to their edges, is grooved so as to fit and slide along the round arrow shaft, which is thus used as a director. The joint is made like that of a dentist’s forceps, so as to allow of any amount of twisting without bending, and, in order to make the instrument still stronger as a twister, one of the handles is mortised, and into this the other handle is made to fit, being tenon-shaped through nearly its whole length. The handles are eight inches long to the fulcrum, and are made very strong in themselves as well as by their mortise and tenon construction. From the tip of the jaws to the ful- crum is two and a quarter inches. When the arrow shaft is in place, the instru- ment is slid down upon this as a director, until the head is reached, when the jaws are opened, and made to grasp the head by its edges, encircling it almost like a loop. The handles having been then tied together for security, a gentle but decided twist will unseat the arrow head as easily as a dentist twists out a bicuspid tooth. If the head is not lodged in bone, the forceps are passed, closed, beyond its point, and the jaws are used as a loop to catch the latter without being opened at all. ARROW WOUNDS. 113 The removal of an arrow head after the shaft has been separated from it, is always difficult, and frequently impossible. The ancient writers rather made light of arrow heads hidden in the tissues, and there are, in the Army Medi- cal Museum, at Washington, specimens of flint arrow heads, lodged and encapsuled in bone. But who can say what trouble these foreign bodies may not have given during life, and whether they may not have been, indirectly at least, the cause of death ? In my own experience, as well as in that of several of my colleagues, the lodgment of an iron arrow head in soft tissues or in bone, will ultimately produce fatal mischief. I have never seen an arrow head left behind after the withdrawal of its shaft, but it sooner or later required removal, to preserve limb or to save life. In 1862, in an article which I published in the American Journal of the Medical Sciences, I wrote: “ An arrow head cannot become encysted like a ball; it presents too many sharp angles and edges, and is generally too irritating for any such event to be expected The inflammation it produces is the effort of nature to throw off the foreign body.” I might have added that this inflammation will continue as long as the patient lives, unless the foreign body be thrown off by nature, or removed by art. The case of the late General (then Lieutenant) Bayard, of the U. S. Cavalry, as narrated by Dr. C. A. Pope,1 may be quoted in illustration of this doctrine, and may serve to exemplify the characteristics of a case of arrow wound in which the head has lodged:— The spear-shaped iron point, two and three-quarter inches long, . . . entered the face a little below the orbit, and was completely embedded up to the shoulder, the small neck alone remaining in the flesh. Its direction was backwards and slightly outwards. The surgeon of the Post immediately endeavored to extract the foreign body ; . . . various means with forceps were resorted to, and, after a trial of two hours, the effort of extraction was abandoned. The absence of a suitable instrument, the slight hold which could be obtained on the offending body, and, above all, the firm impaction, sufficiently accounted for the failure. (Slight secondary hemorrhage from the nose followed within a few weeks, and again a more serious bleeding occurred while the patient was on his way home.) The patient arrived at St. Louis five weeks after the receipt of the injury, and I visited him immediately. There was some enlargement of the left side of the face. The wound on the cheek had skinned over, so that no- foreign substance could be seen; . . . a muco-purulent discharge, which came doubtless from the antrum, issued from the corresponding nostril. On incising the im- perfect cicatrix, I felt the small neck, and, supposing that the arrow head, after so long a time, might be loosened, I attempted its extraction with the dressing forceps of my pocket case, but failed. I at once supplied myself with instruments of various kinds, but succeeded in the first attempt with powerful forceps. A smart hemorrhage from the nostril and external wound immediately followed. By rest, cold, the administration of opium, plugging, and bandaging, the bleeding was soon arrested. The case now seemed to progress favorably, and the patient was able to get about the streets. On a visit to my office, he complained of a stiffness and inability to open his jaws as widely as usual—a difficulty indeed which had existed all along, and which was the result of the general thickening of the parts from inflammatory exudation. I advised him to make gentle efforts to open the mouth. In less than an hour from this time, his troubles commenced. The whole cheek became hot, swollen, and painful. High fever with renewed bleeding set in, and caused me much anxiety. The means which before were successful, now failed. Extensive extravasation of blood took place, and, to relieve the tension, 1 made an incision in the mouth, and others on the cheek and neck, thus allowing the discharge of large grumous clots. The hemorrhage continuing at intervals, occurring with regularity about twelve o’clock on three successive nights, and the patient being reduced to the lowest point of safety, I determined to tie the carotid artery with- out delay. This was done by candle-light on the night of the 16th of September, two 1 St. Louis Medical Journal, 1864, p. 12, and Hamilton’s Military Surgery, p. 544. 114 SABRE AND BAYONET WOUNDS—ARROW WOUNDS. months after the receipt of the injury. (The operation, though done under the most unfavorable conditions as regarded its time and the state of the patient, was successful. The bleeding never recurred, and the final recovery of the patient was complete.) Let it be received then as a rule without exception, that an arrow head left behind and lodged in the tissues must be removed as soon as possible,, even if this removal should require the severest and most dangerous of ope- rations. Accordingly, as soon as a patient presents himself, and, if possible, before the wound made by the shaft and head has closed, search should be made for the foreign body. A probe should be introduced, and carried along the course of the wound as far as possible, until the arrow head is reached. If a false passage is made, the probe should be left where it has lodged, and a second one taken, and this manoeuvre repeated until the true passage is found. Of course the patient is placed in the attitude which he held when wounded, and the wound itself is injected with carbolized oil, so as to deaden sensibility and diminish reflex muscular action. If the probe has penetrated for some distance into the tissues, and if, though we feel sure that it has followed the course of the wound, its progress has become arrested, it is well to lay the wound open to the depth reached by the probe, using this as a guide. At the bottom of the wound so made, we may be able to find again the track of the arrow, or perhaps to feel the bead with the finger. In any event, such a wound is of trifling consequence in comparison with the important result that may be got from it. But sometimes the most patient and boldest searches fail to discover the arrow head. There is then nothing to do but to wait. Perhaps an abscess will form, and in it we may find the offending body. To save life, it may be necessary to amputate the limb. In these searches for hidden arrow heads, it should be remembered that the course of the arrow is always straight through the tissues, and that therefore an incision carried down in the direction which the arrow had on entering, will reach its head. There is greater hope then from exploratory incisions in arrow wounds than in gunshot wounds. But even if the probe, successfully carried through the wound, should strike the iron head, still, there might be doubt. The foreign body is small and light, and usually presents, not its flat side, but its sharp edges to the contact of the probe. The finger only can give certainty, and to apply this instrument a long, deep incision may be necessary. Before making this, however, and in order to avoid doing so, a plan that I have practised, though unsuccessfully, may be tried. A pair of long, slender forceps may be introduced alongside of the probe, and carried on until the body sup- posed to be the arrow head is reached. Then the forceps are opened, and an effort is made to cause its jaws to strike the flat side of the head, one jaw above and' the other below, the head lying between them as the forceps are shut and opened. The trouble which I found in this exploration, was to manipulate ordinary forceps in so deep and narrow a wound ; but the modi- fication of the Mathieu “crocodile” forceps which I have had made for ex- traction of balls (Fig. 246), would probably answer the purpose.1 If the head has been found, no hesitation or delay should occur in extract- 1 The magnetic probe of the writer may also be used with advantage in these cases of doubt. It consists of a steel probe, made from a coarse knitting needle, highly magnetized. Over one of the poles is wrapped from seventy-five to a hundred feet of No. 40 insulated copper wire, so as to form a spindle-shaped bulb, about an inch long and from a fifth to a quarter of an inch in diameter. This bulb is covered with catheter varnish, or asphaltum varnish. The steel magnet projects from the bulb from an eighth to a sixth of an inch, according to the length of the probe. The wires from the bulb are connected with the audient of a telephone. On touching the end of the magnet which projects beyond the bulb, to a bit of iron, a momentary, induced current of electricity is, at the time of contact, developed in the coil of wire forming the bulb, and this current, passing to the audient, manifests itself there by a grating click. (See American Journal of the Medical Sciences, January, 1881.) ARROW WOUNDS. 115 ing it. Ordinarily the arrow forceps, applied to its edges, will bring it away safely enough, even without an incision. If the head is lodged in bone, the forceps should be used as the dentist uses the bicuspid forceps, giving a slight twist to unseat the foreign body, before making traction. I reiterate, Fig. 246. and would lay it down as a cardinal rule, that an arrow head must never be left in the body, unless patient search has failed to find it. I wrote in 1862, and think yet: “We might as well cut the patient’s limb up until we do find the arrow headfor, if it is left, amputation will be necessary, and worse than this can hardly ensue from the dissection advised. If I should undertake such an operation, I would make up my mind to find the arrow head, even if it became necessary to tear up every fasciculus of every muscle in the injured member. Before leaving the general consideration of arrow wounds, I should men- tion a complication peculiar to the lodgment of the iron arrow head, a com- plication which renders its extrusion by natural processes impossible, and its extraction by art very difficult. If a soft iron arrow head strikes a bone obliquely, or slips between it and its periosteum, or if the muscles contract as the shaft passes through them—the point of the head being at the same time in some dense tissue, such as bone or cartilage—the point is bent. This bending increases as the arrow goes on, until at last the whole head will have been transformed into a hook. A little reflection will show how powerless the wounded part must be to throw off the intruder, and how hard it will be to remove it by forceps, unless we make allowance for its change of shape. The appearance of an arrow head thus dis- torted is represented in Fig. 247, from a case reported by Surgeon B. A. Clements, U. S. Army.1 In a case occurring in the practice of the late Dr. Kennon, of Al- buquerque, Hew Mexico, the femur was found half encircled by a hoop-iron arrow head, which had produced caries, ab- scess, and infiltration, and was only re- moved at last after a severe operation. The chance in any given case that the arrow head may have been thus bent, gives additional force to the rule of always searching the wound with the finger as a probe. tinless the surgeon sees the patient very soon after the plucking out of Modified “ crocodile” forceps. Fig. 247. Bending of arrow heads. (After Clements.) 1 Hamilton’s Military Surgery, p. 530o 116 SABRE AND BAYONET WOUNDS—ARROW WOUNDS. the shaft, he will probably fail to find the foreign body. To leave the shaft intact, or to cut it off carefully an inch from the surface, for convenience of tranportation, is the safety of the patient. Soldiers, or those liable to be wounded by arrows, should understand the danger of meddling with an im- planted shaft, and every effort should be made to keep this in its place until proper surgical aid can be given. Xot only is the presence of the shaft necessary for the easy finding of the head, but it will be the best guide in case it should be necessary to cut for and tie some wounded vessel. Treatment of Wounds of Special Parts. Nerves.—If a nerve has been partially divided, or if such an accident is suspected, it is right to cut down to the nerve supposed to be injured, and complete its division. Our knowl- edge of the cutaneous distribution of the nerves will aid us in determining the particular nerve which has been hurt. Thus, in a case which I saw in 1860, in which an arrow passed through the middle of the leg, I inferred from the intense pain felt in the fibular side of the foot, that the musculo-cutaneous nerve had been injured, and a small incision showed that nerve to be partly divided. I completed the division with the knife, giving immediate relief from pain, and without producing permanent inconvenience to the patient. I think that this would be the correct treatment even if a nerve as large as the sciatic were partly divided. Wounds of Vessels.—If an arrow divides or wounds an artery or vein, and the hemorrhage demands it, we must search for the bleeding point, using the shaft as a director. Then we should act according to circumstances. If the vessel be a small artery or vein, its complete division will probably check the hemorrhage. If the ligature is required, we must apply the thread both to the cardiac and to the distal end of the divided artery; it is well to knot the ligature belonging to the cardiac end, for purposes of distinction. As long as the shaft remains in the wound, there will be little hemorrhage, especially if a bandage be rather tightly applied to the limb, the shaft serving as a means of making pressure on the wounded vessel. Arrow Wounds of Joints.—Usually arrow wounds of the joints do very well, but I can imagine a particular case which would involve the greatest danger. If an arrow shot with force should deeply penetrate the cancellous structure of the femoral condyles, and bury itself so deeply as to make the grasp of forceps unavailing—the joint of course being implicated—the patient would be in the greatest peril. lie would probably die if the foreign body should not be removed, and it could be removed only by a resection of the joint, or by amputation. Although I have never seen such a case, it might well occur, for an arrow head could readily penetrate so deeply into the thigh bone that not even the neck of the weapon would project. Perhaps in such a case the best course would be to employ expectant measures during the acute stage, and resort to secondary excision at a later period. Arrow Wounds of the Head.—If an arrow strikes the calvaria at right angles, it will penetrate, provided that it has not lost its momentum,— the danger to the patient depending upon the depth of penetration and the locality of the wound. If one of the large sinuses or the important parts of the brain be injured, immediate death may follow. So perished Lieutenant Maxwell, of the Second IT. S. Infantry, by an arrow wound of the superior longitudinal shuts. There are numerous specimens in the Army Medical Museum showing arrow wounds of the calvaria. In specimen Xo. 5644, represented by Fig. 240, the arrow went through the thickest part of the ARROW W'OUKDS. 117 supcrciliary ridge, and penetrated deeply into the brain, and yet its presence was hardly suspected during life. If an arrow has penetrated but a short distance—as a quarter of an inch—into the skull, and the patient has symp- toms of cerebral compression, the probabilities are that a scale of bone from the vitreous table has been broken off, and, still sticking to the point of the arrow head, is making pressure on the brain. I have seen a patient with an arrow slightly penetrating the skull, immediately recover consciousness on the removal of the foreign body. It is probable that, in plucking out the arrow head, I drew back into its place a scale of bone which had been broken off from the inner table, and driven in against the brain. In two other cases of arrowr wound of the skull—-not, howover, seen during life—I found by an autopsy, that this depression of the inner table had occurred. The scale of bone was in each case spiked by the arrow point, and borne firpily against the dura mater and brain. The men had evidently been rendered insensible by the wounds in their skulls, for both had perished from other wounds re- ceived at close quarters. I think that this casualty is of rather frequent occurrence, and although there is no example of it in the Army Medical Museum, it must be remembered that this accident would immediately render the wounded man a prey to the savage who had shot him, and, after being scalped and otherwise mutilated, he wmdd be left dead on the field, or possibly buried where he fell. Thus it w'ould not be probable that any speci- mens would he procured. The immediate danger in arrow wounds of the skull, is from internal hemorrhage; and w'e infer that this has taken place if the symptoms of com- pression remain after the arrow head has been withdrawn. If the arrow' head has gone in very deeply, a large trephine should be applied, and the circle of bone and arrow head may then come aw'ay together. Next, any superficial bleeding vessels should be looked for, and twdsted, or, if they are lodged in bony canals, such as the meningeal, the wound should be plugged with lint. The exposure of the deeper parts to the air would at once give outward vent to the blood, thus relieving the compression, and at the same time constringing the vessels and so stopping the hemorrhage. Encephalitis is the secondary danger to which the victims of arrow wounds •of the skull are exposed. If the arrow7 head is removed, this inflammation will usually not be serious, and will yield to purgatives, ice, aconite, and rest. But if the arrow head is not removed, the irritation wTill produce abscess, wdnch will probably prove fatal. In these cases the patient is usually conscious, and perhaps unawrare that an arrow head is lodged in his brain, and quite skepti- cal as to the ultimate danger. If, after a cautious examination with the probe, the surgeon cannot find the missile, the case must be left altogether to nature. Should chronic inflammation be developed, as indicated by pain and delirium, and more particularly should abscess form, as indicated by stupor, it might be right to trephine. The pus might thus possibly make its escape, •or, by rare good luck, the arrow head itself might be found. Arrow Wounds of the Face.—Arrow wounds of the face are often attended with considerable hemorrhage, both primary and secondary. They are troublesome, also, on account of the sponginess of the bones, which permits the arrow to penetrate deeply, and then, by allowing the part to close over the head of the missile, opposes obstacles to its extraction. Fig. 248, from Circular Xo. 3, S. G. 0., 1871, represents a skull in which the arrow entered just above the zygoma,and,passing inwards, penetrated the brain through the temporal region. The shaft of the arrow had been plucked away, leaving the arrow head deeply embedded and entirely hidden in the temporal muscle, and hooked under the zygoma by one of its shoulders, so that its pres- 118 SABRE AND BAYONET WOUNDS—ARROW WOUNDS. ence was only conjectured by the surgeon. The specimen shows what difficulty would have attended the extraction of the foreign body, wedged down as it was under the zygoma, at its base, and penetrating into the skull as it did by its point. The specimen and the history of the case are demonstrations of the advantages in all cases of thorough digital exploration, not merely to determine the presence of an arrow head, but to enable the surgeon to decide what manoeuvre will best serve for its safe removal. In the above case, it would probably have been necessary to resect the zygoma, in order to get enough of the arrow head exposed for the grasp of the forceps. The man survived the injury about a month, and was, during most of this time, without threatening symptoms. Fig. 248. Arrow Wounds of the Neck.—This part of the body is often wounded, but, as the' table on page 109 shows, not with serious effects. Yet if the great vessels should be wounded, or the trachea spiked to the vertebral column—injuries not unlikely to be met with—the case would in all probability end fatally. I have never seen such an occurrence, but it is in tradition that Conrad of Lorraine, having removed his helmet at the mo- ment of victory over the Hungarians, received such a wound, and speedily died. Arrow wound of temporal bone with entangle- ment of arrow head by the zygoma. (A. M. M., Sect. I. Spec. 5907.) Arrow Wounds of the Chest.—Arrow wounds penetrating the chest and wounding the lung, although serious, are by no means necessarily mortal injuries. The table shows that in 18 such cases, there were 18 deaths, or about 72 per cent. The lung does not collapse after an arrow wound, as it is apt to do after a wound made by a ball, for the arrow shaft is tightly grasped by the cutaneous tissues, and the integrity of the pleural vacuum is preserved. But in this very collapse and contraction lies the patient’s safety against bleeding, and hence arrow wounds of the lungs are apt to be attended with internal hemorrhage, which, if at all profuse, leads to almost immediate death by apncea. If the patient survives the period of hemorrhage, the prognosis is favorable, for the consecutive inflammation is usually trifling, and requires no treatment beyond placing the patient at rest, and affording a supply of pure warm air. If the head of the arrow lias been left in the lung tissue,, nothing probably can be done for the patient. Only the most superficial examination with the probe is allowable. The patient will probably die with hectic, in the course of six weeks, or, if he survive, will remain an invalid all his life. If the shaft has not been removed, the external wound should be cautiously dilated with bistoury and finger, and the arrow head then snared by the bent loop, or grasped by the arrow forceps, and withdrawn. The loop is the better instrument in these lung cases. The greatest care should be taken not to detach the head from the shaft, for if this should hap- pen, and the head be lost, the patient would almost certainly perish. If an arrow has passed from one side of the chest to the other, as from the breast to the back, it is better to push it on, and make it emerge through an intercostal space, than to draw it back. If it is lodged in a rib, after travers- ing the chest from side to side, the point of this lodgment must be ascer- tained by gently striking the feathered end of the shaft whilst the fingers of ARROW WOUNDS. 119 the other hand are passed backwards and forwards over the rib until the point of greatest impact is determined, this, together with the direction in which the shaft points, fixing the position of the head. The rib is then to be tre- phined at this point. If an intercostal artery has been wounded, the applica- tion of the actual cautery is the most convenient means for arresting the bleeding: I have used a bent nail, heated, both in intercostal wounds and wounds of the inferior dental artery. Or the whole rib may be encircled by a ligature passed around it with a bent probe, or with a Gibson’s aneurismal needle, or with the blunt needle of the chain saw. An arrow transfixing both lungs, or the heart, would, if it lodged, necessarily cause immediate death. If it passed out at once, as it sometimes does through the chest of the buffalo, the patient might speedily recover. In wounds of the chest, if the pleura should fill with blood, this should be removed by the aspirator, if possible. If the blood is clotted, it might per- haps be rendered fluid by the injection of a solution of pepsine, as in the case of vesical coagula. Pus in the pleural cavity always requires the use of the aspirator, but empyema is not a common result of arrow wounds. Arrow Wounds of the Abdomen and Pelvis.—Arrow wounds of the abdomen are generally fatal. Hot only is there a liability to peritonitis from fecal extravasation, but the wound is apt to he immediately fatal from hemorrhage. But all wounds of the abdominal cavity are not followed by death. The table on page 109 shows two recoveries in twenty cases, a mortality of 90 per cent. In a very interesting case under the care of Surgeon Forwood, U. S. Army, and described in Circular Ho. 3, S. G. O., 1871, a large calculus which had formed upon an iron arrow head was removed from the bladder of an Indian. This man had been shot in the buttock while mounted, and at close range. The shaft of the arrow had been withdrawn, and the head was left behind in the bladder. The man made a good recovery. The treatment of arrow wounds of the abdomen consists in the removal of the missile; the checking of bleeding, by torsion or otherwise; the suturing the intestine, if wounded ; the thorough cleansing of the part from excre- mentitious matters; and the enforcement of rest. An incision should he made sufficiently large to admit the finger, and when the position of the arrow head has been determined, it is to be seized with forceps, and removed. If the shaft has been plucked away, the chance of finding the head is very slight; but the attempt should be nevertheless made, and if fecal matter is found in the cavity of the abdomen, no hesitation should be felt in laying this open and searching thoroughly for the foreign body. Bleeding points should then be twisted, and the intestine, if wounded, sewed up. Very fine carbolized catgut should be employed for this purpose, and it is of compara- tively little importance what particular form of suture is used, so that the operation is finished with as short an exposure to the air as possible. The parts, having been cleansed with water containing a little salt and egg serum, are to be carefully returned, and then the incision in the abdominal walls is to be secured by figure-of-eight sutures passing through the muscles as well as through the integument. Opium should be given to stupefaction, and the patient kept under its infiuenoe for several days, or until the pulse loses the characteristics of peritoneal inflammation. Any one who has used opium in this way will agree with me, I think, that it possesses, over and above its power of enforcing rest, a specific power of preventing or subduing perito- nitis. If any outward application is to he made, I should prefer moist heat, applied by means of large bran poultices. But it must be remembered that,, unless frequently renewed, and kept very hot (about 110° F.)—yet not too hot, for the patient, being nearly insensible, may easily be burned—they will 120 SABRE AND BAYONET WOUNDS—ARROW WOUNDS. do harm. A trusty and intelligent corps of nurses is indispensable, if heat is to be used in this way. After the primary danger of peritonitis is past, the patient should be kept in the horizontal posture for a month, and fed chiefly on beef, or mutton, or fowl, to which it will be prudent to add some pepsin. Olive oil will keep the bowels in a proper condition. In concluding the subject of arrow wounds, I would briefly recapitulate as follows:— (1) An arrow head must be removed as soon as found. (2) In the search for the arrow, extensive incisions are justifiable. (3) An arrow may be pushed out as well as plucked out. (4) The finger should be used for exploration in preference to a probe. (5) Great care must be taken to avoid detachment of the shaft. (6) Healing by first intention should be encouraged. (7) The surgeon should strive to comfort the patient. Although arrow wounds are not attended with much shock, they are usually the cause of great depression of spirits. “The constitutional disturbances following these wounds . . . are liable to be out of all proportion to the apparent amount of damage. There are almost always considerable . . . sleeplessness and great irritability, dejection of spirits, and intolerance of pain. The tendency to despondency becomes frequently a prominent symptom, to be carefully combated, and everything should be done to cheer the patient.”1 1 Coues, loc. cit. GUNSHOT WOUNDS. BY P. S. CONNER, M.D., OF SURGERY AND CLINICAL SURGERY IN THE MEDICAL COLLEGE OF OHIO, CINCINNATI J PROFESSOR OF SURGERY IN THE DARTMOUTH MEDICAL COLLEGE, ETC. Gunshot Wounds, as declared by John Bell, are “ of most desperate nature, more various than can be imagined, to which all parts of the body are equally exposed.” Their frequent occurrence, their danger, and the influence of correct diagnosis and proper treatment upon their progress and result, render the consideration of these injuries of the highest importance to every surgeon, in civil as well as in military practice. Whether produced by small or large shot, by bullet or shell-fragment, or by some one of the much less commonly met with vulnerating bodies (percussion-cap, portion of gun, piece of stone, etc.), directly or indirectly propelled by the explosion of gunpowder, they are, with almost no exceptions, to be classed under the head of lacerated and contused wounds. Their gravity varies according to the importance of the part injured, and to a considerable extent is proportionate to the size and velocity of the missile. Other things being equal, a perforating wound •of any part is less dangerous than a penetrating one in which lodgment lias taken place, and a large shot, though moving at a low rate df speed (when nevertheless the momentum is great), may produce extensive damage. Missiles. As met with in civil life, these wounds are usually produced by small shot or pistol balls; very occasionally by parts of an exploded piece, by cap, by wadding, by cartridge-shell, or by ramrod. So-called “ shot” vary in weight from 133 grains (the largest buck-shot) to as low even as less than one-fifth of a grain (2700 to the ounce), and pistol balls from 25 -f grains to 350 grains, of a diameter ranging from .22 up to .50 of an inch. The U. S. service revolver bullet has a diameter of .458 inch and a weight of 230 grains. The heat of the powder explosion may at times fuse a bird-shot charge into a single ball of nodulated exterior. In military surgery, the great majority of wounds result from rifle bullets; quite a number from shell fragments or ■case-shot balls; some, but not many of those coming under treatment, from solid shot or unexploded shells, and, as in siege operations, from grape-shot. In battles fought in the open country, about nine-tenths of all the wounds received are from bullets—91 per cent, among the Germans in the Franco- German war (Fischer), 94.2 in the Italian campaign of 1859 (Longmore); in siege operations and assaults upon fortifications, the relative proportion of large shot, shell, and grape injuries is, as might naturally be anticipated, very much higher—in the Crimean war about 46 per cent. 121 122 GUNSHOT WOUNDS. With the use of the modern arms of precision, the old-fashioned round balls, of f to 1| oz. weight each (Fig. 249), have almost entirely disappeared as vulnerating bodies, except as secondarily projected by the bursting of case- shots filled with them. The muzzle-loading smooth bore, with the single Fig. 249. Fig. 250. Fig. 251. Fig. 252. Fig. 253. Round musket ball. Springfield rifle ball Enfield rifle ball. Ball for Snider gun. Ball for needle-gun. ball or “ buck and ball” cartridge, is as much a thing of the past as “ brown Bess” herself. The service bullet of to-day, long and generally conoidal (Figs. 250, 251, 252)—egg-shaped in that used with the needle-gun (Fig. 253)—has a diameter of from .41 to .45 inch, and weighs from 315 to 480 grains. The Swiss magazine-gun bullet measures .41 inch, and weighs 315 grains; the Russian .42 inch, 375 grains; the Austrian .425 inch, 318 grains; the French .45 inch, 380 grains; the Bavarian .45 inch, 340 grains; the Prussian .45 inch, 380 grains; the English .45 inch, 480 grains; and that of the United States .458 inch, 405 grains. In the English and American service the bullet is made of hardened lead—13 parts lead, 1 part tin (English); 16 parts lead, 1 part tin (American)—and such bullets may perhaps do less damage than those of soft lead, though it must be remembered that in the experi- ments that have been made, the diameter of the pure lead Enfield bullet (Fig. 251), was considerably (0.1 inch) greater than that of the hardened one fired from the Martini-Henry rifle (Fig. 257). The Mitrailleuse ball (Fig. 258) weighs about If oz.; the Gatling guns use calibres .45 and .50 small arm ammunition, a “ half pound solid elongated projectile,” and a one inch Fig. 254. Fig. 255, Fig. 256. Fig. 257. Fig. 258. Austrian ball. Chassepot (French) ball, Bavarian ball. Martini-Henry (English) ball. Mitrailleuse (French) ball. canister holding 15 buck-shot; the projected Hotchkiss revolving cannon to to throw shells of a little over one pound weight, and case-shot filled with one ounce balls. , From field guns, the sizes of which vary considerably, shell and case-shot are fired, the use of solid shot having been of late abandoned; the cases con- taining from 41 to 245 or more balls each, of iron in the English service, of 123 EFFECTS OF GUNSHOT WOUNDS UPON THE VARIOUS TISSUES. •lead in our own. From fixed guns and from the larger guns on shipboard, are thrown both solid and hollow shot, the weight of the single-shot and shell missiles employed ranging from seven to two thousand pounds. If it was true three hundred years ago, as declared by Pare, that a gunshot “going with mighty violence pierces the body like a thunderbolt,” how much more- so is it now, when a bullet fired from an ordinary Springfield rifle can be driven through 2 inches of pine wood, and from a long-range Springfield rifle through 5 inches of pine at 2500 yards distance; and when a ball from the latter arm is able to pass through 2 inches of pine and penetrate the sand to a depth of 6 inches at a distance of 2 miles (more exactly, 3500 yards). Effects of Gunshot Wounds upon the Various Tissues. Before proceeding to the consideration of the results, immediate and secondary, of gunshot wounds, it will be well to notice the general effects- which they produce upon the various tissues that may he damaged. Skin.—If merely grazed, there will occur either limited erythema with decided pain (“brush-burn”), slight contusion with associated blood-extravasa- tion, or such impairment of vitality as will be followed by the formation of a dry slough. If more fairly struck, there will be either penetration or con- tusion, according to the velocity and size of the vulnerating body. So great is the elasticity of the integument, that it may yield sufficiently to escape- laceration, while there will yet take place extensive extravasation of blood,, crushing—even purification—of the muscles, and comminution of bone. Such destruction is often produced by large shot, solid or hollow, or a massive fragment of an exploded shell, either passing lightly, but at a high rate of speed, over the surface, or striking only when nearly spent.1 infrequently it happens that a bullet, striking at an oblique angle, pierces the skin, runs- underneath it for a greater or less distance, and passes out again, forming what has been denominated a seton-wound, the track of which is often indicated by a line of discoloration upon the surface. Fascia:.—In the passage of a shot through the superficial fascia, laceration and contusion occur, not confined to the part actually traversed, but extend- ing for a variable and often considerable distance on either side, there being seldom, if ever, when the wound is inflicted by a round ball, any actual removal of tissue, though a conical bullet carries along with it a greater or less amount of that which it has killed. In piercing the dense external layers of the deep fascia, balls, conical ones particularly, separate somewhat the crossing fibres, so that these fascial openings are of less diameter than the track generally, for which reason they more or less interfere with the subsequent outflow of pus. If of any considerable size, they oftentimes are not filled up in the progress of repair, but their edges cicatrize, leaving a permanent opening through which in after life muscular bulging readily occurs. Oftentimes fascial resistance will be sufficient to deflect the shot,, the angle of the line of new direction to that previously travelled varying according to the shape and velocity of the ball, being much greater in the 1 Macleod, for example, reports that at the Alma, “ a round shot ‘ en ricochet,’ struck the scale- from an officer’s shoulder, and merely grazed his head as it ascended. Death was instantaneous. The scalp was found to be almost uninjured, hut so completely smashed was the skull that its fragments rattled within the scalp as if loose in a bag.” Under my own observation, an exten- sive shattering of both bones of the leg resulted from the blow of a large piece of shell, which did not break the skin, the case having been sent in from the field as one of contusion simply. 124 GUNSHOT WOUNDS. •case of the round than in that of the conical bullet, and being greater when the movement of either form of ball is comparatively slow. The heavy pointed rifle-bullet, tired from a modern rifled musket, is unlikely to have its course much altered; while a pistol hall is frequently turned aside; and a round ball has over and again been found to “ run around” the half or even whole circumference of the body, its rate of speed being relatively low, and its axial rotation favoring the apparently anomalous course. Muscles.—These, when injured, are always considerably lacerated and con- tused, and infiltrated with extravasated blood; and, when the damage has been done by a large body, it will generally be found to extend through the whole length of the muscle, particularly so if there has been simple contusion without associated open wound. When the entire belly of the muscle has been broken across, marked separation of the divided parts takes place. However, when a portion of a limb has been carried away, as by a round shot, retraction of the torn muscles does not occur, their contractility having been destroyed by the intense force of the blow. So great is the momentum of the small muscular fragments detached by the conical ball in its passage, that they themselves become actual missiles, and often materially add to the damage resulting from the shot. As might naturally be expected, tendons are much more resistant than the fleshy parts of the muscles. They are often pushed out of the way by the passing ball; and even when they must necessarily feel the force of the blow, as from a large shot, they may be protected by the earlier giving way of the muscular bellies. In a case, for example, reported by Gillette, in which there was a very extensive crushing of all the other soft parts from a wound of the leg and foot, the ten- dons of the extensors, of the tibialis anticus, and of the flexors were not involved. Bloodvessels.—These, as has long been known, though lying in the direct path of a ball, are not infrequently pushed aside, and escape all injury—arte- ries, because of their greater thickness and elasticity, being much more likely than are veins to be thus preserved from harm. Very frequently, however, damage is done,- and there will be produced either (1) complete division, which is almost certain to occur if the wound lias been made by small shot at short range, or by the sharp edge of an angular piece of shell, and which is fre- quently observed in rifle-ball wounds ; (2) the cutting out of a piece of the vessel wall; (3) contusion, followed by temporary or permanent occlusion of the canal, or by sloughing of the bruised vessel and consequent secondary hemorrhage; or (4) the formation of a traumatic aneurism, which may be limited to the artery itself, or may be arterio-venous, if both artery and vein have been involved in the injury. It is possible, also, as shown by a case reported by Lidell, that an aneurism may be developed from the extremity of a completely divided artery. Nerves.—Much less often than bloodvessels are nerves found to have safely glided away from the vulnerating body, their more usually observed injuries being division, complete or partial, contusion, and concussion. Occa- sionally small foreign bodies (such as splinters of wood or pieces of lead) become lodged in a nerve, causing either little or no inconvenience, or, as is more common, severe and persistent neuralgia. Impairment or entire loss of motion or sensation; pain of varying degree and duration, at times burning (the causalgia of Mitchell); trophic changes, or absolute destruction of the vitality of the parts supplied, are the results of these nerve injuries. 125 DIAGNOSIS OF GUNSHOT WOUNDS. Bones.—The violent impact of a ball or piece of shell will produce either contusion or fracture. The fracture is very rarely simple, though such an accident may Tfesult from the blow of a piece of wood, or iron, or stone, set in motion by a gunshot projectile which has struck it. It is ordinarily com- minuted, frequently extensively so, though there may be (rarely it is true) pene- tration or perforation without shattering. The contusion may be so slight as to cause little or no damage; so severe as to at once destroy the life of the part struck; or, as generally happens, sufficient to light up destructive in- flammation. Penetration and lodgment of the missile may occur; the bullet,, if not removed, either becoming encapsulated, or, as is generally the case, causing inflammation and suppuration, and being often, months or years afterwards,found lying loose in an abscess cavity. When it is a long bone that has been pierced, the shot or a part of it may, as in a case reported by Sur- geon-general Murray of the British Army, drop down in the medullary cavity, and, by its presence, keep up an osteomyelitis of low grade. Diagnosis of Gunshot Wounds. That a gunshot wound has been received, is generally determined by the history of the case and the observation of an abnormal opening or openings upon the surface of the body. Very seldom does it happen, except in attempts at suicide, that the bullet enters by a natural orifice, though it may do so.1 Ordinarily, the points to be decided are: (1) Whether or not penetration and lodgment have occurred; (2) What course the ball has taken; and (3) Whether the discovered multiple wounds are due to a single shot or to several. At first sight it would seem to be a very simple matter to determine that a bullet had lodged, a single opening only being found. But it may already have been removed, or it may have rebounded, as happens at times when the skull or other comparatively superficial bone has been struck, owing to the elasticity—not of the lead—but of the osseous tissue; or, what not infre- quently happens in cases of spent balls, particularly round ones, it may have been drawn out by the clothing, a part of which, uncut, had been carried like a glove finger over and in front of it. Inspection should always be made, therefore, of the clothing that covered the wounded part. Much more difficult is it oftentimes to know in what direction the ball has passed, and where it has stopped. The clothing is to be examined, and the position noted of the openings in the various layers, relatively to each other and to the skin wound. The body is to be placed as nearly as possible in the same position as when struck, if this can be determined; a rule of practice as old as the time of Pare. The direction in which the shot was fired, if known, must be taken into consideration. By use of the probe, or better, the finger, the track is to be followed, as far as possible, or until penetration of one of the great cavities is ascertained. A conical bullet, moving at full speed, ordinarily passes straight from the point of entrance to the place of lodgment, if it does not, as it is likely to do, pass through and out; but it is a mistake to declare, as has been done by many, that deflection cannot take place. Fascife, and still more bone, will at times turn the bullet aside. Pistol balls are not infrequently thus affected. I have seen, for instance, a case in which the shot, entering the right temple, passed through the anterior lobes 1 This was instanced in the case of a distinguished general officer during our late war, who was killed by a shot that passed in through the anus. Gillette reports, on the authority of a M. Boissimon, a hardly credible story of a French officer who was shot in the face, the hall enter- ing through the anterior nares, passing back and striking the posterior pharyngeal walls, and rebounding through the mouth. 126 GUNSHOT WOUNDS. of the brain, struck the skull on the left side, and was turned almost at a right angle to its previous course, and lodged in the left posterior lobe. The old-time round ball was very apt to glance and pursue an erratic way, at times making a complete circuit of the body, and emerging through the entrance wound. A spherical shot of considerable size may be turned aside; thus Otis reports a case in which a “one and a quarter inch grape, from a battery about three hundred yards distance, was deflected on striking the hyoid bone, and buried itself in the muscles over the right shoulder-blade.” Even when the direction has been determined and the track followed, it may not be easy to ascertain the location of the ball. It may be masked by a piece of cloth (and nothing but the finger will, as a rule, recognize the pres- ence of such), or it may be a question whether the probe is in contact with ball or bone; a question that of late years has ordinarily been settled by the •employment of the “Aelaton probe” (Fig. 259), the unglazed porcelain tip of Fig. 259. Nelaton’s bullet probe. which will take a slight bluish stain when rubbed or pressed upon lead. {Having once taken such a stain, however, it is likely to ever after retain it, so that practically a fresh instrument will be required for each new case that is to be examined.) In default of a probe, a clean clay pipestem,1 or a piece of soft pine may be advantageously used as a searcher. At times it may be practicable to pass in a pair of cutting forceps, and bite off a small piece of the body, examination of which will reveal its metallic or other nature. Various electrical appliances have been used: either probes to be carried along the track of the wound—contact with the metallic foreign body causing the ringing of an attached bell, or deflection of a galvanometer; or needles thrust through the overlying tissues and made to touch the supposed ball, and, by the establishment of a circuit, act on an annunciator or galva- nometer; or surface electrodes, which in passing the current through the lead, will cause pain, burning, tingling, and perhaps shock. Thus far the use of electricity in enabling the surgeon to recognize the existence and location of a ball, has been but limited, and, in the main, unsatisfactory in its results. Of such chemical methods as that of Deneux, who suggested the use of a weak acid, either upon an exploring instrument or injected through the track, it may be well said that “ though they are ingenious, they are too delicate and too uncertain to be of any great service in Military Surgery.” (Eocliard.) Where no positive evidence of the location of the projectile can be obtained, either by exploration of the wound or by palpation of the area of the skin towards which it must have passed, its position in a particular part is often rendered very probable by the localized pain which is experienced, by the swelling which, after a few days, is developed, and by the decided interfer- ence with the making of certain movements which is recognized. Wounds of Entrance and Exit. Speaking generally, the entrance wound is smaller than that of exit; but under certain cirumstances, and at certain times, the reverse is found to be 1 Legouest, ten years ago, reported that he was in the habit of using the clay pipestem, and Heighway employed it during our late war with Mexico, twenty-five years earlier. WOUNDS OF ENTRANCE AND EXIT. 127 true. The differences in this respect that have not infrequently been noticed, and the resulting, conflicting views of observers and writers, may be easily understood and readily explained. It is a well-known law that splintering and tearing are in inverse proportion to momentum, and according as the velocity of a missile is lessened in passing through a portion of the body, will the orifice of outlet present greater size than that of inlet. This dimi- nution of force being much more in the case of a spherical than in that of a conical ball, wounds produced by the former will show correspondingly greater differences in size than those produced by the latter; indeed, often- times, a pointed bullet, moving at a high rate of speed, will in its perforation make skin openings that cannot by their size alone be distinguished the one from the other. Again, if the point of entrance is over a surface of bone but a little beneath the skin, as, for instance, on the chin or over a rib, and especially if the shot has been fired at short range, the extent of laceration will be very great; and on the other hand, if the ball in its course shatters a bone just before going out, or carries along with it a quantity of crushed and separated tissue, the amount of skin-tearing will be much in excess of that which otherwise would have occurred. The size of the primary wound will also be decidedly affected by the obli- quity of the angle of entrance, a large degree of which will cause raising of the skin and consequent bevelling of the orifice. After a few days, when separation of the slough has taken place, the entrance wound will usually be as large or larger than that of exit, especially when the injury has been caused by the passage of a round ball. When the shot has been fired at very close range, and has struck an uncovered part of the body, the entrance wound may often be recognized by the powder staining around about it, though such evidence is not as likely to be had at the present time as for- merly, since the modern improved powder is so much more thoroughly burned up at the time of its explosion. Multiple Wounds are often met with, and may be due to several shots or to a single one. When to several, these may all have been inflicted at once— as from the bursting of a shell or of a “ spherical case,” or from volley firing— or they may have been received at different times; and when due to a single shot, they may be consequent upon the repeated passing in and out of the same ball, as in traversing both upper and lower extremities, or the forearm, Fig. 260, Fig. 261. Section of frontal bone with split musket ball impacted at left frontal eminence. (A. M. M., Spec 1293.) Interior view of frontal bone represented in Fig. 260. arm, and chest, or may depend upon the splitting of the bullet, either before entering the body, or by contact with a ridge or edge of bone. Not infre- quently, the fact that the existing three, four, or more wounds are due to the* same shot, can be ascertained only by placing the several parts of the body in 128 GUNSHOT WOUNDS. similar position to that held at the time of the injury, and by seeing that the various openings are then all in line ; and even this study of position will not always answer, for there may have been deflection of the ball at some- point of its course. That bullets, particularly round ones, are occasionally split, either in passing into or through the body, every one knows, and such division may be complete or partial. In a case under my care, a round musket hall that struck and fractured the frontal bone was so far split as that one part passed into the opening in the hone, while the other rested on the extenial surface, a narrow bridge uniting the halves. (Figs. 260, 261.) Conical rifle bullets are much less likely to be thus affected, but abundant evidence has accumulated to prove the incorrectness of Macleod’s belief that “ with their immense force of propulsion the}7 cannot be split.” (See Figs. 262, 263.) Pistol balls, elongated though they are, are every now and then divided. Fig. 262. Fig. 263. Section of right parietal bone on which a conoidal musket ball has split. (A. M. M., Sect. 1, Spec. 2121.) Interior view of parietal bone represented in Fig. 262. Quite recently I saw, post mortem, that one of these missiles, after boring through the head and neck of the humerus, had, in striking the edge of the glenoid cavity,. Fig. 265. Head and neck of humerus perforated by a pistol ball which was smoothly cut in two upon striking the scapula. (See Fig. 265.) Pistol ball split by striking upon bone. (See Fig. 264.) been smoothly cut in two, one half lodging in the supra-spinous and the other in the infra-spinous fossa (Figs. 264, 265). Had in this case the propulsive power been a EFFECTS OF GUNSHOT WOUNDS. 129 little greater, these pieces would have been driven out, and there would have been three wounds, one of entrance and two of exit. Much more rarely than multiple openings from a single shot, has there been noticed a single wound from two projectiles, a condition of things that has been recognized only upon removal of the bullets, or from the persistence of discharge and non-closure of the track after one ball has been extracted. Effects of Gunshot Wounds. The general effects of gunshot wounds may be classed under two heads, 'primary and secondary.. The former are consequent upon nervous and vascu- lar disturbances, and are pain, hemorrhage, and shock. Pain is exceedingly variable in character and amount, depending upon the shape and velocity of the shot, the part struck, the constitutional suscepti- bility of the subject, and the special mental condition at the time. Occasion- ally acute, it is more often dull and tingling, a sensation of contusion as if from the blow of a stick, the degree of the pain, speaking generally, being in inverse ratio to the velocity of the shot. It may not be felt at all: ordi- narily because the shot has been received at a time when the individual was under strong excitement, but not necessarily so, as instanced, for example, in the case of wound through both hemispheres of the brain reported by Harvey. The patient, who was seated in a buggy at the time of the accident, experienced no pain and felt no blow on the reception of the injury, but remarked to a gentleman who occupied the buggy with him, that one of their guns must have gone off prema- turely, as he judged from a sensation similar to that produced by the report and con- cussion of a shot fired near the ear.1 When large nerves or nerve cords are divided, there may be immediately experienced a severe pain, lasting ordinarily but a few moments, but in nu- merous cases little or no suffering is caused. Hemorriiaqe, too, is very variable in artiount, being affected by the size of the vessel, the extent to which this is damaged, and the nature of the vul- nerating body. Wounds of the main trunks, if made by large bullets or angular shell-fragments, are very generally followed by immediate and fatal bleeding. To such we are undoubtedly justified in attributing many of the deaths in action, though it is impossible to estimate the proportion of mor- tality due to this cause with any degree of accuracy, owing to the small num- ber of battle-field examinations that have been made. The French reports from the Crimea place it at 18 per cent., a figure certainly none too high. Lidell has shown that hemorrhage was evidently the cause of death of nearly one-half of the forty-three soldiers whose bodies he examined after an engage- ment in front of Petersburg; and that of the remaining half, most were shot in the head. But while they are of the gravest character, these wounds of the great vessels are not necessarily at once mortal. The aorta itself has been pene- trated by a round ball, and life preserved for days and even for weeks. During our late war, cases were treated in hospital in which the vertebral, carotid, subclavian, axillary, and common iliac arteries, and internal jugular, internal iliac, and femoral veins were divided, as was proven by post-mortem exami- 1 Asst. Surg. P. F. Harvey, U. S. A., in American Journal of the Medical Sciences, July, 1879. 130 GUNSHOT WOUNDS. nation. I have myself seen a patient live for ten hours after a pistol ball had passed through the superficial femoral and profunda arteries and the femoral vein; and another in whom death did not occur until the eleventh day, though the pistol ball had cut the left subclavian. Ordinarily, the primary hemor- rhage, aside from the first gush, which may or may not be considerable, is but slight, so much so that it lias often, though incorrectly, been declared that “ gunshot wounds do not bleed.” The explanation of this is, of course, to be found in the contused character of the wound of the vessel—contraction, retraction, curling up of the divided inner coats, and coagulation, all combin- ing to close up the orifice. At a later period in the progress of these cases, secondary hemorrhage is very likely to occur, and is often followed by a fatal -issue. Shock.—This nervous disturbance, of the intimate nature of which little -or nothing is known, but which for the present may be assumed to concern 'chiefly the ganglionic system, is in some degree or other an almost constant accompaniment of gunshot wounds. This “ reflex effect of the injury of nerves, large or small” (Mitchell), is indicated by enfeeblement of the heart’s action, and occasionally disturbance of its rhythm ; by resulting pallor, especially of the face, with clamminess of the skin, and at times decided and great reduction of temperature; by nausea and vomiting; by relaxation of the sphincters; by mental irritability, amounting it may be to delirium; and by more or less complete loss of consciousness. These reflex phenomena are very often markedly aggravated by the effect of fright on the one hand, and of hemorrhage on the other, so much so that in a given case it may be difficult, indeed impossible, to properly apportion the observed symptoms to these simultaneously acting causes. The nearer the wound is to the three great centres—those of intellection, of circulation, and of digestion—the greater, other things being equal, is the degree of shock produced, the greatest being, as a rule, noticed when the intra-peritoneal viscera are damaged, as might naturally be expected from the intimate nervous connection which these all possess with the semilunar ganglion, “ the abdominal brain.” From the earliest times, surgeons have laid it down as a law that severity of shock is proportionate to, and consequently indicative of, the gravity of the injury ; and this is un- doubtedly true, though the original constitution of the individual and his special mental state at the time of the wound (as regards fear, excitement, drunkenness, etc.) exercise a great influence upon the degree of development of this condition. In a diagnostic point of view, the most important symp- tom of shock is reduction of temperature. Redard, as the result of careful observation of fifty cases in Paris, declares that “ In gunshot wounds, a fall of temperature is a constant phenomenon. . . . Every wounded man brought to field hospital presenting a temperature lower than 35.5° C. (about 96° F.) will succumb, and consequently it is useless in such cases to resort to any operation. Every wounded man in whom a salutary reaction does not come on by the ond of the fourth hour, and in whom the reaction is not in direct proportion to the fall [of temperature previously], ought to be considered as in a very serious state. Pene- trating wounds of the abdomen produce an exceptionally low fall of temperature, which is more marked as the stomach is approached. . . . Wounds by shell, other things being equal, produce a more marked fall of temperature than those by ball.” Secondary Effects.— The secondary effects are those of inflammation, the degree of which will he very materially affected by the condition of the sub- ject, the location of the wound, the size of the shot, and the treatment em- ployed. Although at times flesh wounds, especially those made by single bird-shot and small pistol balls, are quickly recovered from, and the healing COMPLICATIONS OF GUNSHOT WOUNDS. 131 is accompanied with very little local disturbance—so little that practically the repair is by first intention—yet, in the great majority of cases, gunshot wounds follow the ordinary course of lacerated and contused injuries. The devitalized tissue along the track is thrown off, suppuration occurs, granula- tions are developed, adhesions take place, and the external wounds in due time cicatrize. The inflammation which attends the reparative process is early set up, frequently within a few hours—six or eight—almost certainly within twenty-four, and in simple cases presents nothing peculiar. In the severer injuries, as those in which a bone is damaged, both the local and constitutional symptoms are much graver, and there is a strong probability of the development of one or more of the several complications to which re- ference will presently be made. In proportion as the patient is in good health, receives prompt attention, and is kept quiet, is the probability of but a moderate degree of inflammation resulting; and, on the other hand, when, as is so often the case in time of war, the constitution is already enfeebled by excesses, over-work, or disease—the wound is for hours, perhaps days, neglected—and the patient has been jolted for miles over rough roads—even the simplest of flesh wounds may be attended by local and general disturb- ances of high grade. Complications of Gunshot Wounds. Of much greater importance, because of their much greater danger to life, are the not necessary, but frequently occurring, complications of inflammation and results of wounds: secondary hemorrhage, septicaemia and pyaemia, gan- grene, erysipelas, and tetanus. Secondary Hemorrhage.—Though, as we have already seen, severe primary bleeding is of comparatively infrequent occurrence in the cases of gunshot wound coming under treatment, a later hemorrhage very often takes place, and contributes largely to the fatality of such injuries. This bleeding may come on within a few hours after reaction has been established (when it is simply “ delayed,” and not properly “ secondary”), or, which is much more common, after the expiration of several days or even weeks; complete cer- tainty of its non-occurrence being only secured by the entire healing of the wound. In the great majority of cases, secondary hemorrhage depends either upon the separation of an originally contused portion of the vessel-wall, or upon the melting down of an artery and of its plugging coagulum, in the midst of an inflamed and suppurating area. In the former case, it is most likely to come on during the second week, and probably the first half of it; and in the latter, somewhat later, quite generally from the fifteenth to the twenty- first day. The first hemorrhage is usually very profuse, when the artery is opened by the detachment of a slough, and may be so when due to ulceration, though frequently in such a case it is primarily but slight, but soon recurs in larger and perhaps fatal amount. The blood may almost wholly escape externally, or may be chiefly poured out into the surrounding tissues ; or there may be both extensive infiltration and large discharge from the wound. The accident may come on without any special exciting cause; or may be due to injudicious movements—as, for instance, of a limb in which a sharp edge of bone has been for days fretting away the arterial coats, or in which a bone fragment is thrust against an already softened vessel—or of the whole body, as when the patient makes an unwonted exertion, as in jumping out of bed; may result from sudden dis- turbance of the circulation from mental excitement, as from anger; or, which 132 GUNSHOT WOUNDS. is a very frequent cause, may follow upon violent straining, as at stool. Ca- chectic conditions, especially scurvy and chronic diarrhoea, and the very much more rarely met with peculiar constitutional predisposition of “ bleeders,” render the occurrence of hemorrhage after the receipt of a wound much more likely. However produced, secondary hemorrhage may quickly end the life of the patient, as it is very apt to do if the artery is above medium calibre; or recurring again and again, by the resulting prostration and mental de- pression, it may more slowly, but none the less surety, bring about a fatal result. Septicaemia and Pyaemia.—To “ blood-poisoning,” especially in military practice, is due in a great measure the mortality of gunshot wounds not necessarily and speedily fatal. Consequent, probably, upon the absorption of an organic, septic material, developed in the injured tissues, it may manifest itself by phenomena due to the circulation of blood untit for nutrition, the nervous system being thereby profoundly impressed (septicaemia); or by the formation of visceral metastatic abscesses, chiefly in the lungs and liver (pyaemia). Occasionally both conditions exist together. The poison, what- ever it may be, is ordinarily formed in connection with an open wound, either produced by the shot or by subsequent operation; but is at times generated in the damaged tissues of a contusion. The lymphatics are its chief primary carriers in the septicsemic cases, the veins in the pysemic. In the former, the symptoms are ordinarily developed at an early period, sometimes within the first thirty-six hours ; in the latter, they do not appear until after suppura- tion has been established. Diffused metastatic inflammations, with result- ing suppurations, are met with in both forms of blood-poisoning, but more commonly in the pysemic; and such inflammations attack by preference the larger joints and the superficial fascia, and occasionally the viscera and glands. The circumscribed, multiple abscesses of the lungs, liver, spleen, kidneys, or brain, are due to embolic infarctions, the emboli being not simple, but septic, and the poisonous impress having been made upon them while they were still component parts of the primary venous thrombus. Whether or not external aerial organisms are the exciting causes of the poison-genevating changes that take place upon and in the immediate vicinity of an open wound, is still a question. That the poison once generated can be transferred from one wounded man to another by sponges, by dressings, by attendants, or by currents of air, admits of no doubt. For can it be denied that everything that tends to lower the general tone of the system renders an individual more likely to suffer from septic disease. Malarial affections, scurvy, forced marches, insufficient and improper food, excesses, the depres- sion of defeat, captivity, with its frequently associated overcrowding—each and all have contributed much to the predisposing of wounded soldiers to outbreaks of this bane of military surgery, that at times becomes, as it was in the late siege of Paris, a “ hideous scourge.” Symptoms of Pyaemia and Septicaemia.—Though these two affections have in their symptoms much in common, yet they present sufficient differences to permit ordinarily the ready establishment of a differential diagnosis. Both are marked by rapidly developed high fever, with great, irregular, and quickly recurring (almost always daily) variations of temperature, the thermometer indicating a body-heat at one time as low as normal, at another as high as 104°, or 106°, or even 107° F.—higher as a rule in septicaemia than in" pyae- mia. The pulse is feeble, and generally rapid, though there is not of necessity the ordinarily observed relationship between pulse-rate and temperature. Profuse sweatings occur, especially in pyaemia; diarrhoea is often present; and the breath acquires a peculiar and characteristic odor. Little or no pain is COMPLICATIONS OF GUNSHOT WOUNDS. 133 experienced ; mental hebetude is generally well marked ; a low muttering deli- rium is very frequently present, and, much more rarely, an active maniacal state. As we have already seen, septicaemia may set in at any time, pyaemia only after suppuration has occurred. Septicaemia is very seldom ushered in with a chill, and, when it is, never has more than the initial one; pyaemia always commences with a chill, and sub- sequent rigors, occurring at irregular intervals, are very rarely absent. The skin in septicaemia is pale and sometimes muddy; in pyaemia it is jaundiced, often deeply so, though the discoloration may be noticed chiefly, perhaps only, in the conjunctiva. In septicaemia, viscercd inflammations are not com- monly present; in pyaemia, pleurisy and • pneumonia, or hepatitis, are lighted up around the abscesses, though frequently these occasion comparatively little distress. A septicaemio parotitis has not infrequently been observed, and in most instances in which it has been seen, the case has terminated fatally. The pyaemicjof/d suppurations, and abscesses in the superficial fasciae, are very rapidly developed, and frequently give rise to no subjective symptoms what- ever. The attending wound, if suppuration has become established, usually becomes dry, the granulations are pale and withered, and what pus there is, is often fetid, though at times little or no change in appearance or secretion is observed. Prognosis.—The fatality of acute blood-poisoning is extreme; and every one who has seen much of it will be almost if not altogether ready to declare, with Mr. Longmore, that it is doubtful whether in military surgery it is ever, when thoroughly manifested, “ checked in its deadly advance.” In civil life, recoveries occasionally take place. Death may, particularly in septicaemia, occur within twenty-four hours, but usually the patient lives from four days to a week. Subacute and chronic cases much more often terminate favorably, though even in these the percentage of deaths is high, especially in the chronic variety, in which very often, after weeks of little or no apparent change in the symptoms, as indicated by pulse and temperature, the patient finally succumbs to the slowly but surely progressing prostration. Gangkene.—Consequent upon, or at least associated with, gunshot wounds, both traumatic and hospital gangrene are met with ; the former frequently, the latter rarely, and then, usually, occurring as a local epidemic. Traumatic Gangrene.—The ordinary traumatic gangrene of military surgery is of the moist variety, and may depend upon one or other of several causes. Very occasionally, the death of a part is immediate upon the receipt of the blow—for it is usually due to contusion by large shot—both bloodvessels and nerves being functionally, if not actually, destroyed at once. The color of the skin is at first unchanged, or whiter than normal; arterial pulsations are absent, and the local temperature is much and rapidly lowered. Again, after the receipt of a bullet wound, apparently of no special severity, pain may, in the course of a few hours, be experienced in the injured part, followed by rapidly forming great swelling, lividity of the skin, and gaseous distension, with constitutional symptoms of high grade—an intense typhoid condition being often developed before death, which takes place generally within twenty-four hours.1 The development of such “gangrene foudroyante ,” asso- 1 As an example of speedy death, may be cited Gillette’s case, in which, on the fourth day after the receipt of a shell wound of the forearm, “in the morning, the whole left upper extremity, from the hand to the clavicle, was found to be extremely swollen, the skin as tense as a drum' head, presenting in places a violet-blue discoloration with blebs. Emphysematous crackling could he felt all over the limb. In spite of numerous incisions, the patient died in the middle of the day.” 134 GUNSHOT AVOUNDS. ciated with open wound, has of late been generally attributed to the influence of septic bacteria, but by Wyatt (who saw’ it in Paris during the siege) it is declared, though incorrectly, to be confined to the low7er extremity, and to always indicate division of the sciatic nerve. The great majority of cases of gangrene are consequent upon interference with either the inflow or outflow of blood in the wounded part, or below it; and such interference with the circulation may be caused by inflammation, by blood infiltration, by the plugging or ligation of the main vessels, or, occa- sionally, by the constriction of badly applied dressings. In inflammation, there is both stasis in the vessels of the affected area, and pressure exerted by the effusion and exudation upon the arteries and veins of the adjacent parts ; in the hemorrhagic infiltrations, there is like pressure .exerted by the extrava- sated blood, which may be in a single mass of considerable size, from tear- ing of a large vessel or vessels, or in many small collections from the general laceration that is always found extending some distance on either side of the wound. Very generally these two causes, in varying relative proportion, are found acting together. The gangrene thus produced presents the ordinary symptoms which cha- racterize it when resulting from traumatisms other than gunshot, the pain, the after insensibility, the coldness, the color changes, and the tendency (stronger or weaker, according to the extent of the damage and the general condition of the patient) to the formation of a line of demarcation and spontaneous separation of the dead tissue. When the chief artery or vein, or both, of a limb have been contused, their closure is very apt to occur, either from the pressure of blood from the ruptured vasa vasorum, extravasated between the sheath and the vessel, or, much more probably, from the formation of a thrombus; sometimes, perhaps, from inflammatory stenosis. The resulting mortification begins at a distance, and usually, if left to itself, advances steadily and rapidly up the limb, with not even an attempt at the establish- ment of a line of demarcation, and speedily causes death. In such a case, following a wround from side to side through the popliteal space, I savr the whole limb become gangrenous, and the patient (lie in less than thirty-six hours after the first symptoms manifested themselves in the foot. When the cause is not plugging, but ligation of the main artery, though there may be a similar uninterrupted extension of the mortification, spontaneous arresta- tion not infrequently occurs; just below the knee, for example, when the femoral or popliteal is the trunk that has been tied, the vitality of the parts above being maintained by the blood carried through the profunda. The fatal result in these cases of gangrene is usually due to blood-poison- ing—either septiosemic, from absorption of the fluids from the dead and dying parts, or pyamic, from the formation of thrombi and their subsequent destruction—though wdieu death occurs suddenly, as it does at times, it may be, as maintained by Parise, because of the entrance into the heart of "the gases of decomposition, which produce results the same as those that follow the admission of atmospheric air through veins divided in an operation. Hospital Gangrene.—This, unlike ordinary gangrene, is not an effect—a death in mass from injury of nerves, or more generally of vessels—but is a disease which manifests its presence by tissue destruction of greater or less extent. Occasionally occurring sporadically, and in private practice, in the great majority of cases it is met with in hospitals, where large numbers of wounded are aggregated. Any wound, even the smallest, may suffice for its starting point, but it does not commence on an unbroken surface; shell wounds are said to be particularly likely to be attacked by it. Regarded by some as COMPLICATIONS OF GUNSHOT WOUNDS. 135 primarily a constitutional affection, it is believed by most to be of local origin, the general symptoms occurring only secondarily, and sometimes being absent altogether. Attacking more often those broken down by dissi- pation, overwork and over-worry, scurvy, diarrhoea, or malaria, it yet may seize upon the strongest and the healthiest. It cannot depend upon weather or place, since it has prevailed at all seasons and under the most diverse cli- matic and atmospheric conditions. Many of the Germans have seen in it but a wound diphtheria; but by surgeons generally tjie two diseases are regarded as separate both as regards etiology and symptoms, though both are charac- terized by the deposit of fibrinous infiltration on the affected tissues. Be- lieved by some to depend upon the presence of a special organism, none of the more competent observers have been able to discover in its discharges anything else than the ordinary bacteria of putrefaction. Heine’s statement is still a true one, that its cause is “a specific poison of unknown nature, which exerts its action upon the surface of the wound and produces a coagulation of the fluids, passing step by step through the superficial to the deeper parts. ” That hospital gangrene is both contagious and infectious, is certain, and when prevailing epidemically, its direct transmission from patient to patient may generally be easily shown. Three varieties are met with—the ulcera- tive, the pulpy, and the gangrenous—the two latter being very often, if not generally, associated. The ulcerative is the rarer and the milder form; the others are more com- mon, and are always attended by general disturbances, often of great inten- sity. Locally, the ulcerative form shows “ a small cup-shaped excavation, with raised edges of a deeper color than the rest of the wound, filled with a brownish tenacious ichor. Many of these ulcers may be simultaneously de- veloped on the same wound ; extending superficially and in depth, they de- stroy the granulations, and give rise to an abundant secretion of an ichorous fluid. The fusion of a number of ulcers accelerates the progress of the dis- ease that soon affects the entire wound, the suppuration of which is arrested, and in place of the pus, there is poured out a fetid liquid, colored dark by blood.” (Legouest.) In the 'pulpy variety, which may be the primary form, or may be consecu- tive to the ulcerative, there are developed “ false membranes, firmly adherent, covering a part or the whole of the wound. This semi-concrete material of a dirty grayish-white color, with blackish points as it were sprinkled over it, exactly covers the invaded parts ; it steadily and rapidly increases in thickness and consistence, then softens down, and becomes converted into a violet-gray putrilage, horribly fetid, that partially or completely falls off, leaving underneath sometimes an ulcerated surface, sometimes a layer of material that afterwards goes through the same changes.” (Legouest.) The gangrenous variety attacks usually “ recent wounds and stumps. The whole injured surface is covered with a layer of material that presents the appearance of moist gangrene, in which are found numerous particles of dead cellular tissue, with disseminated small blood clots of grayish, brown, or greenish color, and from which there exudes a grayish and very fetid fluid. The gangrenous layer is thrown off in mass, or in pieces of some size, on the third or fourth day ; dead masses, made up chiefly of the connective tissue, are drawn out in pieces of greater or less size from the muscular interspaces and the subcutaneous layers. The skin over the affected part is of a wine- lees redness, thinned at certain points, and softened at others where fluctua- tion is present. The detachment of the sloughs sometimes exposes a new pseudo-membranous layer; more often it leaves uncovered the tissues, which show themselves of a pale rose color, and which secrete a sero-purulent liquid of bad odor.” (Legouest.) 136 GUNSHOT WOUNDS. Hemorrhage not infrequently occurs in hospital gangrene, especially when the exudations are colloid in character, and if of considerable amount, the bleeding forms so important a feature of the case that some writers have de- scribed a special variety of the disease—the hemorrhagic. Hospital gangrene has an incubative stage of uncertain length, shorter in proportion to the after-severity of the attack. During this stage the wound ordinarily becomes dry, and the granulations perhaps oedematous, perhaps very vascular and irritable. Pain is always present from the start, and is usually a very important symptom, becoming not infrequently excruciating. High fever of typhoid character attends the severer and more acute cases. The temperature of the affected part is often but little elevated. The extent of the local destruction varies with the character of the attack, the con- dition of the patient, and the nature and thoroughness of the treatment. The connective tissues and the muscles rapidly melt down, while the tendons and ligaments resist for a considerable time. The larger nerves and blood- vessels do not readily yield, and have not infrequently been observed for days bridging over a chasm made by the destruction of muscles and fascife ; and oftentimes they escape altogether. In the worst cases, even the cartilages and bones are eaten up, and Ollivier reports that he has seen a whole extre- mity destroyed within 48 hours. The milder attacks may spontaneously terminate in recovery, but usually a favorable result is secured only by pro- per treatment. The severer cases judiciously cared for are ordinarily cured in fair proportion, though in certain epidemics the mortality has been enor- mous, as high even as 80 per cent. Death, when it occurs, may be due to erysipelas (which has been known to attack one-third of the cases), to hemor- rhage, to pyaemia, or to septicaemia. Not so very seldom, the disease has been seen affecting one wound on a patient’s body, while another on the same person remained unattacked. Thus Thomson has reported a case of simultaneous wound of both thighs, in which, “ whilst the gangrene was ravaging the left thigh, the rapid cicatrization of the right proceeded uninterruptedly.” How is such a condition of things reconcilable with the theory of a constitutional origin of the disease ? Erysipelas.—This affection is frequently seen associated with gunshot as with other wounds, occurring both in the simple and in the phlegmonous variety, and presenting its ordinary phenomena. The simple cutaneous form of the disease may appear early, but is often not developed until the healing of the wound is well advanced. When occurring in comparatively healthy subjects, it adds but little to the gravity of the case, merely, as a rule, delay- ing recovery. Phlegmonous Erysipelas (which oftentimes affects primarily the subcutane- ous connective tissue, and only secondarily involves the skin) is, on the other hand, a very serious complication, causing extensive destruction of tissue, and being, in a considerable proportion of cases, followed by death from exhaus- tion, or, more often, from blood-poisoning. Consequent upon either the influ- ence of outside organisms or septic material developed in the dead and dying tissues of the wound, phlegmonous erysipelas is commonly a hospital affec- tion, highly contagious and infectious, which may attack its subject early or late after the receipt of the injury. More likely of course to seize upon the weak and debilitated, its victims are often among the strongest and healthiest. Tetanus.—This most fatal of all the complications of gunshot injuries is, fortunately, of comparatively rare occurrence. Its cause is unknown. Usually regarded as consequent upon nerve injury, its symptoms being developed either 137 TREATMENT OF GUNSHOT WOUNDS. by reflex irritation or by induced pathological changes in the spinal cord, it is believed by many to be the result of a peculiar form of blood-poisoning, and br- others is thought to be due simply to atmospheric conditions. Tetanus is very seldom met with in connection with wounds of large nerve trunks, but is generally associated with lacerations of the peripheral filaments, especially in regions in which the Pacinian corpuscles are most abundant. It may manifest itself at any season of the year, but more frequently when there is a marked difference of temperature between midday and midnight,1 or when cold, wet weather follows a warm, dry spell. Prolonged high heat, as in tropical climates, unquestionably predisposes to tetanus, or at least favors its develop- ment. It seems to be of rarer occurrence among the wounded of modern wars than it was formerly, because, as may be properly assumed, gunshot injuries are now less irritated, and are better cared for than in previous times. Usually acute, and almost certainly fatal, it may be of milder character, of more prolonged duration, and of proportionately less mortality. Its action may be confined to a few muscles, those of the jaw being usually affected (itrismus), or may be more widely exerted, producing in the great majority of cases a backward bending of the body [opisthotonos). Larrey’s opinion that the direction of the arching depended upon the location of the wound—on the back, front, or side—is believed by few, if any, of the surgeons of the present day to be correct. Death usually occurs within a few clays; in half or more of the whole number of cases, within five. Prognosis of Gunshot Wounds. This must, of course, depend upon the nature and location of the wound; upon the treatment adopted, and upon whether it is instituted promptly or not; upon the hygienic surroundings of the patient; and upon his general condition before and at the time of the reception of the injury. Other things being equal, the patient’s chances of recovery are better in civil than in mili- tary life, for, as Sir W. MacCormac has very truly said, the danger of gunshot wounds “ often arises more from external circumstances—overcrowding, want of after-care, long transport—than from the nature of the injury itself.” Taking large numbers of wounded together, the mortality of cases coming under treatment is from 10 to 15 per cent.; but such a statistical statement is of little or no value, since the probability of recovery in any given case depends upon its particular circumstances. Treatment of Gunshot Wounds. This consists in clearing the wound from foreign bodies; combating, as far as may be, the primary effects (pain, shock, hemorrhage); moderating the resulting inflammation; and meeting such secondary complications as may arise. Removal of Foreign Bodies.—From the earliest times, “immediate explo- ration” has been the rule, to the end that any foreign bodies which have 1 In his account of the Austrian campaign of 1809, Larrey wrote : “The wounded who were most exposed to the cold, damp air of the chilly, spring nights, after having been subjected to the quite considerable heat of the days, were almost all attacked with tetanus, which prevailed only at the time when the Reaumur thermometer varied almost constantly between the day and the night by the half of its rise and fall; so that we would have it in the day at 190, 20°, 21°, and 23° above zero (75° to 84° F.), while the mercury would fall to 13°, 12°, 10°, 9°; and 8° during Ihe night (50° to 61° F.). I had noticed the same thing in Egypt.” 138 GUNSHOT WOUNDS. lodged, may be detected and removed; these being either the missile itself (small shot, bullet, or shell-fragment), which has not passed through and outy or other substances carried in with the ball, such as coins, keys, fragments of watches, etc., and especially punched-out pieces of clothing.1 Bird-shot, fired from a distance, and small pistol bullets, are very likely to lodge, often being much flattened, generally from striking upon bone. An- gular pieces of shell, if projected edgeways, are almost certain to lodge, even when of large size; cloth, when carried along with a bullet, though occa- sionally adhering as a cap or even complete covering, is generally left some- where in the track, whether the wound is penetrating or perforating, and under such circumstances, if not removed, remains as a constant source of irri- tation, with resulting sinus and attendant discharge, due, according to Xeu- dorfer, to the organic nature of the material. The sooner the exploration is made the bettersince the search is less painful at first than it becomes sub- sequently, and since the track of the ball is then more open, and therefore more readily followed. After the inflammatory stage has set in, the wound should be left undisturbed until suppuration is well established, any interfer- ence with it at this time being likely to increase the existing irritation. The most serious results, even in some cases the development of tetanus, have been produced by such inopportune exploration. For the discovery of foreign bodies, the finger is by far the best of all instruments, and it should always be employed when the size and length of the track will permit. In other cases, the probe must be used, either the ordinary probe of the pocket-case, or a much longer one (which, however. Fig. 266. Vertebrated probe (Sayre). may easily be made in two or more segments, and thus readily carried), or a vertebrated, or better, spiral probe, which, by its flexibity, will more readily follow the course of the ball. But of the use of any of these probes, it may still be said, in the words of Pare; “Oftentimes you shall scarce by this means find the bullet,” and only by lucky chance a piece of cloth, the pres- ence of which can, as a rule, be recognized only by the finger. Are all wounds to be explored? In civil practice I believe not, or at least not to any great extent. Very frequently the injury has been inflicted by scattered bird-shot, or by a pistol ball of small calibre. In the former case, if the lead does not lie near enough to the surface to be felt upon palpation, much less damage is likely to result from its presence than- from attempts to find it. In the latter, if judicious and not long continued probing fails to reveal the location of the little bullet, it may safely be left, either to become encysted or to be loosened and brought to the surface in the process of suppuration. When the wound has been made by a musket ball, or by a pistol ball of large size, the case is altogether different. Here an exploration should always be made, so that it may be known what damage lias been done, and so that the 1 The sizes and kinds of foreign bodies that may be lodged, sometimes unknown to the patient and unsuspected by the surgeon, almost surpass belief: a round shot of 32 lbs’, weight “ buried itself under the skin and muscles of the hip” (Hennen); one of 12 lbs. in the thigh (H. W. Davis); one of 8 lbs. in the thigh (Guthrie) ; one of 6 lbs. under the scapula (Chenu) ; one of 5 lbs. in the thigh (Larrey)—the four last mentioned having been discovered only upon amputation. TREATMENT OF GUNSHOT WOUNDS. 139 nature and location of the foreign body may be determined. But a pene- trating wound of either of the three great cavities, no matter how made, is to be explored only so far as to prove that the bullet has passed through the wall. Though by judicious probing, as we shall see hereafter, it may be possible to ascertain the location of a missile, and thus determine the feasi- bility of an attempt at removal; yet the most experienced surgeon may easily and unknowingly produce visceral injury in a fruitless effort to trace the course of a shot, and the safest rule for general adoption is that just given. FTot so very seldom in pistol wounds, the surgeon and his probe together do more harm than the bullet. The existence and position of the foreign body having.been ascertained, it should be removed, if this can be done without too much risk. For this purpose the finger or forceps, one or both, will usually be employed. Bullet forceps of many patterns have been used from time to time, the best at the present day having rather slender but very firm jaws, with or without slightly projecting teeth that will take a secure hold of the ball. (Fig. 267.) The Coxeter forceps (Fig. 268) has long been a favorite with English surgeons, Fig. 267. Bullet forceps (U. S. Army pattern). but there lies against it the serious objection that it is often very difficult to carry its scoop under and beyond the shot. For the extraction of small pistol Fig. 268. Coxeter’s bullet extractor. bullets, or bird-shot, the common dressing forceps answers very well. When the ball is fixed in a bone, or wedged between two bones, an elevator may often be employed to advantage, or a sequestrum forceps, or some one of the many forms of tirefond or screw instrument. The bullet can often be removed much more easily through a counter-opening than through the original wound, care being taken to thoroughly fix the foreign body, and to divide all of its coverings by an incision that shall at least equal in length the diameter of the shot. 27ot infrequently it happens that the extraction of the foreign body is no easy matter; it should never be roughly jerked away, but the track should be enlarged with the knife if necessary. Much has been written and said about the proper way of grasping the missile, but “ the truth is that, on most occasions, one seizes the projectile or the foreign body as he can ; the important thing is to seize it firmly, so that it may not escape from the jaws of the forceps during the extraction.” As respects pieces of bone, the rule is to remove only those fragments that are entirely detached, leaving the others either to be thrown off at a later period, or 140 gunshot wounds. to be incorporated in the reparative callus; the extraction of loose fragments (the primary sequestra of Dupuytren) should be effected as soon as possible, in order to prevent or moderate the irritation that almost always results from their presence—almost always, but not always, for once in a while spicula will be found, long after the receipt of the wound, resting quietly in the midst of perfectly healthy tissue. Treatment of Primary Effects : Hemorrhage.—The immediate effects of the wound, pain and shock, are to be treated in the ordinary way. What shall he done for the arrestation of hemorrhage, is, perhaps, the most important question that can be asked respecting the treatment of gunshot wounds. Pri- mary bleeding, as we have already seen, may and often does spontaneously cease. Secondary hemorrhage, too, may stop without surgical interference, hut com- paratively rarely. To control bleeding, resort may be had to compression, to the use of styptics, to the employment of the actual cautery, or to the application of the ligature. Compression, when it can be properly effected; when there has been a com- plete division of the vessel, and that not a large one; when there is under- neath the artery a firm bony surface, affording counter-pressure; or when the bleeding is venous, oftentimes answers an excellent purpose. When applied, not over the seat of injury, but above, upon the main vessel, or completely around the limb, it is of great temporary value, and may for the time being be the only practicable method of checking the flow of blood; but in mili- tary surgery it is well known to be a dangerous measure, being very apt to be too tightly or too long applied, when it produces great swelling of the parts below, if not their actual death. By pressing with the finger in the wound, directly upon the bleeding point, the outflow of blood can be per- fectly prevented until time and opportunity have been afforded for the appli- cation of a ligature; and it should always be borne in mind that very little direct force is required to stop the circulation through even a large artery.1 Delayed hemorrhage after amputations, if not in large amount, may often be readily and perfectly arrested by methodical compression with a bandage, thus obviating the necessity of reopening the stump. Styptics should not, as a rule, be employed for the checking of bleeding, other than that from very small vessels (when pressure or torsion will gener- ally answer better), or from the general surface of the wound—capillary or parenchymatous hemorrhage, which is very often but the precursor of an attack of pyaemia—or when it is from an artery which is deeply seated and difficult to find and take up. Even in the latter case, the use of the persul- phate or of the perchloride of iron, which are the styptics ordinarily em- ployed of late, very often fails of accomplishing the desired object, and only serves to waste valuable time, and to put the patient, because of recurrent hemorrhage, in a much worse condition than he was at first. So much abused and improperly employed are these per-salts of iron, that it would certainly be better for the subjects of gunshot wounds if these agents were banished from the surgical pharmacopoeia. 1 As illustrative of the good effect of digital pressure, and of an exceptionally favorable result of compression, may be cited Larrey’s case of wound of the external carotid. The ball cut the vessel at its point of separation from the internal carotid, and as it entered the parotid gland. “The fall of the wounded man and the considerable spurt of blood that came through both openings, attracted the attention of the cannoneers. One of them, a very intelligent man, had the presence of mind to thrust his fingers into the openings, and thus stop the bleed- ing. ... A methodical compressive bandage, to my great astonishment, arrested the rapid inarch of death, and saved the officer.” TREATMENT OE GUNSHOT WOUNDS. 141 Actual Cautery.—The hot iron has often been very advantageously applied to bleeding surfaces, but its use is always attended with risk of recurrence of the hemorrhage upon the detachment of the slough which it produces. Ligature.—By far the surest and best haemostatic is the ligature, which should be applied, whenever possible, to the wounded vessel just above and below the point of injury. When placed at a distance, on the proximal side,, it may control the bleeding; but very often with the establishment of the collateral circulation, the hemorrhage will begin again, and there will then have been added to the original wound one higher up, and with it a new danger from premature separation of the ligature. Dupuytren’s opinion that tying the artery in the midst of inflamed and suppurating tissue would prob- ably result in too early cutting through of the thread, and consequent bleeding,, has over and again been proved to have been an erroneous one, and surgeons to-day are almost unanimous in declaring that a wounded and bleeding ex- ternal artery should be sought for and tied in the wound. It may be found that the blood is issuing from a vessel of but small size, and at times, when the shot track is opened up, the source of the hemorrhage may not be discov- ered ; but the bleeding will nevertheless probably stop not to begin again. In a musket-ball wound of the popliteal space, secondary hemorrhage came on in such amount as to make it probable that it was from the popliteal artery ; yet, when the track of the wound was laid open, I could not lind the injured vessel. There was no bleeding afterwards. Abundant cases are on record, in which ligations of important trunks have been practised—sometimes with resulting death—and in which the hemor- rhage has subsequently been ascertained to have arisen from easily found ves- sels that might and should have been tied. Shall an artery that has bled, but is not actually bleeding, be ligated? G-uthrie said Ho ; but for want of ligation in such a case, when the bleeding has been secondary, many a life has been lost. Though it may not be neces- sary, it is certainly safer, when the hemorrhage is known to have come from a large vessel, to expose this and tie it j and this should be the rule in all cases other than those of primary bleeding. In these, no operative interfer- ence should be adopted until recurrence of the hemorrhage has proved that it is required. Venous Wounds should be treated on the same principle as those of arteries. Properly applied compression is more likely to produce a favorable result in these than in arterial wounds, and should, as a rule, be the method employed. When, however, a large venous trunk has been wounded, it should be tied. If the opening in the vein involves but a small part of the circumference of the vessel, lateral ligation, as recommended by Travers, may be adopted, but it is very apt to be followed by secondary bleeding. In all cases of wounds of the main venous trunks, there is much danger of resulting death, from gangrene, recurrent hemorrhage, or pyaemia. Langenbeck has advised that m this class of injuries, both the main artery and the vein should be simul- taneously ligated, or the artery alone tied, declaring that when double ligation is practised, gangrene of the parts beyond “ could only occur if extensive thrombosis of both trunks should prevent the establishment of the collateral circulationand believing that “ ligation of the wounded vein will without doubt prove unnecessary, and should, as a rule, be avoided, on account of the danger of thrombosis.” In such treatment of both the artery and the vein, or simply of the artery, he thinks we have a “sure remedy to control venous hemorrhages that have heretofore been considered absolutely fatal.” Whether 142 GUNSHOT WOUNDS. or not future experience will establish arterial ligation as the proper mode ol practice, is a question. According to Wyeth, of nine cases of simultaneous ligation of both the common carotid artery and internal jugular vein for in- juries of various kinds, seven ended in death, and only two terminated in recovery. In all cases in which ligation is to be practised, much advantage will be derived from the preliminary application of the Esmarch bandage, any neces- sary dissection being thus rendered very much easier. The elastic cord or band is much to be preferred to the ordinary tourniquet, for the temporary control of bleeding, until it may be practicable to effect a formal ligation. In a paper presented at the late International Congress, at London, Prof. Esmarch laid down, among other propositions, the following, which must command the assent of all surgeons:— The practice, formerly in use, of ligating arteries above the wound, is uncertain, and ought therefore to be entirely discarded. The application of styptics is equally objectiona- ble, not only because of their uncertain action, but because they foul a wound and interfere with its healing. The use of styptics is very objectionable; all such remedies ought therefore to be banished from the surgeon’s field case. In all cases of hemorrhage threatening life, the wounded vessel must, if possible, be exposed at the seat of injury, and ligatured above and below this point, either with catgut or antisepticized silk. The most effectual method to render sucli an operation easy, rapid, and thorough, is to make a free incision parallel with the axis of the limb. When life is at stake, it matters little whether such an incision is one inch or one foot in length, provided that the hem- orrhage is arrested, and that the wound is kept sweet; the large wound heals just as well as the small one. After freely incising the skin, the operator inserts his left index finger deep into the wound, and, with a button-pointed bistoury, opens up just as freely the deeper layers of connective tissue, fasciae, and muscles, while an assistant now separates the parts with retractors. The blood-clot, which is generally found to fill the wound, and to have infiltrated the surrounding cellular tissue, is now rapidly turned out, either with the fingers, or sponges, or raspatories, partly because it hides every- thing, and partly to avoid subsequent decomposition. It is only under these circum- stances that any operation can be carried out with anything like exactitude. As soon as this is done, the operator feels with his finger for the vascular and nerve trunks, and endeavors with the aid of a clean sponge to learn the exact nature of the injury. When the large veins are empty and collapsed, it is sometimes difficult to distinguish them from strands of connective tissue. On this account it is advisable to provide a little reserve of blood, which may be done in this manner. For the arm, a cord may be fastened around the wrist, below the wound, before the elastic (Esmarch) bandage is applied; then, on loosening this cord and raising the arm, the blood shut up in the hand will, if the vein be injured, flow into the wound, and so make it manifest. As soon as the injured spot of the artery or vein has been laid bare, so that its full extent can be clearly seen, the vessel must be isolated and then securely ligatured, either with catgut or car- bolized silk, above and below the injury. If the continuity of the vessel has not already been destroyed by the injury, the vessel must be cut between the two ligatures. The operator should convince himself that no lateral or deep branches are given off to the injured part of the trunk. Should any small branches be found, they ought to be care- fully isolated, ligatured, and then separated from the parent trunk. The Esmarch ban- dage should now be removed, and all bleeding vessels carefully tied, the limb being raised, as after amputation. Occasionally, the nature of the wound, the position and condition of the bleeding vessel, and the state of the patient, will render it advisable, instead of attempting to control the hemorrhage in any of the above-mentioned ways, to at once perform amputation. Such an operation is much less likely than ligation to be followed by recurrence of the bleeding, the artery very prob- ably being secured at a point where its coats are healthier, and, still more, the vis a fronts, which has so much to do with the production of secondary hemorrhage, being altogether removed. TREATMENT OF GUNSHOT WOUNDS. 143 Treatment of Secondary Effects.—Aside from the relieving of pain and shock, and the arresting of hemorrhage, the general treatment of gunshot wounds, as ordinarily practised, is very simple, having reference to the mod- erating of inflammation, and to preventing, as far as may be possible, the development of the secondary local and general infections already referred to. As in other injuries, the maintenance of rest, whether effected by position, by skilful bandaging, or by immobilization, is of great importance. The application of cold, by wet cloths, by irrigation, or by ice-bags, is very gener- ally found to afford comfort and to moderate inflammation, but is not to be employed as a mere matter of routine, but judiciously, with reference to the indications of the particular case; repair has often been much delayed by the too long continuance of cold dressings. Occasionally, though rarely, warm applications prove much more comfortable. In former times, enlargement of the track of the wound, by incision, was the regular practice, and it is still advocated by a few surgeons of eminence, especially among the French, the object sought being to provide a readier outflow for fluids, and to prevent, by division of the fibrous and aponeurotic tissues, any strangulation of the underlying parts. Such immediate dilatation, however, is not at the present day favored by the majority of surgeons, who believe, with Hunter, that the track should not be opened merely because it is a wound, nor unless “ there is something necessary to be done which cannot be executed unless the wound is enlarged.” With the object of converting the existing contused and lacerated wound into a simple subcutaneous one, Simon, half a century ago, advocated cutting away the edges of the wound, and suturing the incised skin margins, so that they might unite by the first intention; and thirty years later, Chisolm wrote: “ Many ragged wounds may have their edges pared off and then be brought together, with every prospect of speedy union, provided the after- treatment with cold dressing is judiciously followed.” Against such a method of treatment, it has been truly said, “both reason and experience protest.” Of extreme value, in the treatment of gunshot injuries, is the observance, as far as may be practicable, of the ordinary hygienic rules; the part and the person are to be kept clean, sufficient fresh air secured, proper food in due amount administered, overcrowding prevented, and the subjects of infectious wound-diseases isolated. A very large percentage of the deaths after gunshot injury are from preventable causes, or causes that would be preventable were it not for the exigencies of military service. Though it must necessarily be of primary importance to cripple and dest roy the enemy, and only of secondary importance to save the wounded, yet there is no good reason for crowding men into churches, and barracks, and warehouses; and still less for continu- ing the occupation of such buildings as hospitals, long after they have become mere hot-beds of infection. Treatment oe Complications.— Traumatic Gangrene, when complicating gunshot wounds, and consequent upon extensive blood infiltrations or inflam- matory effusions or exudations, follows the same course, and is to he treated in the same manner, as wThen associated with other severe injuries—special interest attaching to it only when dependent upon excessive violence, destroy- ing at a blow the vitality of the limb, or when due to occlusion of the main artery; the latter is by far the more frequent occurrence. In either of these cases, amputation should be performed at once. As a general rule, it may be declared that when mortification of an extremity sets in after a shot wound of the main artery, or vein, or both, removal of the limb should be effected as soon as possible, anil on a level at least with the point at which the vessel is injured. There should be no waiting for the establishment of a line of demar- 144 GUNSHOT WOUNDS. cation, for in the great majority of instances this does not form, but there is a rapid and uninterrupted, upward progress of the gangrene, and early death;, the exceptional cases of spontaneous arrestation serve only to prove the rule. It is in the lower extremity that the death-in-mass thus occasioned, is usually seen, as a result of a wound of the femoral or popliteal artery. As has already been mentioned, in cases of such injury, a successful result will fre- quently attend amputation just below the knee, the blood carried through the unharmed profunda artery sufficing to keep alive the parts around and above that joint. In all cases of traumatic gangrene, great attention must be paid to the hygienic surroundings of the patient, and to the proper ad- ministration of food, stimulants, and tonics. Hospital Gangrene.—In the treatment of hospital gangrene, two things are aimed at:# the arrestat.ion of the local mortification, and the prevention of the spread of the disease. The former indication requires that the wound should he carefully cleansed, and then thoroughly cauterized. The strongly adherent sloughs will usually have to he taken away with forceps and scissors (or knife), any existing pockets or sinuses being freely laid open ; and the work of removal is to be continued until “ we meet evidences of vitality, or by hemorrhage are warned to go no further.” (Weeks.) The parts are next to be well scraped —to still further get rid of the diseased tissues—freely washed with warm water, plain or carbolized, and afterwards dried by the application of lint, oakum, absorbent cotton, or blotting paper. Then, and not until then, the cauterization is to be accomplished, and the utmost care must be taken that no portion of the wound is left untreated. Of the many cauterizing agents that have been used, the best are the hot iron, nitric acid, the permanganate of potassium, the perchloride and the persulphate of iron, and bromine. Tur- pentine, sugar, glycerine, and camphor have been largely used, but the re- sults, though satisfactory in the milder cases, are not such as to warrant the adoption of these agents in preference to those previously mentioned. During our late war, bromine was found by the majority of surgeons who saw much of the disease to be the most reliable application, promptly stopping local extension, and promoting rapid healing.1 In the few cases that came under my own observation, the permanganate of potassium was employed with very satisfactory results. The acute pain, which is often so prominent a symptom of the diseaseT necessitates the use of opium or morphia, in full doses, or, as has lately been recommended, chloral, which, however, can act only as a calmative or hyp- notic ; when it will answer the purpose, it is preferable to opium, as not impairing the appetite nor producing constipation. Hemorrhage, if it oc- curs, is to be arrested in the ordinary way, by the application of the actual cautery, or one of the salts of iron already mentioned, if the bleeding is from the general surface; by the use of the ligature, if it is from a vessel of some size. The patient is to be well nourished, and stimulated if necessary: the bad effect of depressants was long ago established. An abundant supply of pure air is always to be secured. To prevent the spread of the disease, those affected must be separated from the rest of the wounded, and there should be absolutely no communication between the gangrenous arid non-gangrenous patients, whether by attendants, by dressings, or by currents of air. An infected ward or an infected hospital should be abandoned—permanently if possible, but, at all events, temporarily. 1 F. H. Hamilton, Jr., showed that the average duration of treatment was less than one-half of that after the application of nitric acid. ANTISEPTIC DRESSINGS IN GUNSHOT WOUNDS. 145 If, however, its occupation must he continued, though this seldom need he the case in military practice, we have in antiseptic surgery, as we shall see hereafter, a more or less complete protection for its wounded inmates. Hos- pital gangrene ought not to appear spontaneously in a hospital, and its de- velopment de novo is a positive proof of maladministration—the fault being either in the building, its ventilation, or its drainage, or in the responsible officer, by his permitting or compelling over-crowding. The disease may, however, be brought into any hospital, no matter how well managed, and the most prompt isolation may not always prevent infection; but only by iso- lation can the spread of the affection be prevented. Pyaemia, Septicaemia, etc.—The treatment of the other so-called “ hospital diseases,” septicaemia, pyaemia, and erysipelas, when they occur as complica- tions of gunshot wounds, differs in no respect from that which is appropriate when they are met with in ordinary civil practice. If possible, their sub- jects should be taken out of hospital, and placed under more favorable hy- genic conditions. Sedillot has declared that he has “ seen numerous examples of wounded men attacked with pyaemia, who had recovered after amputation, after having been moved to other more salubrious placesand amputation or resection is always indicated in severe wounds, especially of the larger bones or joints, when this complication appears. Tetanus, when it occurs, which is fortunately not very often, cannot, if acute, be controlled in the vast majority of cases by any treatment whatso- ever. Notwithstanding the fact that, since the days of Ilennen, curare, calabar, chloral, and the bromides have been introduced, and each declared to be curative, the surgeon must still say, with that author, “ My observations have tended more to show me what I could not trust to, than what I could place the smallest reliance on, when the disease was once fully formed.” Amputation and nerve-stretching have occasionally been followed by re- covery, but usually by death. Of the four cases of recovery from the acute form of the disease reported from our army during the war of the Rebellion, two were after amputation. The cases of tetanus among the wounded of the great wars of the last twenty years u have not modified the conclusion of Romberg, that, wherever tetanus puts on the acute form, no curative pro- ceedings will avail, while in the milder and more tardy form, the most various remedies have been followed by cure.” (Otis.) Antiseptic Dressings in Gunshot Wounds. As respects the general treatment of gunshot wounds, the most interesting question of the day is: What is the value, and how wide the applicability, of the antiseptic dressing in this class of injuries ? Almost all the deaths after gunshot wounds, which are not fatal because of the vital importance of the parts damaged, are consequent upon protracted suppuration, or upon the inflammatory complications which have been noticed. Eliminate these morti- ferous causes, and the prognosis at once becomes comparatively favorable. Is it true, as averred by MacCormac, that “ it is not the presence of the hall, nor the fact of the bone being splintered, which occasions inflammation and sup- puration, but the entrance of septogenic matter from without, or of pieces of soiled clothing carried in by the ball ?” or, as declared by Hussbaum, that “ the fate of a wounded man depends almost entirely upon the surgeon who treats the wound during the first hours ?” That in the past few years, in 146 GUNSHOT WOUNDS. civil practice, severe compound injuries, very analogous to those produced by gunshot violence, have under this plan of treatment beei) recovered from in extraordinarily large numbers, is a fact that cannot be disputed. That local and general diseases, unquestionably consequent upon wound-infection, have been very greatly lessened in frequency of occurrence, and that, too, in hos- pitals where previously they had been most prevalent, is undeniable. Are the changes that have lately taken place in the course of wounds due to their less frequent disturbance, their more careful cleansing, their more complete 'drainage ; or are they due to the employment of germ-destroying agents, or to the filtration of septic organisms from the air that is permitted to come in contact with the injured tissues ? The question may be readily answered; but will future experience prove the correctness of the answer ? If the “ antiseptic treatment” is to be carried out in its strictness, the in- jured man must not be touched until it is possible to antiseptically explore the wound, remove the foreign bodies, make the necessary counter-openings, put in the required drainage-tubes, and apply the investing coverings and bandage. All this can never or only very exceptionally be done on the field; and the primary dressing must consist in simply covering the wound with an antiseptic tampon of “ salicylic wool contained in salicjdic gauze, and inclosed in a square of oiled paper” (Esmarch), or of “ chloride of zinc jute inclosed in gauze” (Bardele- ben), and holding this tampon in place by a bandage. Possibly, some other agents (such as boracic acid, eu- calyptol, or iodoform) may hereafter prove more ad- vantageous and of easier application. “Nothing is more diastrous to the possibility of an aseptic course than the ‘ regulation search’ immediately after the receipt of the injury, and the repeated examination of the wound by the finger or instruments to discover the ball, or to diagnose the extent of the damage to the bone. It is impossible for either finger or instrument to be clean.” (MacCormac.) Ho harm will result, it is claimed, from a delay of one or even two days in the examination of the wound, providing that the above mentioned tam- pon is kept constantly applied, a clean one being substituted for the soiled one as often as may be necessary. Cammerer, in the Servian war, found it possible to render the wound aseptic even as late as two weeks after the receipt of the injury. If fracture of an extremity has occurred, immobilization is to be at once effected as perfectly as may be possible. A\ hen the patient lias finally reached the “ thoroughly well organized hospital” in which he is to be treated— Fig. 269. Bardeleben’s antiseptic tampon. “ Any foreign bodies (bullets, bits of bone, fragments of clothes) which may be found, should be removed. Should any nerve trunks or tendons have been divided, their extremities must be sought for and sewn together, either with fine catgut or carbolized silk. The whole wound must now be thoroughly disinfected, either by irrigation or by rubbing in chloride of zinc or strong carbolic solution, taking care that the fluid gets into every little recess. After counter-openings have been made in suitable places, and drainage-tubes put in, the wound must be closed with antiseptic sutures, and finally the antiseptic compressive dressing applied.” (Esmarch.) The results of this system of treating severe gunshot wounds, as practised by one or two of the few surgeons who have made considerable trial of it in recent wars, we shall notice hereafter, when upon the subject of bone and joint injuries. Early in 1871, A. Guerin, having, during the preceding six months 'of the siege of Paris, lost all hut one of his amputation cases, adopted CONTUSION OF BONE. 147 the cotton-dressing, intended by filtration to exclude all atmospheric germs; and, as the result of such treatment, of thirty-six patients submitted to ampu- tation from April to June, but thirteen died; one-half of the thigh amputa- tions were saved. Originally placing the cotton directly upon the surface of the wound, and keeping its edges apart, Guerin subsequently so modified this dressing that it was placed upon the cutaneous. surface of the flaps, pre- viously brought together by several points of the interrupted suture. The advantages claimed for this method of dressing, besides its germ-excluding; power, are, the gentle and elastic pressure which it exercises, and the uniform and sufficiently elevated temperature which it maintains. It has never been much employed except by a few of the French surgeons, and by them chiefly or only in the treatment of amputation wounds. Gunshot Injuries of Bones and Joints. Aside from penetrating wounds of the cavities and injuries of large vessels, the great majority of dangerous gunshot wounds are those involving bones and joints. Contusion of Bone. When it is struck by a ball, a bone may be either contused or broken. As the result of a grazing shot, moving at a high rate of speed, or of the more direct blow of a small or large body whose velocity is not sufficient to produce fracture, the osseous tissue may be bruised; the consequences of such an injury differ from those of contusion of the soft parts only as far as they are necessarily modi tied by the peculiarities of histological structure. There may be either a simple jarring, attended by no appreciable symptoms other than those of the associated injury of the overlying tissues; or, what more often takes place, there may be limited blood extravasation and consecutive inflam- mation ; or, as has been occasionally noticed, there may be immediate death of the bone at the point struck, and for a variable distance around. The first of these morbid conditions is of little importance, and is quickly recovered from, while the last can only result in the loss of the damaged part, the pro- cess of separation beginning very early, and being completed usually in from six to eight weeks ; the thickness of the separated piece varies from that of the most superficially exfoliated scale to that of the bone itself, as, for instance, the two tables and interposed diploe of a part of the cranial vault. As, ordinarily, contusion of the soft parts causes inflammation of them, so ■contusion of bone gives rise to periostitis, osteitis, or osteomyelitis—the three essential parts of bone (periosteum, bone proper, and medulla) being commonly associated in the morbid process. This inflammation ends in its usual ways: in resolution, in new formation, in gangrene or in suppuration, circumscribed or diffused; the two last mentioned terminations are by far the most import- ant. 27ot so very seldom, necrosis involving a considerable part of a long bone is produced by the jarring and resulting osteitis of a raking shot. I have had occasion to remove from the tibia a sequestrum 8 inches in length, which resulted from the passage of a bullet across the bone just below the tuberosity; and Lidell has reported a very similar case (the bullet passing “ across the tibia about four inches below the patella, bruising the bone and slightly grooving the surface”), in which, five months after the receipt of the wound, “a large part of the shaft of the tibia was necrosed and loosened, but not sufficiently detached to justify removal by operation.” Suppuration may be either periosteal or the result of osteo-myelitis. In 148 GUNSHOT WOUNDS. the compact tissue, it may or may not be associated with necrosis, and in the medullary cavity, may involve either isolated portions of the medulla—the pus being in small, distinct pockets—or may be diffused. In diffused medul- lary suppuration, which is always consequent upon a high degree of inflam- mation, and which generally occurs in debilitated subjects, or in those placed under most unfavorable hygienic surroundings, the medullary canal is filled with a mixture of unhealthy pus, blood, and broken down marrow. In this putrid osteo-myelitis, especially when affecting spong}7 bones, moist gangrene (the mephitic gangrene of Lidell) may, though rarely, be developed ; the bone being “ moist, dirty gray, dirty pale green, or dirty greenish-brown in color, and exhaling to a greater or less extent the intolerably offensive odor of rotting bone.”1 These suppurative inflammations sire very likely to give rise to general infection, and a large percentage of their high mortality is due to pyaemia. As Fayrer has said, “ it is not the mere local mischief that one dreads, although that may cause the loss of the limb. It is the constitutional disease to which it gives rise . . . that we must consider the great source of danger.” There may be, in the milder cases, no symptoms other than those referable to the accompanying injury of the soft parts, and even when there has been killing outright, delay in healing or re-opening of the apparently closed wound may at times be the only effect produced by the presence and elimi- nation of the dead bone. In the severer inflammations which yet do not terminate in pus formation, the osteitis may generally be diagnosticated by the character of the pain and the nature of the swelling of the affected part; as it may in the milder, externally located, suppurative cases, after a time, by the added discharge of pus, the detection with the probe of denuded bone, and the associated constitutional symptoms.. In the very grave form of osteo- myelitis which is ushered in with a chill and attended with delirium, the acute inflammation, if it does not cause death within a few days, is likely to abate, and recovery may ultimately take place after separation of the ne- crosed bone. In many of these cases, there conies on “ from the tenth to the twenty-fifth day a new fever, with an intense initial chill followed after a day or two by several more; then all the symptoms of purulent infection are developed. As death is the ordinary termination of this complication, an autopsy permits us to recognize the lesions of putrid osteo-myelitis, and often, at the same time, those of a suppurative phlebitis which is equally putrid in most of the cases of this sort.” (Gosselin.) Treatment.—When there are no symptoms apparent, except those of an ordinary contusion or wound of the soft parts, treatment of the latter is all that will be required. When to these are added symptoms indicative of necro- sis, nothing should be done until the dead piece is separated, when it should be speedily removed. In the much more common cases of periosteal or osseous inflammation, if the symptoms are at all grave, the surgeon, in addition to the ordinary constitutional and local antiphlogistic treatment, should make a free incision through the periosteum, and, if the disease is not superficial, a longitudinal section of the bone with a Iley’s saw; or should open the me- dullary cavity with the trephine. If a considerable part of the shaft of a long hone is found to be involved, or if the severity of the constitutional symptoms shows that the disease is of the diffused, suppurative, or gangrenous form, amputation in contiguity, at the articulation next above, should be resorted to at once; and even when pysemic symptoms have manifested themselves, the patient may occasionally, 1 A like condition is at times met with in long bones “ as the result of violence which suddenly deprives the part of its vitality.” 149 FRACTURE FROM GUNSHOT INJURY. though rarely, it is true, be saved by such an operation. Amputation in continuity, except in slowly progressing cases, is of no benefit, the disease quickly re-appearing above the line of section. When the symptoms are less acute, and the patient has survived the dangers of the earlier weeks or months after the receipt of the injury, secondary disarticulation may be practised with strong probability of a successful result. A chronic osteo- myelitis—not likely to follow contusion, but not infrequently met with after gunshot fracture—may spontaneously terminate in the death of the affected part, removal of which will be soon followed by complete recovery from the injury; or it may slowly but very surely go on to the involvement of the whole bone, necessitating amputation at the joint above. The progress of this form of the disease is at times exceedingly slow.1 If possible, infectious bone-inflammations should be prevented rather than treated, and it is to protection against the occurrence of these septic processes, and thereby against blood-poisoning, that methods of dressing must in the future be directed. “Listerism” has already been tried on a limited scale in these cases, and in civil practice it can, under favorable circumstances, be thoroughly carried out; but in military surgery, it must ordinarily, or at least often, be almost if not altogether impracticable. As far as can possi- bly be done, the parts should be kept quiet and clean, free drainage secured, over-crowding prevented, and abundant fresh air supplied. Fracture from Gunshot Injury. Of greatly more frequent occurrence than Gunshot Contusions of bone are Gunshot Fractures.2 These .fractures may he simple (in only a few cases, and then almost always not directly produced by the impact of the projec- tile), or compound; they may also he classified as jissured, as comminuted— .sometimes extensively, with a variable amount of scattering of the fragments —as penetrating, as perforating, or as “resecting”—the missile carrying away the entire thickness of the bone for a greater or less distance, with little or no associated splintering. The extent of damage done depends in great measure upon the size and velocity of the shot, and has been therefore found to be much greater in recent wars than formerly. In a comparatively few cases, round balls or pistol bullets or, yet more rarely, the modern, elongated rifle hall, has bored through a bone (if a long one, usually near an articulating ex- tremity) without producing any splintering,3 the osseous tissue being in part condensed, in part carried on into the neighboring soft structures. Penetra- tion with lodgment may occur, even (though but seldom) in a diaphysis, without other bone lesion. But in the great majority of cases, when a ball strikes a bone, it either splits it or shatters it according to the manner in which the force is applied. The conical bullet exerts a wedge-like action: striking an epiphysis, it may simply fissure it, the cracks extending “ per- pendicularly upwards and downwards without perforating the articular carti- lages. Such fissures are more or less frequent, especially when great force is applied, i. e., when the channel made by the shot is long.” ' Iii a case under my care, in which, in October, 1880, I successfully amputated at the hip- joint, the operation was rendered necessary by a gunshot fracture of the femur in its middle third, which had been received 33 years before in the battle of Molino del Rey, Mexico, in Sep- tember, 1847. 2 Of more than one hundred thousand (107,898) wounds summed up by S. W. Gross, nearly ten per cent. (9.64) were fractures of long bones, including among these the clavicle and scapula. 3 Becher reports having seen a number of such cases, the wounds having been made by the chassepot bullet of 380 grs. weight. 150 GUNSHOT WOUNDS. The diaphyseal fractures, according to Bornhaupt, “ sometimes resemble a stick bent in its longitudinal axis; or a ring compressed from two opposite sides. In the first case, there may be simple transverse fracture1 (mostly through spent bullets); in the second, two, three, or four longitudinal fis- sures. If the diaphysis be injured more towards the middle part, then the two mechanisms combine in tin) production of a peculiar form of fracture, viz., the ‘ spiral longitudinal fracture.’ The bone divides into four fragments ; in addition to an upper and lower fragment, two triangular splinters are to lie found opposite the part which has been struck, forming the posterior longi- tudinal fissure. When the bullet has not hit directly the posterior wall of the bone, the longitudinal fissure originates through direct force, and not through the hydraulic pressure of the marrow.” It is to this “ pressure de- veloped by projectiles in the liquids which they traverse,” that Kocher has attributed, “ in great measure, the lateral splintering produced by the ball.” Otis has called attention to the fact that when the femur has been struck by a heavy conoidal ball, in addition to the damage at the place of impact, there is, at times, an added transverse fracture two or three inches above or below, according as the shot has struck below or above the middle of the shaft. However extensive the splintering, if consequent upon a bullet wound, the fissures generally, at least in children and young adults, do not extend beyond the epiphyseal lineand in some cases in which they run through the arti- culating extremity, “ the synovial membrane remains intact, and the joint is not opened.” It would appear from the observations and experiments of Kircher and Longmore, that though there is, as the result of the blow of the conoidal bullet, more extensive splintering than when the injury is inflicted by a round ball, there is not so much separation of the fragments, which are to a considerable extent held in place by untorn periosteum; and, further, that the hardened bullet does not as extensively comminute nor as widely scatter the pieces of the broken bone as does the soft lead one. In accepting this latter conclusion of Mr. Longmore, due allowance must be made for the difference in diameter of the bullets used, that of the Enfield pw re-lead ball being .55 in., and that of the Martini-Henry lead-and-tin ball .45 in. The probability of recovery with preservation of a useful limb, if the wound is located in one of the extremities, is, of course, much greater, other things being ' In the Army Medical Museum at Washington there is a specimen of “the left clavicle transversely fractured, without comminution, directly in the middle. (Fig. 270.) The missile Fig. 270. Transverse gunshot fracture of right clavicle by conical ball. (A. M. M. Spec. 1210.) was a conoidal ball which entered near the third dorsal vertebra, fracturing the corresponding rib at its angle, and was found after death encysted immediately beneath the fractured point of the clavicle.” MacCormac reports a case in which “the ball entered on the inner side of the right thigh, close to the perineum, and after traversing the femur just beneath the lesser trochanter, emerged on the outer side of the thigh. There were, when first examined, two inches of shortening and great deformity. The fracture must have been almost a transverse one, for the bone, after considerable extending force had been applied, went into its place with a jerk, and there remained. The patient recovered without a bad symptom, and the most accurate measurements failed, six weeks afterwards, to detect any appreciable amount of shortening.” TREATMENT OF GUNSHOT FRACTURES. 151 equal, when the fragments are held in close apposition than when they are separated; and Kircher, who declares that wounds from conical bullets heal more readily than those from round ones, believes that there is at times, because of the fixation of the pieces by their unruptured periosteal covering, union of the fracture without suppuration. Fig. 271. Fig. 272. Fissured gunshot fracture of right humerus re- moved by amputation. (A. M. M. Spec. 486.) Fissured gunshot fracture of right femur hy conical ball. (A. M. M. Sect. 1, Spec. 3931.) The danger to life in gunshot wounds of bone lies in the liability to the occurrence of fat-embolism, of violent inflammation, of blood-poisoning, or of exhaustion or amyloid disease from profuse and protracted discharge of pus. Treatment of Gunshot Fractures. The treatment of gunshot fractures must have reference to the condition of the injured part, and to the various constitutional symptoms which may be developed. Primary splinters, that is, those entirely detached, should be removed at once. Upon this all are agreed, unless the case is to be treated antiseptically, when, as we have already seen, the cleansing of the wound and removal of foreign bodies (and such are these bone fragments) are to be postponed until circumstances will permit of a systematic dressing, or, indeed, may be omitted altogether if the pieces are not large—some (as, for instance, Schmidt, of St. Petersburg) going so far as to declare that extraction of splinters is only necessary when sepsis has occurred. Whether or not secondary sequestra (those still somewhat attached) shall be taken away, must depend upon the extent and degree of their adherence. If simply held by narrow bands of periosteum, the sooner they are removed the better, for their vitality cannot long be maintained. If more firmly united to the unbroken part of the bone, even though standing off at a considerable angle, they will often, if left undisturbed, be included in the callus, and contribute effectually to its development and strength ; the disadvantage of their retention is the danger of necrosis, and the consequent persistence of sinuses until the dead fragments 152 GUNSHOT WOUNDS. are removed. Great annoyance and even fatal visceral disease are sometimes caused in this way. Necrosis may thus occur years after the apparent firm consolidation of the fracture, when from any cause whatever the general health becomes seriously impaired. In cases of Assuring without separation, or where the periosteal invest- ment of the fragments is not much disturbed, these should he left untouched. In gunshot as in all other fractures, it is of the utmost importance to hold the fragments in apposition, as far as can be done; and no matter what bone it may be that is damaged, rest as complete as possible of the injured part should be secured—by dressings, if they can be applied—otherwise, by posi- tion. In the extremities, where, according to Sedillot, “ever since firearms have been used on the field of battle, and in sieges, the same question lias always presented itself to surgeons: viz., in what cases should fractured limbs be saved, or sacrificed in part (resection), or in whole (amputation)?”— if an attempt at preservation is made—the injured part together with the joints next above and below should be at once immobilized. The less the wound is disturbed, and the more completely movement of the fragments is prevented, the better are the chances of recovery. To secure the necessary quietude of the damaged tissues, the application of a plaster-of-Paris dressing1 is of great value, and it matters little what parti- cular form of the dressing is employed—the continuous roller, or the Bava- rian, or longitudinal strips—provided that the immobilization is sufficiently made, and, what is of much importance, that the wound itself is not covered in, and the limb not constricted at that level. If the patient is not to be moved, and can be constantly kept under proper observation, the latter point need not be so much regarded, since the investing bandage can be at once sufficiently cut open if the swelling necessitates it. It has been objected to this method of dressing that the opening opposite the wound weakens just where there should be the greatest strength ; that the splint will soon break in transportation; and that it quickly becomes soiled by the discharges, which both render it bffensive and rapidly soften it so that it no longer possesses the requisite firmness. These are certainly not insuperable objections ; the fenes- trum may be bridged over with a piece of tin, iron, wire-gauze, or even wood ; a properly made bandage will stand the jolting of any ordinary trans- portation ; and, by the use of oiled silk or thin rubber cloth, the fluids from the wound can be kept off' the plaster. Great advantages are claimed for wire-gauze splints, that can by pressure of the hand be moulded to the shape of the broken limb, and yet are firm enough to keep the parts quiet, and to permit the patient to be removed, if necessary, by ambulance or rail. Beside external support, there must be protection from the danger conse- quent upon the retention of extravasated blood and effused serum ; in other words, free drainage must be secured by counter-openings, by position, or by tubes, one or all. A gunshot fracture does not differ from an ordinary com- pound fracture, except in the frequent smallness of the wound in comparison with the extent of the injury, and the same general principles must govern the treatment of both sets of cases. The essential requisites for successful conserva- tism, in either case, are the securing of rest, cleanliness, and thorough drainage. Future experience must determine the value of the antiseptic dressing. As we have already seen, its formal application on the field is, at least in its entirety, seldom practicable; yet the comparatively few trials that have been made of it in military surgery, show very clearly that its primary applica- tion, before inflammation has set in, gives very much better results than those 1 The use of plaster was recommended as long ago as 1814 by Hendriksz, of Holland, and Pirogoff employed the plaster bandage in 1854 during the Crimean war. AMPUTATION .FOR GUNSHOT INJURY. 153 obtainable when it is secondarily resorted to. Reyher, for instance, out of 22 cases treated in the former way, lost but 4, or 18.1 per cent, (from septic inflammation 1, from pyaemia 1, from fat embolism 1, from extravasation 1); three of these (out of six in all) being wounds of the thigh, and one (out of three) a wound of the forearm, while of 65 cases in which the antiseptic method was only applied secondarily, 23 (35.2 per cent.) terminated fatally: 5 of the arm, out of 12 cases; 13 of the thigh, out of 25 ; and 5 of the leg, out of 22—13 of these 23 deaths having been from septic phlegmon and pyaemia. Exsection in Gunshot Fracture. Putting aside, for the present, excisions of the articular extremities for frac- tures involving the neighboring joints, and taking no account of removals, more or less extensive, of detached fragments, with or without associated •cutting away and rounding off of the sharp ends of the upper or lower un- broken parts of the diaphysis, there remain for consideration Resections in Continuity, and entire Extirpations of fractured and necrosed bones. It may be said in general, of the former operations, when primary, that the mortality which attends them is higher than that of the simpler informal removal of fragments, and that the ultimate results, as far as the functional value of the damaged parts is concerned, are no better, if as good. It should never be forgotten that, as Sedillot has said, these resections, “ sanctioned neither by theory nor by experience, . . . cannot be done without great disturbance .-and violence, and an unavoidable increase in the extent of the wounded sur- faces.” Nor can early, complete extirpation be regarded more favorably; only exceptionally can it be justified, and, even then, as satisfactory a result would probably follow extraction of the entirely detached pieces of the broken bone, or, on the other hand, it might be better to amputate. Secondary ope- rations, whether partial or complete, for necrosis, or more rarely for caries, may be both proper and necessary; and they should be determined upon, and ■executed, upon the same general principles as when the death of the bone has resulted from causes other than gunshot injury. Amputation for Gunshot Injury. Excellent as are the results that frequently attend attempts to save fractured limbs, in an unfortunately large number of cases removal of the injured member will prove to be the truest conservatism, the lesser being sacrificed for the good of the greater. Joint injuries excluded, when should amputa- tion be resorted to ? (1) When there has been great destruction of soft and hard parts, as in a crush by large shot, or when the limb has been almost completely or alto- gether carried away. Under such circumstances, the operation would natur- ally be performed at once, and, if possible, at a high enough point to get above the region of contused and blood-infiltrated tissues. (2) When the fracture is associated with laceration of the main vessels or nerves of the part, though, as will hereafter be seen, in certain regions such ■complicated fractures may be conservatively treated with good prospect of success. (3) When acute, infective osteo-myelitis has been developed. In the chronic form of this disease, when the entire length of the bone has become affected, 154 GUNSHOT WOUNDS. it may or may not be necessary to amputate, according to the general condition of the patient and the particu- lar bone that is diseased. If the general state is good, and the affected bone not absolutely required for sup- port, excision may very properly be substituted, unless it be apparent that the result can only be an useless- limb. Even in such a case as that reported by Cutter, in which, after a primary excision of the head of the humerus and a small portion of the shaft, the remainder of the humerus and the elbow-joint were removed by a secondary operation—notwithstanding that it was de- clared two years later that the limb hung pendulous and useless—still, if the man was able after steadying the forearm to satisfactorily use his fingers, he was certainly better off' than if there had been a disarticulation at the shoulder. In many of the cases of chronic osteo- myelitis of the bone or bones of a stump, reamputation in contiguity is unnecessary, it being sufficient to fully expose the end of the bone, and forcibly pull out the sequestrum. (4) When there is severe secondary hemorrhage from an eroded vessel, or from a ruptured traumatic aneu- rism. (5) When traumatic gangrene has supervened. The development of tetanus may also be deemed an indica- tion for amputation. In cases of gunshot injury other than those involving the bones and joints, amputation may be rendered necessary by the large extent of the laceration, hy the injury of the great vessels or nerves, or by the complication of gangrene or tetanus. Fig. 273. Necrosed lower part of hu- merus, with parts of radius and ulna removed by excision. (Cutter.) When evidently necessary by reason of the locality and extent of the injury, amputation should be resorted to as soon as shock has been sufficiently re- covered from, before the development of inflammation, which may show itself some hours, or not for several days, after the receipt of the wound—ordinarily in not less than eight nor more than twenty-four hours. Even at the hip, Otis’s observations “ do not sanction the conclusion that ablation of the thigh is an exception to the general rule requiring amputations that are indispensa- ble to be done immediately.” These 'primary operations are much less fatal than those which are performed during the period of active inflammation1— the so-called intermediary operations—when indeed no avoidable surgical interference of any kind should be permitted. With the subsidence of acute inflammatory symptoms, and the thorough establishment of suppuration—in from ten to thirty days, according to circumstances—begins the period of secondary amputations, the mortality of which is between that of the primary and intermediary. As in removal of limbs on account of the ordinary in- juries of civil life, no more should he taken away than is absolutely neces- sary; but as a gunshot injury generally damages parts at a considerable distance above the point struck, the place of operation must be selected accordingly. An amputation in contiguity should always be preferred to one higher up, if the condition of the soft parts will permit; for instance, through 1 In nearly ten thousand (9891) primary amputations in military surgery tabulated by Ash- hurst, the mortality rate was 37.6 per cent., while that of 3775 late operations was 43.3 per cent., and a large proportion of these were undoubtedly secondary. (See Vol. I., page 635.) GUNSHOT INJURIES OF JOINTS. 155 the knee-joint (or at the knee), rather than at the lower third of the thigh.1 As a rule, having, however, numerous exceptions, such an amputation is also to be preferred to one in continuity just below, as, for instance, that through the tuberosities of the tibia, which was so much favored, by Larrey. The head of the humerus should be saved, however, when possible, since the resulting stump is more shapely than that of amputation at the shoulder, and less likely to be injured in after life (not “ useless and inconvenient,” as de- clared by Larrey); again, if an inch or more of the bones of the forearm can be left, the resulting hook, in cases in which the motions of the elbow are preserved, is of great service; and a successful Pirogoff amputation gives a longer, firmer, and better stump than a Syme. The operative procedure to be adopted in any given case, must depend upon the locality and the condition of the damaged part, and the subsequent mode of dressing should be determined upon the same principles as those governing amputations in general. If the antiseptic system is not adopted, care must be taken to at least secure thorough drainage. Notwithstanding the excellent results that may at times follow the “ open treatment,” it is, as a rule, desirable to secure union by first intention, as far as it may be possible to do so; and for this purpose bleeding from the cut surfaces must be arrested (preferably by the use of catgut ligatures and hot water); drainage-tubes should be inserted; and the parts should be closely apposed, and held together by one or two deep, and a sufficient number of superficial stitches, aided, if thought best, by the elastic compression of sponge or cotton, held in place by a methodically applied bandage. Due attention must always be paid ta what has been styled the “ surgery of salubrity.” Gunshot Injuries of Joints. Joint wounds, which are both frequent and dangerous,2 are of two classes: penetrating and non-penetrating—the latter class including wounds and contusions of the overlying soft parts, extending down to the capsule or secondarily causing synovial inflammation, and fractures of the extremities of bones running to but not into the adjoining articulations. Unless the joint has been widely opened, or there is escape of synovia, an early diagnosis of penetration cannot be made, even though the ball has passed in and out, and the line of direction seems to run through the articulation. In a few cases, the ligaments or other periarticular structures cause deflection of the missile, and, on the other hand, because of the length and nature of the bul- let track, there may be no outflow of the joint secretion. When the diagno- sis is uncertain, the wound is to be explored, if at all, only with the finger; the probe should never be used, for it might very easily pass through an unopened synovial membrane, and thus convert a non-penetrating into a penetrating injury. The chief danger, as in joint wounds otherwise caused, is that of the production of suppurative synovitis, with its resulting local 1 Few American surgeons will agree with Legouest that the knee amputation is “ a had opera- tion, more dangerous than amputation of the thigh in its continuity, and one that ought to be discarded from practice.” Though the correctness of his statement that its mortality (88.7 per cent.) is 13 per cent, higher than that of amputation of the thigh, is sustained by the 88.2 per cent, death-rate of the French operations in the Crimea, and rendered probable even by the 78 per cent, mortality of the 41 cases in the Mexican, Italian, Austrian, and Franco-German wars, tabulated by Salzmann, it is thoroughly disproved by the fact that in our late war, when at least 211 such operations were performed, the death-rate of 202 ascertained cases was more than 14 per cent, less than that of thigh amputations, 50.2 per cent, against 64.43 per cent. 2 Of 12,864 wounds tabulated by Longmore, 403 (3.13 per cent.) were of joints, and of these 130 (32.25 per cent.) proved fatal. 156 GUNSHOT WOUNDS. destruction, exhaustion, amyloid disease, or purulent infection; and gun- shot wounds of the articulations are more fatal than others, simply because they do more damage to the joint structures and cause a greater amount of hemorrhage into the articular cavity. When the joint has not been opened, the synovitis may be simple, and the prognosis consequently very much more favorable, but oftentimes intra-articular suppuration sooner or later occurs; the overlying structures at times become gangrenous, occasionally, without doubt, not so much because of the original injury, as of the injudicious use ■of cold applications, combined it may be with compressing bandages. The extent of destruction of the soft parts may be so great as of itself to necessitate amputation; and in many cases, otherwise successfully treated, decided impairment of the joint or even fixation of it may result from peri- articular cicatricial contraction. In penetrating bullet-wounds, it has un- doubtedly happened once in a while that the missile has passed through with- out injuring the bones, but in the vast majority of these cases, osseous lesion is produced ; rarely perforation, or even lodgment, without Assuring or smash- ing ; almost always splintering, often in high degree. The early symptoms, even in these latter cases, are frequently very mild ; there may he little or no pain, and no constitutional disturbance. The untorn periosteum may hold together the splintered fragments so firmly that it is difficult or impossible to elicit crepitus, and that it may be possible to use the injured limb, as in a case reported by Legouest, in which though there was a fracture of the coty- loid cavity, the man walked about for ten days after he was shot. Usually, fever sets in on the second or third day. According to the joint affected, and the extent of its damage, an attempt may be made to save the limb, by cleansing the wound, removing foreign bodies (including all detached pieces of bone), securing drainage, immobilizing the part, and controlling inflammation, particularly by the application of cold ; or the injured part may be taken away, either by complete or partial excision of the joint, or by amputation. Until quite recently, the non-operative treatment of wounds of the larger joints was attended with a greater mortality than either excision or amputation ; and by the majority of surgeons, operation has been advised in all cases of such injury, excepting those which are very slight, or when the patient’s surroundings are unusually favorable. Other things being equal, the chances of saving part and life are much better in joint wounds of the upper, than in those of the lower extremity. In the last few years, a number of severe injuries of the major articulations have been treated anti- septically, with results very much better than those previously obtained in military surgery—the great object being to prevent suppuration, with the setting in of which the chances of recovery decrease very rapidly. (Keyher.) Whether this or the ordinary treatment be adopted, immobilization is of the utmost importance, and equally so, in the ordinary mode of treatment, is the removal of foreign bodies. With the antiseptic dressing this is a matter of very much less importance, as is shown by two of Bergmann’s cases in which healing took place, although, as was proved some time afterwards by post- mortem examination—the patients having meanwhile died of intercurrent disease—in one, several small pieces of cloth were shut up in the joint, and in the other, a fragment of bone had grown into the insertion of the crucial ligaments. Whether, in cases that must he operated upon, exsection or amputation shall he preferred, will depend upon the extent of the laceration of the soft parts and of the destruction of hone, upon the particular joint injured, upon the general condition of the patient, upon whether or not he is to be treated at the place of operation, and lastly, upon his hygienic surroundings. If no use be made GUNSHOT INJURIES OF THE SHOULDER. 157 of antiseptics, an amputation wound may be expected to heal sooner and with less suppuration than that of an excision. The difference in the fatality of the two operations is not very great; the ad- vantage on the side of exsection is, that, if successful, there remains an useful limb. Unfortunately, in no small proportion of the cases of joint removal,, though life is saved, the part is of little, sometimes of no value. In about every fortieth case, Gurlt found that the limb was not only useless, but a burden; in one-ninth (75, or 11.5 per cent.) of the 652 cases the 44end-results” of which he ascertained, the functional value of the part was nil; in one- half (322, or 49.38 per cent.), the limb could be satisfactorily and properly used only with the aid of some prothetic apparatus; in less than one-third (202, or- 30.98 per cent.) was the part quite useful; and in only one in seventeen (38, or 5.83 per cent.) was the functional integrity of the limb completely regained. Occasionally, when the conditions have been exceptionally favorable, and when it has been possible to make the operation sub-periosteal and subcapsular,. complete osseous regeneration has taken place, so that even in size and shape- the joint has been restored. Practically, a 'primary sub-periosteal resection cannot be effected, and it is an useless waste of time to attempt it. Subse- quent amputation has been found necessary in about one case in every twenty (152 out of 3161), with a resulting mortality of 48 per cent. (73 out of 152).. Of late-occurring deaths of individuals operated upon more or less success- fully, a very considerable number have been from pulmonary tuberculosis hut this form of disease is generally, it is probable, in no way consequent upon either the wound or its treatment. As respects the time of operation, exsections, like amputations, are divided- into the primary, the intermediary, and the secondary; of which the interme- diary are most dangerous to life, and the primary least sod Of the six larger joints, the shoulder and elbow are those much the most frequently exsected,. the percentage being, according to Gurlt, for the shoulder 45.29, elbow 39.21,. wrist 3.62, hip 3.79, knee 3.98, ankle 4.39 ; the shoulder and elbow together- are thus operated upon eighty-five times in every hundred ; or, in other words, nearly one-half of the exsections for gunshot injury are of the head of the- humerus, and two-fifths are of the elbow. Although perhaps more properly coming up for consideration under the- general head of 44 injuries of the extremities,” it is for many reasons prefer- able to notice in this connection the wounds of the several major articulations.. Gunshot Injuries op the Shoulder. The frequent injuries of the shoulder-joint are almost always penetrating’ wounds, with fractures of one or both of the bones entering into its forma- tion. There may, however, occur also a fracture without accompanying skin laceration, as from a large shot or shell fragment; perforation of the soft parts,, with contusion of the joint-structures; penetration without osseous lesion —seventy-two cases of the two last-mentioned injuries were reported during our late war; or, rarely, splintering of the humerus from an injury of its 1 According to Gurlt’s tables, of 1056 primary exsections, 317 were fatal (30 per cent.); of 286 intermediary, 131 (45.80 per cent.); and of 1622 secondary (not including “late” cases andi those the time of performance of which was unknown), 610 (37.60 per cent.). That primary operations give the best results, is further shown by the fact that while of 141 German primary operations, 50 (35.46 per cent.) were fatal, and of 1126 secondary, 416 (36.94 percent.); of 915 primaries during our late war, 267 (29.18 per cent..) were fatal, and of the 496 secondaries, 194. (39.11 per cent.). 158 GUNSHOT WOUNDS. diaphysis, tlie fissures running up to or into the epiphysis, without primarily opening the articulation. (Ordinarily, as has long been known, an epiphy- seal line limits the Assuring, whether from a wound above or below.) In the non-penetrating wounds, the joint may be “contused and wrenched, and filled with extravasated blood; more severely injured than from a simple penetration of the capsular ligament (Xeudorfer),” since suppurative synovitis is likely to be developed. As regards the side of-the body, the left slioulder-joint is more often wounded than the right, “ doubtless due,” as pointed out by Otis, “ to the exposed position of the left shoulder in firing.”1 Associated with the joint injury, there is often fracture of the scapula or clavicle; damage to the important struc- tures in the axilla, or to the chest walls; and, very oc- casionally, wound of the chest cavity—a lesion of great danger, which patients rarely survive. At times, the ball penetrates without perforating the head of the humerus (Fig. 274), such cases of lodgment being de- cidedly graver than those in which the shot has passed through. Prognosis.—The prognosis of a shoulder wound, like that of any other, will depend upon the nature of the injury; the size, weight, and velocity of the missile; the presence or absence of complications; the health of the patient when wounded; his subsequent hygienic surroundings; and the treatment adopted; but, speaking generally, it may be said that one-third of the cases will die from blood-poisoning, from hemorrhage, or from the effects of protracted suppuration. Fig. 274. Musket ball impacted in head of left humerus. (A. M. M., Spec. 2696.) Treatment.—Leaving out of consideration cases of such extensive destruc- tion of the overlying soft parts, or crushing of the bones (produced ordina- rily by cannon shot), as compels immediate amputation, and those of non- penetrating injuries in which evidently no operative interference is required, the treatment of shoulder wounds consists in either amputation, excision, or expectancy. Amputation.—Primary amputation is indicated only when, in addition to the joint lesion, there is either extensive shattering of the humerus, through and beyond its upper third, or laceration of the axillary vessels and nerves; and even in these cases, the experience of surgeons during the wars of the last twenty years has shown that the other plans of treatment may very often he advantageously substituted. Though early removal of the limb may be expected to be recovered from in three out of four, if not in four out of five of the cases operated upon, yet there is incurred during the period of treat- ment a very decided risk of serious secondary hemorrhage; and the patient, at the best, must go through life with what is, functionally, the severest of mutilations, the loss of a whole upper extremity. An intermediary disarticu- lation should never be practised, unless rendered absolutely necessary by the occurrence of gangrene, of acute osteo-myelitis, or of otherwise uncontrollable secondary hemorrhage ; the mortality of such operations is nearly or quite twice as great as that of primary, and almost double that of secondary, shoul- der amputation. Secondary removal of the limb may be required on account 1 Harlan writes : “ The rule seems proved by the exception, that in cavalry the reverse is the case, as far as I have seen. The right being the sword arm, is, of course, advanced in a charge, as well as in the use of the pistol.” , GUNSHOT INJURIES OF THE SHOULDER. 159 of extensive bone-disease, whether or not there has been previous excision, but rarely for any other cause in cases of wound of the joint or upper third of the shaft.1 The particular way in which the operation shall be performed, whether by the fiap or the ovoid method, will depend upon the character of the injury and the preferences of the operator. For such cases as are com- monly met with in civil life, other than those in which a charge of small shot, fired at close range, has torn through the axilla as well as the joint, or the bone just below it, amputation is not to be thought of. Excision.—Very much to be preferred to removal of the limb, is removal of the damaged part. Though the mortality of shoulder-joint excision is some- what higher (5 to 10 per cent.) than that of amputation, yet the preservation of the arm, especially of the right arm, even though an apparatus must be worn in order to permit its being of much use, is of great importance to the patient, and well worth the additional risk incurred. In an uncomplicated fracture, in which the humerus is not splintered below the line of junction of its middle and upper thirds, or for not more than four inches, excision, if recovered from, may be expected to result in the securing of an useful arm. Even more than this amount of the bone may at times be taken away and the patient do excellently well,2 though Gurlt states that of fifteen cases in which more than four inches was removed, twelve had arms the functional value of which was far from good. The partial regeneration of bone which sometimes takes place improves correspondingly the usefulness of the arm. In a case reported by Chipault, seven months after a secondary excision of five and a half inches, there had been a regeneration of two inches of the shaft, of diameter almost equal to that of the original bone ; and the patient was ultimately able to carry the arm four inches away from the body, and to place the hand on the top of the head, the arm shortening, and muscular thickening below the shoulder occurring. Associated injury of the scapula or clavicle, or both, does not render ex- section improper: if there is simple Assuring of these bones, operative inter- ference, as far as they are concerned, is not required; but if there is commi- nution, the broken parts should be taken away. Of forty-two removals, during our war, of the head, or head and shaft, of the humerus, with portions of either scapula or clavicle, or both, thirty-one recovered, only ten per cent, of the primary cases resulting fatally. From the Servian War, five such cases are reported with one death (20 per cent.), all operated upon after the close of the early period. In nearly one-half of the cases that recover, a very useful limb remains,3 1 The percentages of mortality of shoulder-joint amputations during our late war were: pri- mary, 24.1 (485 cases, 117 deaths); intermediary, 45.8 (157 cases, 72 deaths); secondary, 28.7 (66 cases, 19 deaths); and of unspecified date, 25.5 (110 cases, 28 deaths). In the French army in the Crimean war, the average mortality was 65.21 per cent., and Legouest has placed it in general at 59.5 per cent. It should he always borne in mind that disarticulation is adopted in very many cases for causes other than those connected with the joint itself, and that the mortality must be proportionally affected. 2 In a case reported in the “Medical and Surgical History of the War of the Rebellion,” the head and six inches were removed, and twelve years afterwards, the patient could, without diffi- culty, place his hand on the top of his head ; and could, without pain, lift a weight of two hundred pounds, or more, with the injured limb. The movements of the forearm and hand were not in the least impaired, and there was great freedom of all the movements of the arm, except abduction. The muscnlar development of the arm equalled that of its fellow. No apparatus was requisite, and altogether the result was most satisfactory and successful. 3 Glurlt (whose great work on “ Joint Resections” has been, and will hereafter be, freely drawn upon) states that of 213 shoulder excisions, 94 (44.13 per cent.) afforded useful limbs, while 119 (55.86 per cent.) gave arms the functional value of which was not satisfactory, and which could be well used, if at all, only with some applied apparatus. Under the head of useful limbs, are classed, besides the rarely met with cases in which there is ability to execute all the normal movements of the shoulder—even to vertical elevation of the arm—those in 160 GUNSHOT WOUNDS. becoming more so in progress of time; and in the great majority of the re mainder, by the aid of proper apparatus, the patient is able to write, feed himself, carry burdens, etc. An immovable shoulder joint seldom results—in less than ten per cent. (9.85) of the cases. In more than one-third of the preserved arms, there is no material shortening, and in the rest, such shorten- ing (which is functionally better than the lengthening that is occasionally met with) tends to become progressively of less importance, the upper end of the humerus being gradually drawn up towards the glenoid cavity and the range of movement increased. The atrophy, which is so commonly seen soon after the wounds have healed, is largely from disuse, and diminishes as- the arm is employed. The operation is, as a rule, most readily accomplished by means of the straight incision, no special attention being paid to the location of the bullet wound, the presence of one on the posterior surface of the limb being really of advantage, as facilitating drainage. The ultimate result does not seem to be materially affected by the operative procedure adopted, but does in large measure depend upon the time at which it is resorted to; a 'primary excision, according to Otis’s tables, has a percentage mortality of 24.1; an intermediary excision one of 45.8, and a secondary excision one of 28.7. Guilt, in his table, which includes nearly 600 (568) additional cases from the German wars, and in which the number of American late excisions is increased by 160 cases carried forward from the intermediaries, gives the percentage of mortality as 31.83 for the primary, 53.12 for the intermediary, and 39.25 for the secondary operations. Either set of figures proves that, at the shoulder-joint, primary excisions are decidedly the best, and intermediary very much the worst, as far as the preservation of life is concerned, though, as respects “ end-results,” the later operations give decidedly the larger percentage of useful limbs (45 as against 35). When circumstances permit, and it is evident that the ope- ration will be sooner or later necessary, it should be done on the field at once, or, in civil life, as soon as the patient conies under care, if the existing shock is not too great; late excisions should be reserved for cases of necrosis. Fig. 275. Fig. 276. Stromeyer’s cushion. (Mac Cormac.) Application of Stromeyer’s cushion. (Mac Cormac.) In the after-treatment of these exsections, great care must be taken to pre- vent or quickly relieve any undue constriction, which can so readily be caused in this region by a retentive dressing. Many have advised that, the arm should be simply placed on a pillow, or a Stromeyer cushion,1 and that all which there is complete functional integrity of the elbow, wrist, and finger joints, with power of elevation to a right angle with the body. Mr. Holmes’s statement that “ the arm can never, as it seems, be elevated beyond the horizontal line” is certainly, while true in the main, not absolutely correct. 1 This cushion, which the distinguished surgeon whose name it bears considered the “ most valuable appliance he had invented during his life,” “ may be described as a right-angled GUNSHOT INJURIES OF THE SHOULDER. 161 attention should be directed to the controlling of inflammation, while others have used a bracketed splint; but very satisfactory immobilization can be made by the application of a plaster-of-Paris roller, up and down over the external and posterior surfaces of the arm, extending it above and below so as to fix the scapula and forearm ; with this form of dressing, strangulation cannot take place. What would be, in large numbers of cases, the results under antiseptic treatment, is, at present, a matter of inference. Reyher, at Kars, lost three out of eleven cases (27.27 per cent.), but of his five primary cases treated antiseptically from the beginning, none died, the three deaths occurring among the six patients who were not at once brought under the influence of antiseptics, and who were operated upon in the intermediary or secondary period. From such a limited number of operations, of course, no general conclusions can be drawn as to the value of the antiseptic method and the necessity of its adoption. With as much or more propriety, the English Crimean statistics might be held to show that the success of shoulder ex- cisions is greater when antiseptics are not employed, since of eight primary operations recorded during the second period of that war, only one died (12 per cent.), and of five secondary operations, none—being a total of thirteen cases with only one death, a mortality of but 7.7 per cent. Expectant Treatment.—From the earliest times, there have been reported occasional recoveries from shoulder wounds in which no operative interfer- ence was employed. Much attention has been lately directed to such treat- ment by “ expectancy,” and the opinion has been held by many experienced surgeons, especially among the Germans, that it is quite as likely to be fol- lowed by recovery as either excision or amputation; and some have even gone so far as to declare that the “ end-result” is a better one, the limb being more useful. Statistically, it would appear from Otis’s investigations that the death-rate may be placed at about one-third f but the value of such a state- ment, in determining the acceptance or rejection of this plan of treatment, is very much lessened when it is remembered that, as a rule, it has been adopted only for the less severe injuries. “An attempt to establish direct numerical comparisons between the results of expect- ant treatment, excisions, and amputations, after shot fractures of the shoulder, would probably be undertaken only by some sciolist or dabbler in statistics, since the injuries involved are so variable in nature and extent, that the terms of comparison cannot be fairly ascertained, and any strict application of the numerical method is impracticable.” (Otis.) In civil life, in which the wounds are almost always produced by missiles which are smaller, and which move with less velocity, than those causing the lesions met wTith in time of war, the expectant plan may be adopted with greater prospect of success; but even in cases of small-ball fractures, there is much danger of the occurrence of secondary hemorrhage, or of the development of general septic infection. Associated fracture of the scapula or clavicle, or both, if not very extensive, will not contra-indicate the adoption of a con- servative course of treatment; and in the somewhat rare cases of joint injury isosceles triangle, four inches thick at the apex, which rests against the chest and supports the elbow, the forearm being bent at a right angle with the arm. The cushion gradually thins down till the base is a mere edge, and of the two other angles, one is passed up into the axilla, while the other rests on the chest under the wrist. The cushion is readily fastened in its place by a tape round the neck, and one round the body.” (Mac Cormac.) 1 In our war there were 505 cases with 139 deaths, or 27.52 per cent. ; collected from various European writers on military Surgery, 185 cases with 90 deaths, or 49.73 per cent. ; total, 690 cases with 229 deaths, or 33.18 per cent. 162 GUNSHOT WOUNDS. without osseous lesion, it is of course the method that should be at first se- lected.1 Even if after some weeks exsection should be rendered necessary, the result, it would appear from the statistics previously given, would not be in any great degree worse than if it had been primarily resorted to. Unfortunately, however, during the period in which, if it can possibly be avoided, no ope- rative interference should be allowed, a considerable percentage of the more Seriously injured patients who have been expectantly treated, die, while many of them doubtless might have recovered had an early operation been prac- tised. But as amputation, as the result of extended experience, gave place to excision as the proper measure to be adopted in the graver cases of shoulder wound, so future observation may lead to the substitution, for either, of the skilful aiding of nature in her efforts at restoration. Such a report as that of Beck’s, who saved twenty-six out of twenty-eight cases (one dying of tetanus, the other coming under treatment only when in such bad condition as to be no longer a proper subject for any operation), is certainly very en- couraging ; particularly so if, by the adoption of an antiseptic course, early healing can be secured and wound infection prevented, in considerable part, if not wholly. When expectancy is tried, the ordinary measures for the main- tenance of rest of the part and of the fragments, and for the securing of thorough drainage, must be adopted here as everywhere else. As Beck has written:— By absolute rest, appropriate position, and corresponding bandages ; by immobility; by constant application of cold; by an antiphlogistic regimen ; by incisions (extended, in cases of severe tension of the capsule with threatening suppuration, even into the synovial sac, for the purpose of allowing the accumulated fluids to escape) ; by well timed opening of burrowing abscesses; by extraction of loose splinters or fragments ; by the administration of opium ; by subcutaneous injection of morphia in case of severe pain—the course of the injury may frequently be controlled, and even a cure with use- fulness of the limb, though comparatively limited, may be accomplished. Anchylosis may be expected to take place when the comminution and the necessary removal of fragments have not been very extensive, but freedom ot movement of the scapula much lessens the resulting impairment of the func- tions of the arm. Stiffness of the joint, in greater or less degree, will almost certainly attend the cure; and even in many of the peri-articular injuries, false anchylosis from contracted cicatricial bands will occur. Gunshot Injuries or the Elboav. Like those of the shoulder, wounds of the elbow-joint may be either accom- panied or unaccompanied with fracture; and in cases of the former kind, which are by far the more numerous, all the bones of the articulation may be injured, or only some of them. Peri-articular wounds and contusions commonly oause very decided synovial inflammation, but it becomes suppurative only after opening of the membrane by ulceration, by gangrene, or by injudicious surgery. Cicatricial contraction and muscular shortening usually cause more or less false anchylosis ; and nerve lesions, primary or inflammatory, may lead to the development of neuralgia, and may contribute in no small degree to the production of the commonly occurring muscular atrophy, which is due in part also to disuse. A severe contusion, because of both its immediate 1 Among the 84,000 and more gunshot wounds of the upper extremity reported during our war, there were 225 cases of joint wound without fracture 72 of these being of the shoulder ; of these 6 died, or 8J per cent. GUNSHOT INJURIES OF THE ELBOW. 163 and its ultimate effects, is certainly a graver lesion than such a perforation as is met with in the majority of cases. Though usually the diagnosis of penetration is readily made, it is at times very difficult, or even impossible, to ascertain positively that the joint has been opened, without such an explo- ration as it would be improper to make. The prognosis of elbow shot-wounds is not specially grave, as far as life is concerned, the mortality being only about 20 per cent.; but as respects the functional value of the limb, it is far otherwise. Here, again, three methods of treatment are to be selected from, amputation, excision, and expectancy. Amputation, as a primary operation, is clearly and unquestionably indi- cated only when there has been great destruction of the part by impact of a large projectile; or when, in addition to the fracture, there has been laceration of the brachial artery and the radial and median nerves, an ulnar-nerve wound being of comparatively little importance. When the artery only has been injured in connection with fracture of the humerus, surgeons generally are agreed upon the advisability of amputation; but some, such as Legouest, do not regard the operation as “ always indispensable.” The correctness of this opinion is still to be proved. “ Loffler’s assertion that surgical literature has not presented an example of recovery [with preservation of the limb] from shot fracture of the humerus with division of the brachial, remains uncontradicted.” (Otis.)1 Again, when there has been extensive comminution of the humerus produced by a bullet, and the splintering extends so far up into the shaft that the broken portion cannot be taken away with a reason- able prospect of preserving an useful arm, the limb should be removed ; since an attempt to save it will very probably end in the patient’s death from septic infection, or in disarticula- tion at the shoulder at a time when the individual is in very poor condition for any operative interference. In all other elbow-wounds, the choice lies between excision and expectant treatment. Fig. 277. Shot perforation of right humerus at lower third. (A. M. M., Spec. 4109.) Excision of the Elbow, from which, in cases of gunshot injury so much was expected a quarter of a century or more ago, has certainly in large measure failed to accomplish what is desired, the preservation both of life .and of a serviceable limb. Practised in any of the ways adopted in cases of disease, but generally by the straight posterior incision, it may be either com- plete or partial, all the articulating surfaces being removed, or only those which are actually damaged. It has been generally believed that a complete was decidedly preferable to a partial excision, being attended with less risk, and giving a better result as regards the usefulness of the preserved limb. Such was Otis’s and yet it would appear that the mortality in our war was 2 per cent, greater, and, taking together the four German wars and our own, per cent, greater when the whole joint was excised than when only a part of it was removed (22.91 as against 25 per cent.; 23.07 as against 25.50 per cent.). The percentage of good “ end-results” was, however, 2.25 in favor of the complete operation. Primary excisions have resulted fatally in 21.59 per cent, of cases (84 out of 393), a mortality decidedly less than that of the intermediary (29.26 per cent.), and that of the secondary (28.48 per 1 In the very remarkable case under the care of Dr. T. Curtis Smith, in which the joint was extensively fractured with laceration of the brachial artery, the upper part of both ulnar and radial arteries, and the ulnar and median nerves, the articulating extremity of the humerus was laid bare but not broken. Excision was in this case successfully resorted to. 164 GUNSHOT WOUNDS. cent.), though the death-rate of a few (14) late operations (which were, un- doubtedly, practically for disease, and not for injury) was zero. In our war, immediate exsection was slightly more dangerous (1 per cent.) than primary amputation in the lower third of the arm, and very much more so (8.1 per cent.) than removal in the upper third, though nearly 3 per cent, less fatal than that operation when required by elbow-wounds. After exten- sive investigation, 111*. Otis was compelled to write: “Although the point is open to argument, I fear that the substitution of this resection for amputa- tion effected no saving of life and the average mortality of the more recent operations during the Franco-German war was even greater than that pre- sented in Dr. Otis’s Surgical History. Expectancy.—In the cases treated by expectation during our late war, 938 in number, death resulted in but 10.3 per cent. (96). This statistical state- ment is, however, of little value in determining the proper method of treating elbow fractures, since it was only in the less serious cases that no operation was employed ; had it not been so, American surgery would have proved be- yond question the superiority of expectancy. As it is, there has been for years past a growing feeling in favor of this method, when removal of the arm is not evidently necessary, and a conviction, as Liicke has said, that “ a large proportion of shot injuries of the elbow-joint may be treated conserva- tively, that is, without any operation whatever.” Of seventy-seven cases under the care of eighteen surgeons, during the war of 1870-1, only six died (8.6 per cent.). That a successful result may be secured, if “ Listerism” is not carried out, there must be removal of all detached splinters, thorough drainage of the joint-cavity, immobilization of the limb (which may be well effected by using an Esmarch’s bracketed splint (Fig. 278) having an elbow angle Fig. 278. Esmarch’s bracketed elbow splint. of 130°), and moderation of inflammation. The free laying open of the joint, which has by some been recommended as a measure of prevention, should not be resorted to, unless necessary for the securing of a ready outflow of pus. If life is saved, and secondary excision or amputation does not have to be adopted—and one of these has unfortunately heretofore been required in a large number of cases, perhaps a third of all those treated by expectation— what is the after condition of the limb, and how does its usefulness compare with that of one in which there has been a primary exsection ? Very seldom has recovery taken place with preservation of the motions of the joint, and not very often with no other functional impairment than anchylosis in good position. Even though flexion and extension are lost, pronation and supina- tion may remain, if the radius is uninjured and if only one of the other bones has been broken. Muscular atrophy follows, sometimes in high degree, and there may be persistent neuralgia. As a rule having not very many excep- tions, the arm that remains after gunshot wound of the elbow which has been treated expectantly, is functionally a much damaged one. How is it after excision—an operation which in civil life, and when per- GUNSHOT INJURIES OF THE WRIST. 165 formed for disease, succeeds admirably? In nearly one-half of Gurlt’s cases (45 per cent.), the individuals were, years later, altogether unable to support themselves. In only three out of every ten (104 out of 355), could active movements be fairly well made, and could the other joints, particularly those of the lingers, be said to be in perfect condition. In more than seven out of every ten (251 out of 355), there was either a “ dangle-joint,” or such a fixed twist of the arm that the usefulness of the hand was greatly impaired, or an anchylosis at a very obtuse angle (189); or muscular paralysis, or deformity and stiffness of the other joints, especially of the hand (51); or such persist- ent pain as to make the arm worse than useless (11). Of the primary exci- sions, only one in five was followed by a favorable result, and of the secondary, only three in ten ; while of the very late operations, which much resemble those for disease, more than one-half ended well. Anchylosis, which is, of course, much more likely to follow partial than complete excision, if it is uncomplicated and takes place at a good angle (from 90° to 130°), leaves a very useful arm. Through fear of an exceed- ingly loose joint, many, especially of the Continental surgeons, have directed their efforts to the securing of an immovable elbow; and of the two condi- tions of the part, the latter, if the forearm and arm are relatively properly placed, is much the better. But in more than half of Gurlt’s cases of mov- able joint, there was no flail-like condition; and in many of the anchylosed limbs, if passive motion had been instituted as soon as suppuration became much lessened, or as soon as it could be employed without the patient ex- periencing much pain, and had it been kept up long after cicatrization was completed, there can be no question but that a very valuable, movable joint would have been secured, and muscular atrophy largely prevented. This atrophy, which especially affects the muscles of the arm, and of these the triceps most extensively, depends, in part at least, upon disuse; and, if in the operation the muscular insertions have been respected, by beginning passive motion as soon as it can be safely permitted, and by allowing active motion as early as it can be made, the wasting will certainly be in no small degree controlled. Expectation results badly; so does exsection. Nothing but future observation, on a large scale, can determine which is the preferable mode of treatment. What shall be done with gunshot wounds of the elbow, is one of the vexed questions which will demand consideration in the next great war, wherever it may be waged. Gunshot Injuries of the Wrist. Gunshot wounds of the wrist, decidedly more frequent on the left than on the right side, are almost always attended with fracture; are much more dangerous, as far as the part itself is concerned, when the ball has passed from side to side than when it has gone through the antero-posterior diameter of the joint, and are frequently associated with extensive injury to the lower end of the radius or ulna, or both, and often with severe damage to the second row of carpal bones and to the metacarpus. Great destruction of the joint and of the lower part of the forearm necessitates in military, though not so certainly in civil practice, amputation; an operation attended with a tnortality of about ten per cent. (9.6 per cent, in the 1007 primary cases during our war). In wounds of lesser severity, the treatment may he either by expectancy or by excision; the former method, according to Otis’s tables, resulted fatally in 7.6 per cent., and the latter in 13.2 per cent., of the cases in which they were respectively adopted, though there were numerous cases u treated at the outset by expectation, in which excision or amputation was 166 GUNSHOT WOUNDS. eventually resorted to, with an excessive rate of mortality; . . . and consequently the results of the conservative, expectant plan are represented in a too favorable light.” An injury of this articulation, because of the anatomical structure of the damaged region, is almost certain to be followed by inflammation of high grade, attended by great pain, and extending through and beyond the carpus, unless tension is prevented or very promptly relieved. Suppurative synovitis of the tendon sheaths, which is so apt to occur, may be expected to give rise to destructive inflammation of the connective tissue [(lanes of the forearm, and of the like tissue in the palmar subfascial bursa, unless judicious treat- ment be adopted, and not seldom will do so in spite of treatment. If no operative interference be required, the use of the usual remedial measures already referred to in connection with joint-injuries in general—rest, cold, position, etc.—must be thoroughly carried out. Much suppuration and delay in healing may often be prevented, and the chances of recovery correspond- ingly increased, by at once removing carpal bones which have been exten- sively shattered. Such an operation can hardly be considered a formal ex- cision, although cases thus treated have been so included b}’ some authors. At most it is but an excision in, not of, the articulation. Primary hemorrhage from one of the large vessels is not a bar to the adoption of conservatism, as it may be controlled by the application of a ligature; and secondary bleeding, which at times occurs, may generally be arrested in the same way. Anchylosis of the wrist takes [dace in the great majority of cases which recover, but it is a matter of comparatively little importance if the Anger motions have been preserved. Every care should be taken, by the selection of position and by moderation of inflammation, to prevent adhesion of the flexor and extensor tendons to their sheaths; and early but judicious, passive, and at a later period active, motion should be made, in order to preserve, if possible, the finger movements, without which any saved hand is of little functional value. When formal excision is adopted, it should be by lateral incisions, as in the method of Lister, or by the dorso-radial, straight incision of Langenbeck; the cut across the dorsum is proper only when the missile has already divided the tendons. The lower part of either radius or ulna alone should not be removed, since after recovery the hand is almost certain to be deflected laterally, at times Fig. 279. Fig. 280. Deformity following' removal of fragments from com- minuted gunshot fracture of radius. (A. M. M. Spec. 2671.) Deformity following excision of lower portion of radius. (McDermott.) even to a right angle (see Figs. 279, 280); if only one of the two hones is damaged, the lower end ot the other should be equally exsected, in order that a straight position of the hand may be secured. Decided advantage GUNSHOT INJURIES OF THE HIP. 167 Inis been found to result from continuous extension by adhesive straps and weights, the forearm being maintained in a somewhat supinated position. In nearly one-tenth of Gurlt’s cases (9.6 per cent., 12 out of 125) amputa- tion was ultimately required; and one-half of those thus operated upon died. The death-rate of all the resections was 16 per cent. (20 out of 125), pyaemia being, as in the cases treated by expectation, the chief cause of mortality. As respects saving of life, removals of the radius and carpal bones have given the best results, all of the eight cases recorded having ended in re- covery ; and removals of the lower ends of the bones of the forearm with the carpal and metacarpal bones have given the worst, two out of the five persons thus operated on having died (40 per cent.). When the wrist-bones in part or whole are taken away, there is, it would seem, a most marked difference in the death-rate according as the ulna is or is not removed, the percentage being in the former case from 20 to 40, varying with the bones removed. Whether or not this has been in the observed cases simply acci- dental, or really consequent upon the removal of the ulna, future experience must determine; it may perhaps be a significant fact that, when only the lower end of the ulna has been exsected, the fatality has been more than twice that of similar operations upon the radius (19.23 per cent.; 8.1 per cent.). Although, as has been shown, the average mortality of wrist-wounds treated by excision is double that following expectancy, yet, as cases of the latter class are, as a rule, of decidedly less gravity than those of the former, the real question to be settled is wliich gives the best ultimate result. That of expectation is certainly not satisfactory, as far as the functional value of the saved hand is concerned ; anchylosis, deformity, more or less stiffening of the fingers—such is the condition reported as existing in the great majority of cases; but, on the other hand, the same is true of excision:— “ In sixty-eight of the ninety-six patients whose hands were preserved, at least in part, fifty-one had anchylosis at the wrist, five mobility with deformity, and three dangling- joints. Nine, of whom two are still in service, are reported to have had comparatively useful limbs.” (Otis.) Gurlt says that of the 72 American cases which he has tabulated, in only three were the results in “ any way good ;” and that of the sixteen German patients, but one had a good arm and hand, while in eight cases the parts were but tolerably useful, in six they were bad, and in one worse than useless. As a whole, the results were “very unfavorable.” It would certainly seem that the proper treatment of wounded wrist-joints, when there is not such complete smashing as to compel immediate amputation, is by expectation— that is, by removing fragments, immobilizing the forearm and hand, securing drainage, moderating inflammation, opening abscesses, employing antiseptics, and, as far as possible, preventing stiffening of the fingers—and not by formal exsection, either complete or partial. Gunshot Injuries of the Hip. Of much, greater severity than those of the corresponding joints of the upper extremity, are gunshot wounds of the hip, knee, and ankle. Injuries of the hip-joint may he either penetrating or non-penetrating. The overlying soft parts may be simply contused, or the ball in its passage across it may bruise the capsule, or there may be a wound of the femur with splintering up to, but not into, the intra-capsular portion of the neck. In all of these latter conditions, when there is subsequent involvement of the joint itself, synovial inflammation takes place—frequently, but by no means always, 168 GUNSHOT WOUNDS. suppurative in character—with, ordinarily, rupture of the capsule at a later period, burrowing of pus, and, if death does not previously occur, formation of sinuses. Caries at times is developed, or a con- dition of the head and neck of the bone similar to that observed in chronic rheumatoid arthritis. In the penetrating wounds, there may be perforation or odgment of the ball; limited or extensive shatter- ing,1 the fissures running, it may be, through the trochanters, or far down the shaft; fracture of the acetabulum or other part of the innominate bone, or penetration of the pelvic cavity with or without visceral lesion ; wound of the neighboring great ves- sels or nerves; or associated through distant injury of, at times, the same extremity. Diagnqsis and Prognosis.—Difficult as is often the diagnosis of a wound of any joint, it is especially so in the case of the hip, positive evidence in the escape of synovia, digital exploration, or the severity and character of the after-symptoms, alone sufficing to establish it. The left hip is much more often wounded than the right, no doubt because of its more advanced and exposed position in firing. The mortality of these wounds is excessive. Of 349 which occurred during our war, 297 died (85 per cent.); and in all probability, were the cases of recov- ery in which a mistake was made in diagnosis (no penetration Laving taken place) eliminated, the death-rate would be found to be nearly or quite 95 per cent., the fatal issue being due in most instances to shock, visceral wound, exhaustion, or septic infection. Fig. 281. Upper end of left femur perfo- rated by conoidal ball. (A. M. M., Spec. 565.) Treatment.—Expectancy, excision, and disarticulation, are all but doubtful remedies for a desperate condition. Hip-joint amputation (which should be employed, if at all, only when there has been great destruction of the part, or wound of the main vessels or nerves, or associated fracture lower down), had prior to 1870 resulted fatally in 29 out of 31 cases in which it had been performed for intracapsular wound, that is, in 93.5 per cent.; and it is pro- bable that in the large majority of these cases, the operation only hastened death. jExcision, first adopted in shot-wounds of the hip but a little more than half a century ago (by Oppenheim, in 1829), and done but twelve times in all up to 1861—two of these operations, moreover, having been at a late period, for caries—has resulted fatally in 90.6 per cent, of the cases in which it has been performed for joint-wound (106 out of 117). But not one of Reyher’s three cases antiseptically treated proved fatal, and in the future, the adoption of some method to render the operation wound aseptic, may very materially diminish the mortality. Even if it should not, there can be no question but that the removal of the broken bone and drainage of the cavity greatly con- tribute to the comfort of the patient, while he does live ; and if recovery takes place, it is with a quite useful limb, notwithstanding its being more or less shortened; the result is functionally better under these circumstances than that of similar operations done for disease. All of the 15 individuals suc- cessfully treated were able to use the leg more or less perfectly, and to make a living. As the result of a secondary excision done by Surgeon J. R. Gibson, 1 In a case operated upon by Surgeon Clements, U. S. Army, the cervix femoris was found broken into about forty pieces. GUNSHOT INJURIES OF THE KNEE. 169 U. S. A., in 1868, the man three years later “ could walk almost as well as ■ever.” Dr. Mursick’s patient, four and a half years after an intermediary operation, could perform all the movements of the thigh “ with almost as much facility as in the normal state—rotation, even, as well as flexion, exten- sion, adduction, and abduction. Ilis general health was good. He still worked as a day laborer.” In the present state of knowledge, it certainly seems the part of wisdom, in cases of hip wound, to make an exploratory incision as soon as possible, and, if the damage has not been such as to preclude any reasonable hope of doing good, to excise the broken bone. Ko benefit can be derived from leav- ing, as has been done, an uninjured femoral head in the acetabular cavity, when the neck is taken away; necrosis would certainly follow. Ordinarily, the long, straight or angular incision, from above downwards, along the poste- rior border of the trochanter major, will be found most convenient. If the patient must be moved, the joint should be immobilized; but if he can be treated at the place of operation, the dressing may be conducted according to any one of the several methods which are employed in civil practice after excision for disease. Gunshot Injuries of the Knee. Of more frequent occurrence, and of hardly less gravity, than wounds of the hip, are those of the knee-joint, which may be either penetrating or non- penetrating. The latter undoubtedly occur, oftentimes, when the apparent line of direction of the shot lies through the articulation, the missile having been deflected by the periarticular structures ;x and the joint proper may not he opened, even though the patella has been broken, or the head of the tibia bored through. Such a tibial perforation, which is not very seldom seen .as the effect of a round ball, may be caused by the passage of a pistol bul- let, and, though not very often, even by that of a conoidal musket-ball—the chassepot bullet being the only one used in the Franco-German war which produced such an injury in the cases observed by Becher. Usually, whether the shot has passed through or lodged, there is associated Assuring, and, if not primary, at least secondary opening of the synovial pouch, in which case violent symptoms of joint injury may not manifest themselves until several -days after the receipt of the wound.2 Penetrating injuries, whether made by small or large bullets, are in a high ■degree dangerous, not only to the part but to life itself, the usual gravity of lesions of the knee-joint being greatly increased by the more extensive damage which is always characteristic of gunshot wounds. Expectant Treatment.—Until recently, the expectant treatment lias re- sulted badly, except when the vulnerating body has been of small size, its removal easily effected, and the bone-splintering limited; and when circum- stances have permitted of most judicious care under favorable personal and hygienic conditions. “ In no single instance during the Crimean war” (ac- 1 MacCormac reports that he had under his care, during the Franco-German war, twenty-one such cases, of which only two proved fatal. 2 A typical case, in which a soldier was accidentally shot with a small revolver-ball in the street of Balaklava, was reported from the Crimea. “The missile had embedded itself in the tibia, just below its tuberosity, whence it was easily turned out by a pointed instrument, after .a small incision had laid the site open. The knee-joint did not appear to have been involved, but the man died eight days afterwards from the effects of acute inflammation of it, and the accompanying sympathetic fever. On examination after death, a minute fissure was found to have extended through the head of the tibia into the joint.” (Matthew.) 170 GUNSHOT WOUNDS. cording to Longmore), “ was a knee-joint, which had been opened by a bullet, saved, life being lost in every case where amputation was not resorted to.” By the official “ Medical and Surgical History of the British Army” in the Crimea, however, it is shown that eight cases were saved without operation, Fig. 282, Fig. 283. Partial fracture of left femur by conoidal ball lodged in cancellated structure. (A. M. M., Spec. 4071.) Amputated end of right femur and head of tibia with round musket ball impacted in latter. (A. M. M., Spec. 1481.) though in none of them was the bone within the capsule “ more than grazed (not fractured).” Of 308 cases treated by expectancy during our war, 258 (83.76 per cent.) died, and it is believed that even this does not truly repre- sent the excessive mortality, cases of non-penetrating wound probably having been, by error of diagnosis, included among the 50 that recovered. Of 529 cases similarly treated in the Franco-German war (and reported upon by Heintzel), 334 (63.14 per cent.) died—225 of these after subsequent ampu- tation, which was employed in 288 cases, or in 54.4 per cent, of the whole number which it was •attempted to treat expectantly. Of the entire 529 cases, only 132 (25 per cent.) recovered with a fairly useful limb. Of Reyher’s 19 cases, 18 died (94.7 per cent.). On the other hand, during the war of 1866, out of eighteen cases of gunshot wound of the knee, eleven were cured by conservative treatment (61.11 per cent.). Extensive opening of the joint by a shell fragment is more likely to be followed by recovery than is a bullet wound. Such injuries, if not fatal, are usually followed by anchylosis. Amputation and Excision.—Until within the last ten years, the results following amputation were better than those obtained by expectation, but the mortality rate was still very high, especially when the operation was per- formed in the intermediary period. Of 452 determined cases, duringthe war of the Rebellion, 331 died, or 73.23 per cent. Excision of the knee, which has been adopted 134 times in military practice, has been followed by death in 108 cases, or 80 per cent., and unless the antiseptic treatment should in the future very greatly lessen this mortality, the operation should certainly he, as Sarazin has put it, “ proscribed in army surgery.” In civil life, it succeeds much better, as might naturally be expected, since the injuries are as a rule less extensive, being made by smaller projectiles, and since the after- GUNSHOT INJURIES OF THE ANKLE. 171 treatment can be more satisfactorily carried out. Of twelve such cases, tabu- lated by Gurlt, only three died (25 per cent.). It would appear from the in- vestigations of the writer just quoted (though his conclusions are based upon only 28 cases), that if the patient does not die, he will probably recover with an useful limb—the “ end-result” of this excision being better than that of any other except the hip. But while, prior to 1876, under any one of the three methods of treatment, gunshot wounds of the knee, in time of war, resulted fatally in more than two-thirds of the cases, the reports that have been given of the recent attempts at conservation, under antiseptic treatment, would seem to indicate that the mortality can be very much lessened. Of Reyher’s eighteen cases, antiseptically treated from the first, only three died (16.66 per cent.), and twelve of these which were treated by occlusion, all recovered, each with a movable joint. Of his 40 cases which were only secondarily rendered antiseptic, 34 died (85 per cent.). Of Berg- mann’s fifteen cases treated early, but one died (6.66 per cent.); of his fifty-nine cases in all, only 24 died (44.5 per cent.); and of the thirty that recovered, twenty-eight pre- served their limbs.1 Of four non-military cases treated at Halle, all got well, and in three there was good motion of the knee (Kraske). Even very considerable splintering has not prevented rapid recovery with preservation of the function of the joint. Unless future and extended experience shall show that such favorable results are but exceptional, knee-joint wounds hereafter must be treated conservatively and antiseptically, if the extent of the injury be not so great as to necessitate immediate amputation ; for it would certainly seem as if Reyher was right in declaring that “ under primary antiseptic treatment, the injury loses its danger for life and limb of the patient. The prognosis is better, and to this must be added the assurance with which a prognosis can be made.” Fig. 284. Diagram of gunshot •wound of tibia with fissure enterimr knee-inint. /Kraakn Gunshot Injuries of the Ankle. As in wounds of the other joints, so in those of the ankle, the articulation- may or may not be opened. The periarticular injuries, which usually involve the parts behind the joint—seldom those in front—not infrequently cause- severe hemorrhage, primary or secondary ; may be associated with lesion of the posterior tibial nerve; and are often followed by stiffness of the ankle from cicatricial contractions, and by deviations of the foot from shortening of tendons, the result of loss of substance or of inflammatory adhesions. The 1 Bergmann’s dressing was from necessity quite a simple one : “As soon as possible after the- wound had been inflicted, the vicinity of the spot where the shot had penetrated was cleansed, then the whole limb was wrapped in a thick layer of antiseptic cotton-wool, the latter firmly pressed down by means of an elastic bandage, and the whole, including the ankle and hip-joint, embedded in plaster of Paris, and allowed to remain undisturbed for a fortnight or more. In some cases the first application of this dressing sufficed to effect the healing of the cutaneous- wound.” 172 GUNSHOT WOUNDS. penetrating wounds are much more frequently caused by the passage of a ball laterally than in the antero-posterior diameter, so that malleolar fracture is ■commonly seen either on one or both sides, and, if only one, generally on the •outer. Escape of synovia in moderate amount, without other associated evi- dence, cannot be held to certainly indicate opening of the articulation, since wounds of the sheaths of the tendons may be followed by a similar discharge. Treatment.—The treatment of these ankle-wounds must be conducted upon the same general principles as those already considered in connection with injuries of the wrist, the analogous joint of the upper extremity. When the destruction has been great, as from a large shell fragment in military life, or from a load of shot at short range in civil practice, even if one of the main vessels and nerves be undamaged, amputation may very properly be per- formed, since the danger of the operation to life will be at least no more, while recovery will be quicker—and by the adaptation of an artificial foot the functional value of the limb will be fully as great, if not greater—than when •conservative measures have been successfully adopted, tinder all other cir- cumstances, every effort should be made to preserve the foot, the usual details of the treatment by expectancy being fully carried out. Not only should all foreign bodies be removed, but the gouge may be freely used along the shot track through the bone or bones, and if necessary for the proper drainage of the wound, a malleolus may be cut away. Extensive destruction of the tendo-Achillis does not, as has by many been thought, contra-indicate the to save. In the immobilization of the part, much care must be taken to keep the foot at a right angle to the leg, to prevent the production of the “ pointed toe” that so much interferes with the after-usefulness of the limb ; and suppurative teno-synovitis, which is very likely to occur, must, if possi- ble, be prevented. Almost certainly, anchylosis will take place, and such a termination is really the most desirable. But recovery in the great majority of cases of penetration, certainly of those treated otherwise than antiseptically, takes place only after the lapse of many weeks, and the results of the pro- tracted confinement and suppuration may be such as to compel the perform- ance of either excision or late amputation. Primary excision has been very rarely if ever performed for gunshot injury of the ankle, so that in this joint excision may be regarded simply as the complement of expectancy. Its results have not been such as to make it a favorite operation with military surgeons. Of the 142 cases tabulated by Gurlt, 49 ended fatally (35.5 per cent.), and in 19 cases an after-amputation was required, with a resulting mortality of 63.15 per cent. Death, accord- ing to Culbertson, may in one-sixth of the cases be attributed directly to the operation itself. Of the patients who recover, about one-half (52.72 per cent, of the 55 Germans in whom Gurlt was able to ascertain the “ end-result”) may be expected to have a fairly useful limb, and this whether the resection be complete or partial. If only one of the leg bones has been involved in the excision, lateral deviation of the foot will almost certainly take place. The operation, if done at all, should be effected by means of lateral incisions. The duration of treatment in successful cases is to be estimated by months, not weeks. In contrast to the death-rate of excision (35.5 per cent.), that of ankle-joint amputation is low (13.43 per cent, in the 67 cases tabulated in “ Circular No. 6”); that of supra-malleolar amputation “ surprisingly low” (Otis); and that of leg-amputation in general, while quite high—26.02 per cent. (Otis)—still nearly ten per cent, more favorable. Even compared with Legouest’s statis- GUNSHOT INJURIES OF THE HEAD. 173 tics, excision is more dangerous by 12.5 per cent, than amputation at the joint, though so by 13.5 per cent, than removal through the leg; but Legouest’s figures, here as elsewhere, are largely those of the operations per- formed by the French surgeons in the Crimea, the fatality of which was ex- cessive. Gunshot Injuries of the Head. Gunshot wounds of the head may be confined to the scalp; may also involve the cranial bones; or may present, in addition, an injury of the brain or its coverings, with or without lodgment of the missile. Scalp.—When the scalp alone is damaged, there may be only contusionr which, if severe, is almost certain to be followed by cerebral disturbances; or simple division, differing but little from an incised wound, an accident due almost always to the superficial impact of a shot passing at a high rate of speed; or, what usually occurs, a more or less deep grooving with primary or secondary loss of substance; or, and this is frequently observed, a seton wound, sometimes of considerable length; or, lastly, penetration with lodgment, often seen in wrounds produced by small shot or pistol bullets of small diameter, and at times in those caused by nearly spent rifle-balls. Ordinarily recognized without difficulty, the scalp injury may, for a time, escape detection when the shot has passed up to the head from the neck or face. The prognosis is favorable; the mortality is only 2 per cent.v chiefly from “ some form of encephalitis,” though the various wound-complications may occur, particularly hemorrhage ; and though cerebral disturbances, occasion- ally very persistent, are not unlikely to follow injuries inflicted by missiles of large size. Primary union seldom occurs, though much more apt to take place here and on the face than in superficial wounds in other parts of the body. Treatment.—If a bullet has lodged, its presence can be detected without difficulty, except when located in the temporal fossa; its position then may be indicated only by pain on moving the lower jaw. Bird-shot, and even small pistol-balls, may be so flattened and buried in the tissues as not to be discovered upon palpation, or by the use of the probe. If found, the foreign body is to be removed through either the original wound or a counter open- ing ; but when very small, no extensive search should be made, as the offend- ing substance will probably reveal its presence at a later period, or will other- wise remain innocuous, causing no material delay in the healing of the wound. Seton wounds not infrequently convert themselves by sloughing into deep grooves ; and because of the possibility of such a change being produced, some have advised that they should be early laid open, a procedure, however, that, as a rule, should not be adopted, since in very many cases, when let alone, the bullet track readily heals. As the result of a shell wound, there may be an extensive loss of substance, with or without exposure of the bone. The treatment of scalp wounds is that of ordinary flesh wounds elsewhere, though in cases in which there has been produced scarcely more than an inci- sion, sutures may be very advantageously employed, primary union being not infrequently thereby secured ; and in the cases of grooving the introduction of stitches does no harm, and often by holding the edges closer together lessens the time required for healing. As in scalp-injuries other than gunshot, adlie- 1 162 deaths out of 7739 cases during our war (2.09 per cent.)* 174 GUNSHOT WOUNDS. sive straps are of little service, since they soon become loosened and slip. Hot applications at times are much more comfortable and better adapted to mode- rate inflammation than cold. Cranial Bones.—Like other bones, those of the cranium may be either con- tused or broken; such lesions are, as a rule, more serious than when conse- Fig. 285. Fig. 286. Necrosis following gunshot fracture of right parietal bone. (A. M. M., Sect. 1, Spec. 3859.) Necrosis following gunshot fracture of right parietal bone. (Interior view.) quent upon an ordinary blow, or fall, and are more apt to be associated with cerebral injury. Contusion of Cranium.—The contusion may be slight, unrecognized, and quickly recovered from, as it is likely to be when due to a small pistol-ball wound; or may be so severe as to kill at once the injured part; or may be followed by acute or chronic bone inflammation, causing subperiosteal effusion or exudation, suppurative osteo-periostitis, or necrosis—caries is rarely ob- served—one or all; and complicated with severe inflammation of the overlying soft parts, meningo-encephalitis, cerebral abscess, or pyaemia.1 Not infrequently it happens that no symptoms of bone-injury show them- selves for many days, when suddenly violent cephalalgia is experienced, soon followed by convulsions, coma, and death from intracranial suppuration. Very generally, however, if primary laceration of the meningeal vessels causing compression from blood-clot has not taken place, there will be ex- perienced, after recovery from the immediate effects of the wound, it may be for a long time, headache of greater or less severity, associated in many cases with dizziness, intolerance of light and sound, nausea, and vomiting. Simple 'periostitis does not often occur, and no case of diffuse inflammation of the pericranium was reported during the whole course of our late war. Osteo- periostitis may be indicated by the presence of the “puffy tumor of Pott,” which however is by no means always present, and by the exudation of pus through the contused bone. Purulent infection manifests itself in the usual way. At a later period exfoliation occurs, either superficial or of the exter- nal table, and, at times, separation of necrosed pieces of the entire thickness of the bone. This necrosis is occasionally primary, but is generally conse- quent upon inflammation. Hyperostosis or eburnation may, though rarely, be met with. Chronic cerebral disturbances, more or less well marked, mental irritability, 1 The hepatic abscesses observed long ago, without any pus collections in the lungs, are, it is probable, due to the passage of septic emboli (from thrombi in the diploic veins) from the arteries to the veins, in the lung, in which viscus, besides the usual capillary connection, there is also, as observed by 0. Weber, a “direct merging of the terminal ramifications of the arteries in the rootlets of the veins.” GUNSHOT INJURIES OF THE HEAD. 175 -change in the temper and habits of the individual, and epilepsy, are not rarely found as the result of these injuries. Judging from the cases reported by Otis, one in six of cranial contusions from ride-bullets and shell-fragments may be expected to cause death f and, speaking generally, these contusions when severe are more serious than fractures, the breaking of the bone in a measure protecting the brain and its coverings, lesion of which is the chief element of danger in all head injuries. Treatment.—When contusion is known to have occurred, the maintenance of rest is of the utmost importance, and, if symptoms of internal inflamma- tion show themselves, cold should be applied, either by ice-bags or by a coil of rubber tubing (the mediate-irrigation coil of Petitgand). Subperiosteal Fig. 287. •suppuration occurring, the pericranium should be incised, and if the exposed bone is discolored, porous, and exuding pus, it should be opened with a small saw or trephine; often the external table only, in the latter case, requires to be removed. In a word, cranial suppurative osteo-periostitis should be treated in the same way as the corresponding affection in a long bone. If the early occurrence of compression makes it probable that there has been extensive hemorrhage from a ruptured sinus or meningeal vessel, the trephine should he used, so that, if possible, the clot may be removed and the bleeding stopped. When later-occurring symptoms indicate that pus has accumulated beneath the skull, although “ it is impossible to distinguish intracranial sup- puration from arachnitis” (Ashhurst), and although the result of complete trephining in gunshot contusion has been very unsatisfactory—all of the twelve cases thus treated during our war having proved fatal—yet, as the condition if left to itself is almost certain to cause death; and as the simple removal of a button of bone wTith a conical trephine can only do harm by the resulting admission of air, while such harm can he greatly or altogether prevented by antiseptic after-treatment; and as evacuation of pus may relieve the symp- Mediate irrigation ; coil applied to head. (Petitgand.) 1 Of three hundred and twenty-eight patients with gunshot contusion of the cranial hones, fifty-five, or seventeen per cent., died; ninety-eight, or thirty per cent., were disabled from causes referable to injuries of the head; and one hundred and seventy-five, or fifty-three per cent., recovered. 176 GUNSHOT WOUNDS. toms and save the patient, there is certainly good reason why in these cases operative interference should be attempted. Fig. 288. Fig. 289. Perforation of skull by conoidal musket ball. (A. M. M., Sect. 1, Spec. 5473.) Shell fracture of skull. (A. M. M., Sect. l'r Spec. 2871.) Fractures of Cranium.—These, as consequent upon gunshot injury, may be partial, only one of the two tables of the injured bone giving away; or, and this is ordinarily the ease, complete. More or less comminution is usually produced; at times limited to the immediate vicinity of the point struck, but not seldom affecting the bone over a considerable area, or even involving every part of the cranium, w’ith or without associated separation of sutures.1 The extensive shatterings are almost always due to shell-injuries, or to perforating wounds made by rifle-balls of large size. When the force of impact is not great, only one of the tables may be broken; usually the inner, not because of its special brittleness, but in accordance with Teevan’s Fig. 290. Fig. 291. Section of frontal bone, showing fissure over left supra-orbital region. (A. M. M., Spec. 24.) Internal view of frontal bone, showing splintering of vitreous table. (Same specimen as Fig. 290). law that the breaking takes place in the line of extension. Fracture of the outer table alone very rarely occurs (though it does at times happen) except when the injury is inflicted over the frontal sinus, the mastoid process, or the occipital protuberance.2 In fractures of the lower frontal region, in children, 1 In Circular No. 3, S. GL 0., 1871, a case is reported by Assistant Surgeon Yeomans, U. S. A., in which, in consequence of a musket-ball perforation (the ball fired at a distance of 315 yards entering through the posterior part of the parietal, and emerging through the frontal bone), all of the eight cranial bones were broken, as shown at the autopsy. (Fig. 288.) 2 Otis declared that he was disinclined to admit that the outer table of the skull was ever fractured in the adult, without injury to the inner table, either by projectiles of war or other external violence, except in the rare instances of blows or the impact of missiles upon the superciliary ridges, the mastoid or zygomatic processes, and possibly the occipital protuberance; or in cases of grooving by a sharp shell fragment. Gunshot injuries of the head. 177 both tables must almost certainly be broken, since the sinus is undeveloped until at or about the period of puberty. Though, occasionally, fracture of both tables with greater or less splinter- ing of the internal may occur, without depression of the outer, ordinarily the latter condition is well marked, the portion driven down being, at times, quite limited in area, and the fracture a punctured one, but, as a rule, of con- siderable extent and accompanied with widely extending fissures. The com- minution associated with penetrating or perforating wounds is in no small degree, doubtless, due to the hydrostatic pressure developed in the traversed brain. Busch and Kocher’s experiments have shown that “ in firing at short distance into a skull filled with soft brain-substance, the cranial wTalls are broken up in all directions and widely scattered.” Fractures by contre-coup (if such they may be named) may thus be produced by the force of a grazing or penetrating shot, transmitted through the semi-solid cerebral mass to some part of the base of the skull, as in the form of fracture met with in President Lincoln’s case,1 two examples of which have been noticed by Long- more, while six others, from the Russo-Turkisli war, have not long since been recorded by Bergmann, of Wurzburg—one or both orbital plates being broken, with or without associated lesion of the ethmoid bone. As indicative of the existence of such a basal injury in connection with wound of some part of the vault, may be mentioned “ retrobulbar extravasation and exoph- thalmos, associated probably with a lesion of some of the motor nerves of the eyeball, or even of the optic nerve” (Bergmann); and, if the cribriform plate of the ethmoid has been fractured, anosmia. The diagnosis of gunshot fractures of the skull, if other than linear, and if occupying the vault or sides, is usually easy—the ordinarily associated tegu- mentary wound permitting a ready determination by finger or probe of the existence of a break. At times, however, even when the shot has penetrated, the elasticity of the skull, aided very probably by the tension of the dura mater, and perhaps by the pulsatile force of the brain itself, may so perfectly restore the fragments to position as to make it exceedingly difficult, it may be impossible, to recognize the osseous lesion, or, still more, to detect an existing penetration with lodgment of a foreign body. In the latter case, the establishment of the diagnosis may be greatly facilitated by the possible presence of a shred of clothing or a hair, carried in by the shot and caught between the edges of the break, as in the case reported by Assistant Surgeon Howard, U. S. A.,2 though a hair may be driven in by a missile which does not penetrate.3 When it is the base of the skull that has been broken, the ball having entered through the face or neck, and when the patient lives long enough to come under treatment—the nature of the injury, if recognized at all, will be so by determination of thfe length and direction of the track of the bullet, and by observation of the ordinary symptoms of basal fracture produced by violence other than gunshot. Escape of cerebro-spinal fluid, if it occurs, may, 1 President Lincoln was killed by a bullet which “entered through the occipital bone about an inch to the left of the median line, and just above the left lateral sinus . . . passed through the left posterior lobe of the cerebrum . . . and lodged in the white matter . . . just above the anterior portion of the left corpus striatum. Both the orbital plates of the frontal bones were broken.” 2 American Journal of the Medical Sciences, Oct. 1871. 3 As in the case reported from the Crimean war, in which, an undepressed fracture of the upper part of the frontal bone having been caused by a shell-fragment, the spontaneously separated portion of the external table “ contained a fissure in its centre, into which some hair had been driven and firmly impacted.” (Matthew.) 178 GUNSHOT WOUNDS. hs stated by Roser, be regarded as indicative of a superficial brain lesion, the swelling following deeper injuries preventing such discharge. That the missile has lodged, may at times be ascertained by exploration of the wound, or even, in rare cases, by the detection of an elevation of bone on the opposite side of the head, the ball having partially perforated from within outward at such a point; but usually it is, during life, a matter of conjecture simply, only a single wound existing, and there being no evidence of the missile having rebounded or having been deflected after producing the fracture. Prognosis.—The prognosis of these injuries, though much affected by the mature of the wound, is always grave; not because of the fracture itself, for ■a broken skull-bone heals as readity as any other, but because of associated ■lesions and resulting complications. Aside from hemorrhage from a lacerated sinus or meningeal vessel, and actual cerebral damage, the danger is chiefly due to meningo-encephalitis, because of the nearness of the brain, and the facility with which it participates in the lesions of its coverings. This meningo-encephalitis may he developed at an early period, or, as is more usual, after a number of days—particularly in the latter part of the second w'eek—and is ordinarily, though not necessarily, associated wTith an open wound. Asa result, acute suppuration may take place, a cerebral abscess having been observed by Beck as early as the fifth day, though commonly the pus-collection is either not formed, or does not produce any symptoms, until after three, four, or five weeks. When lodgment of a foreign substance has occurred, and the foreign body remains, it may prove the developing cause of suppurative brain inflammation even years after apparent recovery has taken place. In the Crimean war, 74 per cent, of the cases of cranial in- jury proved fatal (711 out of 961), and during our late war the mortality-rate was 59.2 per cent. (2514 out of 4243 cases the results of which were ascer- tained). Fractures of the internal table alone proved fatal in nineteen out of twenty cases (95 per cent.), penetrating fractures in 85.5 per cent. (402 out of 470 cases), and perforating fractures in 80 per cent. (56 out of 70 cases). In civil life, when the injury lias been inflicted by a shot-gun charge at short range, with result- ing extensive local destruction, the probabilities of a fatal issue are of course very great; but even in such a case, and much more so in a non-penetrating pistol-ball wound, recovery is decidedly more likely to take place than in military practice. For this there are various reasons, such as the earlier and more constant attention that can be given in civil practice; the generally better hygienic surroundings ; the less velocity of the vulnerating body, and ■consequent less damage to the brain; and, not least, the, as a rule, less advanced age of the patient. Young adults bear these injuries better than those in middle or advanced life, and children, who are often the subjects of accidents of this kind, decidedly better yet; and this has been especially noticed with reference to cases of splintering and depression of the internal table. Injuries of the base are much more dangerous than those of the vault, but it would appear from Lidell’s investigations that they “prove mortal much less frequently than heretofore has generally been supposed”—85 out of 137 patients having more or less perfectly recovered, and two or three of these “so ■completely as to re-enlist.” It is generally held, with Guthrie, that a wound ■of the anterior part of the head is more likely to cause death than one of the posterior. But that such is the fact is by no means certain. In the 316 eases of penetration and lodgment tabulated and analyzed by II. R. Wharton, of which 279 were instances of gunshot injury, the relative mortality of GUNSHOT INJURIES OF THE HEAD. 179 wounds through the frontal, parietal, and occipital bones, was, respectively, 44 per cent. (58 out of 182), 46.5 per cent. (27 out of 58), and 70 per cent. (16 out of 23); while the death-rate of those through the temporal bone was but 88.7 per cent. (12 out of 31), probably because of the fact that the larger proportion of such injuries never come under treatment. Wounds of the cerebellum almost always prove quickly fatal, though in a case reported by S. W. Gross the patient lived nearly five days:— “At the expiration of forty-eight hours after the reception of the injury . . . his manner was perfectly rational ... he complained of no pain in the head, nor suffered from special symptoms . . . his thumbs were adducted and strongly flexed in the palms, and he told us that he suffered from persistent priapism, which we found to be the case. There were no other general symptoms: the man had a good appetite, was continually walking about. . . . On the morning of the 11th (April) we found him in his tent dead, and in the supine position. The calvaria having been removed, the somewhat misshapen buckshot was seen to be in contact with the corpus dentatum of the right lateral hemisphere of the cerebellum. A small splinter of bone was lying in the track of the wound, and the morbid appearances were confined to slight ecchymosis of the cerebellum, and a small quantity of bloody serum at the base of the organ.” In the majority of cases which do not prove fatal, more or less cerebral dis- turbance is likely to be experienced during the after-life of the individual; headache, irritability, inability to endure exposure to the sun, etc. Epilepsy is a not infrequent result, as is impairment of the special senses, particu- larly of sight and hearing. Legouest says that he has even seen two cases of immediate and irrecoverable loss of sight after injury of the supra-orbital nerve ; though it is probable that such a condition was really due to either frontal fissure extending into the optic foramen, with or without intra-vagi- nal extravasation, or to hemorrhagic detachment of the retina.1 Impairment of vision at a later period may be caused by plastic choroiditis. Generally, the blindness after non-penetrating injuries is unilateral; when occurring on both sides, the prognosis seems to be more favorable. Wounds of the mas- toid process are very often followed by deafness, and occasionally by facial paralysis. More or less persistent, early aphasia has been not infrequently observed in injuries involving the “ language centre.”2 The frequently occur- ring primary paralysis of the extremities may become permanent in greater or less degree. On the other hand, no damage other than that which is local and tempo- rary may be produced, and ball and even bone may remain for years in the brain without doing any harm. Such cases, however, are but the fortunate exceptions proving the rule; and many times it has happened that, after a long period of apparently perfect health, death lias resulted from the presence of the foreign body. Treatment of Gunshot Fractures.—Respecting the proper mode of treatment of these cases, there has been and is much diversity of opinion, and, whatever rules may be laid down, individual judgment must, in any given case, largely 1 Berlin, upon examining thirty-four such non-penetrating cases, found fractures of the walls of the orbital canal in every one. Cohn observed one case, during the Franco-German war, in which a fragment of shell wounded the right upper eyelid and brow, and caused partial blind- ness of the right eye. Six months later, on account of the development of sympathetic ophthal- mia, enucleation of the right eye was practised, and examination showed that there were remains of a former hemorrhage in front of and behind a projecting fold of the retina, in the region of the macula. 2 As long ago as during Napoleon’s Russian campaign, Larrey noticed two cases of aphasia, due not to gunshot hut to rapier and lance wounds, cases in which, however, the lesions did not, at least directly, alfect Broca’s convolution or the parts immediately about it. 180 GUNSHOT WOUNDS. determine what shall he done. Gunshot fractures of the skull differ from other fractures only in the greater probability of the meninges or brain, or both, being damaged. If there is a linear fracture existing without depression or symptoms of compression, the case should certainly be treated expectantly ; and yet in these very cases there is a strong possibility that there has been splintering of the internal table, and that there will be developed a meningo-encephalitis, though this latter condition is not a necessary sequence. When there is com- minution and depression, without compression—and, for still stronger reasons, when pressure symptoms are present—it is certainly the part of wisdom to remove the fragments; and this can generally be done by the aid of the ele- vator, without having recourse to the trephine. But aside from cutting out a little unbroken bone, what added risk is there in judiciously using a conical trephine to open a way by which to get at and remove existing fragments ? Notwithstanding that the use of this instrument has been absolutely pro- scribed by some most experienced surgeons, such as Stromeyer and Neudor- fer, it certainly seems as if it were proper in injuries like these. The case is altogether different from that of operating upon an unopened skull for a sus- pected, but not definitely diagnosticated and located, intra-cranial lesion. Whether the trephine shall or shall not be used, cannot properly be deter- mined by an examination of statistical tables, embracing as they must do cases of very diverse nature, operated upon under widely different circum- stances. The death-rate among the English, in the Crimea, was 75 per cent. (21 out of 28), while during our war, in which the operation was resorted to seven times as often, it was but 56 per cent. (110 out of 19.6), 3 per cent, less than the general mortality of gunshot fractures of the skull. If penetration has occurred, shall the ball and bone-splinters be sought for? If the cranial opening is large enough to readily admit the finger, careful exploration of the track should be made; if not, and if a probe, or, which is better, an elastic searcher (for instance, a bougie) is used, the utmost care and almost no force must be exercised, lest the instrument should be pushed through the brain substance, instead of passing by its own weight along the sinus. So easy is it to do harm, that it may safely be declared that at least an inexperienced hand should never probe a penetrating head-wound. If the missile or other foreign body is felt, it should be extracted, if this can be done without spe- cial damage to the brain, the opening in the skull being enlarged if necessary. The successful removal of a bullet from within the cranial cavity, however, is a piece of surgical good fortune; and very often the ball does less damage than the search which is made for it. Wharton’s investigations would seem to prove that the search for the foreign body is less dangerous than has generally been supposed. Of his 316 cases, of which one-half (160) recovered, in 106 removal was effected with a mortality percentage of 32, while in the 210 in which there was no attempt at extraction, the corresponding percentage of death was 58. Of 111 cases of recovery in which no mental disturbances remained, in 56 the foreign body had been removed, and in 45 left; that is, in 52.8 per cent, of the whole number of the former category, and in only 21.43 per cent, of the whole number of the latter. But it should be remembered that it was probably only in the milder cases, and when the foreign body was superficially lodged, that its extraction was attempted. Treatment of Cerebral Complications.—For the relief of the meningo- encephalitis, which may be developed early, or more likely during the second week, only the ordinary anti-phlogistic treatment can be adopted, rest and cold being by far the most important elements thereof. When there is a sudden increase in the severity of the symptoms, especially the headache, or GUNSHOT INJURIES OF THE FACE. 181 intense cephalalgia appearing at a later period, with progressive stupor, and often rigors or convulsions, making it very probable that an intra-cranial abscess has been formed, the fractured bone should be removed, particularly if there is such paralysis present as suffices to fairly locate the pressure in the immediate vicinity of the break, and an incision should be made through the coverings and into the brain, so that, if possible, exit may be given to the pus. Though the chances of relieving the patient under such circumstances are very slight, yet, as in the case reported by Assistant Surgeon Weeds, IT. S. A.,1 recovery may follow the operation; and, if left to himself, a man thus affected is sure to (lie. The hernia, or, much more commonly, the fungus cerebri, which not infrequently occurs,2 especially in young persons, and which, as when due to cranial and meningeal injuries not produced by gunshot violence, is so generally followed by death, is best treated by simple and moderate compression; operative interference, whether by removal, cauterization, or injection, seldom avails to prevent a fatal termination. Of the value of the antiseptic method in gunshot head-wounds of all kinds, it is impossible as yet to express any positive opinion. If in the future it prove to be true that it is not the injury of the hard or soft tissues, nor the lodgment of ball or bone, that causes death—except when there occurs fatal hemorrhage, or when parts of the brain essential to life are destroyed—but pathological processes which are due to morbific agents in the air that gets access to the wound, then in the* adoption of some form or other of germ-destroying or germ-excluding dressing, will lie the safety of- the wounded. Gunshot Injuries of the Face. "Wounds of the face, though frequently met with, and often causing great •deformity, are comparatively seldom the cause of death,3 and then usually from hemorrhage, or from the results of maxillary fracture. Flesh wounds, if produced by single bird shot or small bullets, are rarely attended by any material destruction of tissue, are quickly recovered from, and are ordinarily followed by little or no disfigurement. When the vulnerating body is of large size (as, for instance, a charge of shot at close range, a shell fragment, •or a musket ball), and when the nose, lip, eyelid, or ear, is extensively damaged, great deformity is likely to be produced, and unfortunately plastic surgery is not very often of much avail in relieving the effects either of the •original loss of substance, or of the cicatricial contraction. Injury of Steno’s duct may be followed by salivary fistula. In wounds of the orbital •cavity, even those produced by bullets of large size, the eyeball may escape injury; but generally it is more or less damaged, perhaps destroyed outright, perhaps so contused or lacerated that destructive inflammation is soon lighted up, or that the lesion is followed by so-called “ sympathetic ophthal- mia” of the other eye, which is very generally not sympathetic at all, but probably due, as claimed by Lebert, to the direct transference of septic germs along the lymph spaces of the optic nerves. Immediate and total blindness •of one or both eyes is at times caused by the passage of a shot from side to side through the optic nerve or nerves, no other serious damage in some of the cases being done. Penetration of the cranial cavity through the orbit 1 Nashville Journal of Medicine and Surgery, April, 1872. 1 Otis reports 61 cases, of which 50 proved fatal. 3 The mortality-rate during our war was 5.88 per cent. (462 deaths out of 7868 cases), fleeh wounds proving fatal in 1.54 per cent., orbital wounds in 5.7 per cent., and fractures in 11.4 per cent, of the cases. 182 GUNSHOT WOUNDS. almost always causes death ; of eighteen such wounds noticed in Wharton’s table, seventeen died (94.44 per cent.). In civil life, the eyeball is not infre- quently struck by a piece of exploded percussion cap that may produce simply an incised wound of the cornea or sclera, or may penetrate and lodge; and similar injury may be caused by a bird shot. In numerous cases, rifle bullets and other projectiles of considerable size have entered through small openings in the lids, or even under them, and either have lodged deep in the orbital cavity or have penetrated the base of the skull. In a large number of these cases of gunshot wound of the face (more than one-third during our late war) fracture occurs, most commonly of the infe- rior maxilla ; death results in about one-ninth of the cases, and a very con- siderable proportion of the remainder are followed by great deformity, suffering, paralysis, or interference with mastication. Occasionally the greater part or even the whole of the face is carried away by a large shot or a shell fragment, and very extensive destruction is often produced by suicidal shoot- ing through the mouth, or by the discharge of a pistol held close against the chin. By the passage of a bullet through the superior maxilla, the upper dental arch may be entirely detached from the body of the bone, or, as in a case imported by Longmore as having occurred in the Crimea, the palatine process of one side may be separated and turned at right angles to its fellow. Associated wound of the tongue often occurs, with or without considerable loss of substance, and at times with lodgment of a foreign body (piece of bone, tooth, ball). The primary hemorrhage in these cases may be quite profuse, and a very troublesome secondary bleeding from the lingual artery, or its dorsal or ranine branch, is of common occurrence. Local inflamma- tion, frequently of high grade,' is soon developed, and the resulting swelling may become so great as to threaten suffocation. When the anterior part of the organ has been carried away, or when its under surface has been much torn, there is danger of the tongue being so tied down by later cicatricial contraction as to be seriously interfered with in its movements. Balls, even of large size, may lodge in the antrum or in the nasal fossa., or may fix them- selves in the walls of these cavities, frequently remaining there for years, at times causing no trouble, but generally producing more or less slowly pro- gressing necrosis—a process which occasionally secures spontaneous elimina- tion of the foreign body into the nose, mouth, or throat. Complications of Face-Wounds.—Primary, and of greatly more import- ance, secondary hemorrhage from the lingual, facial, or internal maxillary artery, is a frequent complication of wounds of this region, and is the most common cause of a disastrous result : indeed, to this and to the effects of suppuration from hone-disease are due most of the deaths among these cases. Fractures of the lower jaw, with extensive loss of substance, are at times followed bx fibrous union, with consequent impairment of function. True anchylosis of the temporo-maxillary articulation, and more frequently false anchylosis from the presence of cicatricial bands, may occur, and much in- convenience often follows from adhesion of the tip or side of the tongue to the lower jaw. Paralysis, more or less well marked, results in many cases from injury of the facial nerve, and at times muscular twitchings, which may persist throughout the after-life of the individual. It is in this region espe- cially that in civil practice troublesome powder stains are met with, the unburnt grains lodging beneath the epidermis or the conjunctiva, or in the cornea, and producing, if not early removed, very disagreeable markings, while even if they are taken away, permanent tattooing often remains. GUNSHOT INJURIES OF THE FACE. 183 Treatment.—The treatment of these injuries is in general very simple, flesh ■wounds, unattended with much destruction, requiring only the removal of any foreign bodies which are present, and the adoption of the ordinary local measures employed in the management of gunshot wounds. The lacerated and contused soft parts are not to be removed, but readjusted as accurately as possible, and held in place, either by strips of gauze fixed by collodion, or better by sutures or pins; the abundant blood supply of the face secures the preservation of vitality, and oftentimes very speedy repair. In cases of fracture, no fragments that are in any degree attached are to be taken away, but are to be restored to position, and are to be held by appropriate dress- ings, or by frequently applied pressure of the finger, or, if about the mouth, by that of the tongue, the moulding influence of this organ often producing effects which are quite surprising. When the bones of the nose are shattered, every care should be taken to prevent or at least to lessen the sinking in of the bridge, which causes so unpleasant and suspicious a deformity. Fractures of the inferior maxilla are to be treated like similar injuries consequent upon blows, falls, etc. When there has been great destruction of the anterior part of the bone, with its overlying soft parts, every effort should be made to bring forward the edges of the tegumentary wound, and to prevent adhesion of the tongue. Unfortunately, in a large proportion of these cases, great deformity will result, but it may often be very much lessened by subsequent plastic operations. As far as possible, the secretions of the wound are to be drained away from the throat, since their being swallowed not only adds greatly to the discomfort arising from the injury, but, if they are abundant, destroys the appetite, impairs digestion, and may contribute much to the production of a fatal result. Secondary hemorrhage is to be arrested by ligation of the bleeding vessel, when it can be found, or by the use of ice, hot water, the hot iron, or com- pression. When these measures prove insufficient, the lingual, facial, or external carotid artery, according to circumstances, should be tied. Ligation of the common carotid, though frequently resorted to, should not be adopted if it is possible to avoid it, being both dangerous and unreliable. Of 111 cases in military practice, 81 (73 per cent.), and of 16 in civil practice, 4 (25 per cent.), or, taken altogether, 85 out of 127 (67 per cent.) cases have terminated fatally, while death has also followed in three out of seven cases of ligation of the external carotid alone, or 42.85 per cent. (Wyeth). Of the 54 cases of liga- tion of the common trunk which occurred during our late war, in at least 14 (26 per cent.) there was subsequent hemorrhage; and of the remaining 40 cases, 14 ended fatally in the first week, and 11 of these within the first four days ; so that it is fair to infer that had the patients lived a little longer, there would have been a decided increase in the number of secondary bleedings. Wounds of the eye and its appendages are to be treated like those produced by other causes ; if lodgment of the foreign body has taken place, and vision has been destroyed, the eyeball should be removed at once, to prevent the development of sympathetic ophthalmia. If a considerable part of the ear has been carried away, little or nothing can be done to correct the resulting deformity; but this is a matter of comparatively small importance, since the hearing is not affected, and the disfigurement can generally be readily con- cealed. If the bullet has lodged in the external auditory canal, it should be removed, even if it be found necessary to displace forwards the auricle and cartilaginous meatus in order to do so.1 Powder grains are to be carefully 1 Green, of Boston, has recently reported a case in which by making “ a semicircular incision above and behind the auricle, through the periosteum,” carrying forward “the periosteum with the auricle till the edge of the osseous meatus was reached,” and cutting through “ the insertion of the cartilaginous into the osseous passage in its upper and posterior part,” he was able to dis- cover and remove three pieces of two small pistol balls which had been fired directly into the ear. 184 GUNSHOT WOUNDS. picked out, or, if they are so placed as to render it practicable, a blister may be applied, upon the drawing of which the grains will be found either de- tached or so loosened as to be readily removed. Gunshot Injuries of the jSTeck. Wounds of this region are, as a rule, of importance only when involving the air-passages, the pharynx or oesophagus, the great vessels, or the larger nerves. Mere contusions from spent balls or shell fragments may cause tem- porary paralysis of the muscles of the neck, or of the upper extremity, or even muscular rupture with resulting distortion, and may be followed by more or less sloughing. Superficial wounds, that is, those not passing through the deep fascia, usually heal in due time—often very quickly when produced by small pistol balls or bird shot—though occasionally the cure is much delayed by the supervention of erysipelas, or of suppurative inflammation of the sub- cutaneous connective tissue. Of the deeper wounds, those of the lower part of the neck are more dangerous than those of the upper, death in many cases of the former category being consequent upon the extension of inflammation along the fascial planes to the parts within the thoracic cavity. When the injury is confined to the posterior part, but comparatively little damage is usually done, unless the vertebrae are wounded, although temporary paralysis, even to the extent of involving all four extremities, may result from spinal concussion, and more lasting paralysis and muscle-atrophy from lesion of the nerves soon after their emergence from the vertebral canal. Injuries of the muscles are ordinarily recovered from without difficulty, and with no serious after-results other than, at times, deformity consequent upon cicatricial adhesions, when the superficial tissues have been extensively destroyed, and upon contractures from loss of substance in the muscles themselves. Torti- collis, which chiefly follows wounds of the sterno-mastoid, may be permanent, or, as is more usually the case, may ultimately disappear, either wholly or in great measure. The exposed position of the larynx and trachea renders them quite liable to injury, though actual penetration is in a limited number of cases prevented by their deflection of musket bullets and much more frequently of small balls and shot. Small shot may even pierce the cartilaginous wall and lodge under or in the mucous membrane, laryngitis or tracheitis being in consequence de- veloped. I once examined, after death, a case of this sort, in which a charge of bird shot at short range peppered” the upper part of the left chest and the front of the neck, making an extensive laceration just above the right sterno-clavicular articulation. The fatal result was due to laryngitis consequent upon the lodgment of a single shot under the mucous membrane covering the left wing of the thyroid cartilage. Very rarely does the missile enter the air-tube without passing through, though such cases have been observed, the vulnerating body producing results similar to those which follow the introduction of any solid substance through the glottis. Suffocation, actual or impending, may be produced by the pres- sure of inflammatory products external to the trachea. Cicatricial contrac- tion after extensive destruction of the anterior part of the larynx, or inflam- matory stenosis, may compel the permanent wearing of a tracheal tube. Aphonia, in greater or less degree, very frequently follows injuries of this sort; necrosis of the cartilages is quite likely to occur; and aerial fist like at times remain. A missile passing high up may wound the pharynx, or, at a lower point, the oesophagus; only very rarely is there associated lesion of both the air- GUNSHOT INJURIES OF THE NECK. 185 and food-tubes. The existence of an opening into the pharynx or oesophagus may be proved by the ready escape, through the external wound, of liquids or semi-solids taken into the mouth; in many cases the presence of such an injury is hut conjectural, from the line of direction of the shot; and occasion- ally it is revealed only by an autopsy. Persistent fistulse are not unlikely to follow such lesions. Outflow of alimentary substances through a laryngeal or tracheal wound does not necessarily indicate opening of the pharynx or oesophagus, as it is at times due to impaired functional integrity of the epi- glottis, permitting the entrance of food or drink from above into the air- passage. Much the most dangerous of the neck wounds are those involving the great vessels, many of these causing speedy death from primary hemorrhage. Oftentimes even the large arteries and veins escape injury in a remarkable manner, and, when wounded, bleeding is occasionally prevented temporarily by the bullet lodging against the opening and plugging it; or, after the first gush, the discharge of blood may be, though very seldom, permanently ar- rested by the presence of a clot. Traumatic aneurism is not infrequently developed, and arterio-venous aneurisms have also been observed in these cases. Extensive extravasations of blood may take place, at times causing serious or even fatal pressure upon the air-tube; and considerable quantities of blood have been found poured out within the carotid sheaths. Medium-sized bul- lets may lodge in the carotid artery or in the internal jugular vein, or may become encysted upon the vessel’s wall, or, after entering, may drop down and be arrested at a lower level. Wounds of the nerve trunks, unaccompanied by grave injuries of the bloodvessels, of the spine, of the head, or of the chest, cause the ordinary disturbances of motion and sensation in the parts supplied, and by reflex action, in certain rare cases, in regions quite remote. Lesion of the hypoglossal nerve has been followed by motor paralysis and unilateral atrophy of the tongue ;x that of the sympathetic, by contracted pupils, ptosis, and flushing of one side of the face;2 to injury of the pneumogastric, was attributed by Larrey the intense thirst which is at times experienced by the subjects of oesophageal wounds; injury of the brachial plexus, whether pro- duced by ball or bone fragment, very often causes not only the usual mus- cular affections in the upper extremity, but trophic changes in the skin, and that burning pain (causalgia) which is “the most terrible of all the tortures which a nerve wound may inflict.” (Mitchell.) Mere pressure of a lodged ball may give rise to severe nervous symptoms, which disappear with the removal of the foreign body. Of this an instance is reported by Savvtelle, in which pain, clonic contractions, and sensitiveness to heat and cold, were through nearly seven years produced by a conoidal ball that entered “ about half an inch above the left clavicle and about one inch from its sternal extremity, passed transversely between the trachea and the oesophagus,” and lodged on the right side “ between the subclavian and a branch of the brachial plexus, the ball resting on the artery just where it emerges from beneath the clavicle, with the nerve drawn tightly across the missile in front.” Removal of the bullet was followed by rapid healing and progressive relief of suffering, so that in two and a half years the recovery was declared to be entire, “ with the exception of a very slight sensitiveness of the fingers to cold and heat.” Occasionally several of the important nerves are simultaneously injured, as in a case reported by Stromeyer, in which the phrenic, the pneumogastric, the middle ganglion of the sympathetic, and the descendens noni, were wounded together with the larynx and pharynx. It sometimes happens that a deeply penetrating shot, although it may not directly damage important structures, 1 Mitchell, Injuries of Nerves, pp. 218, 335. Philadelphia, 1872. 2 Ibid., p. 318. 186 GUNSHOT WOUNDS. may cause a burrowing abscess which by subsequent ulceration of a largo vessel, or by descent into the chest, will bring about a fatal result. In a case of this sort reported by Surgeon O. A. Judson, U. S. V., the abscess cavity “ reached upward five or six inches along the spine, and downward in the mediastinum to the bifurcation of the trachea, where the ball was found, point downward and resting against the right bronchial tube.” Prognosis.—Leaving out of consideration such as necessarily and quickly prove fatal from hemorrhage, or from associated injury of the brain or spinal cord, neck wounds cause death in a much smaller proportion of cases than might naturally be expected from the number and importance of the struc- tures contained in this region.1 At least one-half of the wounds of the air- and food-tubes that come under treatment terminate fatally, and in a large proportion of those made by musket balls, there are associated lesions of more important parts that speedily cause death. As a rule, when one of the great bloodvessels is opened by a shot, life is quickly destroyed by the primary hemorrhage; but the bleeding may be arrested by compression (as in the well known case of the Duke of Padua, reported by Larrey), by the presence- of the ball, or by the formation of a clot, and an opportunity may thus be afforded for the application of a ligature or of methodical pressure. Accord- ing to S. W. Gross, wounds of the internal jugular vein have always resulted fatally, but in two of the cases which he cites (Schwartz’s and Stromeyer’s), the rent in the vein was completely healed at the time of death from pyaemia. Contusions of the main vessels are very likely to be followed by secondary hemorrhage, the detachment of the slough generally taking place at about the end of the second week, though sometimes much later; in a case of injury of the common carotid, observed by Cruz, of Lisbon, the bleeding “ did not show itself until the thirty-seventh day.” The prognosis in cases of nerve- wound unaccompanied by other grave lesions, is favorable as respects life, but not so as regards the after-comfort of the patient and the usefulness of the parts supplied by the damaged nerves. Treatment.—In the treatment of all varieties of neck-wounds in which the missile has lodged, unless this is quite small, it should he removed, pro- vided that its location can be determined, and that it can be reached (if necessary) by a careful dissection which will not in itself seriously imperil life. Though balls may remain for years without causing inconvenience, yet in the great majority of cases their presence does harm, and not infre- quently develops severe and often fatal inflammation. Even after such in- flammation has been lighted up, it may quickly subside upon the removal of a foreign body, the lodgment of which, though it is perhaps of large size, may not have been at first suspected. In a case reported by Duplay, a mitrailleuse ball, more than an inch and a half in diameter and of over six ounces weight, was for nearly four months lodged undis- covered between the lower jaw and the hyoid bone. Upon its removal, rapid healing took place. Injuries of the larynx, trachea, pharynx, or oesophagus, are to be treated in the ordinary way. Threatened suffocation, if due to pressure of extravasated blood, or superficially located effusions and exudations, is to be relieved by free incision and by removal of the clot, if such be present, or by tra- cheotomy ; if to oedema of the glottis, by scarification, or by the opening of 1 In only 15 per cent, of the nearly five thousand (4895) cases tabulated by Otis, and even this is declared to be an excessive ratio because of the inclusion of many cases of grave injury that never came under treatment. GUNSHOT INJURIES OF THE CHEST. 187 the air tube; and by the latter operation, if consequent upon inflammatory stenosis located sufficiently high to permit of the incision being made below the point of obstruction, or by the introduction of a tube through the origi- nal wound. Tracheotomy, in all these cases, is quite likely to be followed by a fatal result, not because of the operation itself, but because of the con- ditions by which it is rendered necessary. It was resorted to six times dur- ing our late war—twice successfully. In cases of lesion of one of the large bloodvessels, the resulting hemorrhage, whether primary or secondary, should be arrested by the application of ligatures above and below the wound, if such can be safely found; otherwise, by compression. When it is an impor- tant branch of the external carotid that has been damaged, if it cannot be duly tied on either side of the wound, the ligature should be placed upon the external carotid itself, and not upon the common carotid. The ligature of the latter trunk is, as we have already seen, though easier of execution, much more dangerous and more likely to be followed by after-bleeding, and the operation should not be resorted to except for wound of this vessel itself. The internal jugular vein, when wounded, should be tied rather than com- pressed, though by methodical pressure hemorrhage from this vein has often been arrested. As has been before noticed, Langenbeck has advised in these cases that either both the common carotid and internal jugular, or, preferably, the common carotid alone, should be ligatured. Two objections have been strongly urged against tying the vein: (1) that phlebitis was likely to be developed, and (2) that cerebral damage would ensue from the resulting in- terference with the return circulation. The first objection is now known to- have but little weight; and as respects the second, though cases have been reported of early occurring apoplexy after ligature of this vessel, yet by many experiments, as recently by those of Nicaise, it has been clearly shown that an ample collateral venous circulation may be expected to be rapidly established after ligation of the internal jugular vein, as also after that of the subclavian. Gunshot Injuries of the Chest. About one in twelve (at least one in twenty; of all gunshot wounds are of this region, and here, as in the head, the injury may affect the soft parts only,- or the bony wall, or the contents of the cavity; and the gravity, aside from the comparatively few not immediately fatal cases in which the large vessels are damaged, is directly proportionate to the extent of visceral lesion. ISTon-penetrating Wounds.—Superficial wounds, even if of large size, un- attended by fracture, rarely cause death—in perhaps only one out of every two- hundred cases—though, owing to the constant movement of the chest, healing usually takes place very slowly. Very long seton tracks are not seldom met' with, the ball running around over the ribs; and on this account, an erroneous diagnosis of perforation is oftentimes made. Occasionally, and then almost always as the result of contusion by a shell-fragment, there is an associated serious lesion of the lung, laceration or rupture—a lesion which probably can only occur when the glottis happens to be firmly closed at the moment of injury. Such an accident generally, though not inevitably, proves quickly fatal; 25 cases collected by Otis gave 11 recoveries. When any part of the bony wall is fractured, the wound becomes one of much greater importance, not only on account of the fracture itself, but, in higher decree, because of any accompanying injury of the subclavian or ax- illary vessels, when the clavicle or scapula is wounded, and of the intra- thoracic viscera, the pleura, or the intercostal or internal mammary arteries, 188 GUNSHOT WOUNDS. when it is a rib or the sternum that has been struck. Circumscribed pleurisy is a frequent but not necessary consequence of costal fracture, and extensive necrosis may follow the bone-injury. When the fracture is produced by an out-going shot, it is (as was originally pointed out by Brinton) decidedly less Fig. 292. Gunshot fracture of rib by round musket-ball which was embedded. (A. M. M., Sect. 1, Spec. 887.) dangerous than under other circumstances, all splinters being then carried away from the cavity, and bone-fragments being more likely to do harm to the lung than the bullet itself. Small balls at times bury themselves in the ribs, or in the sternum, and a bullet of even large size may wedge itself firmly in an intercostal space, ultimately, if not removed, working its way externally, or by ulceration and absorption getting into the pleural sac. When a costal cartilage is struck by other than a small missile, fracture takes place, but without a scattering of fragments. The treatment of non-penetrating chest injuries, whether there is or is not fracture present, is that of like wounds in general, in no way materially modified because of location. Foreign bodies are to be removed, if they can be found; but their discovery is at times very difficult, as when the projectile, even if of large size, is lodged under the scapula, or buried deep in the mus- cles of the back, or in or near the axillary space. Hemorrhage is to be arrested, preferably by ligation of the wounded vessel above and below the point from which it bleeds, or, if this cannot be done, by compression, or by the use of cold, or of hot water. The exceedingly dangerous bleedings from the axillary vessels (those from the artery being much graver than those from the vein) which often cause rapidly forming, diffused, traumatic aneurisms and blood- tumors, though undoubtedly they have at times been stopped by compression, yet can be safely treated only by ligation, at the seat of injury rather than above it, or by ligation followed by amputation of the whole upper extremity. Wound of an intercostal artery, though fortunately not very common, may, when it does occur, especially if located far back, give rise to a very consider- able hemorrhage, which is to be treated by direct compression rather than by ligation, an operation which is here neither easy nor safe; of eight cases in which it was attempted during our civil war, six proved fatal. Formal ex- cision of fractured bones should not be employed, except ata late period, for extensive necrosis; though the sharp ends of a broken clavicle or rib may often with advantage be cut off*. As in simple fracture, compression of the chest or half chest with a broad bandage, with adhesive straps, or with a plaster-of-Paris roller, will afford much comfort and hasten recovery. Penetrating Wounds.—It is to penetrating injuries that the special interest of thoracic wounds attaches. Though they may vary greatly in the amount of damage done, and in the complications developed, they are always grave lesions. In military surgery, many of the subjects of these injuries are left on the field, and in civil practice speedy death is not infrequent. For their production, it is not absolutely necessary that the projectile should enter the thoracic cavity, as the pleura, alone or together with the lung, may be wounded by bone-fragments. At times, chiefly when the vulnerating body is a pistol-ball or a small shot, laceration of the pleura or even penetration GUNSHOT INJURIES OF THE CHEST. 189 of the lung may occur without associated fracture, the missile entering through an intercostal space. Still more rarely, in an apparently external seton wound, the ball may cut the serous membrane for a considerable dis- tance in its passage between two ribs. In the non-fatal cases of entrance, with or without lodgment, it is usually the outer surface, or the thin edge,, of the lung that is wounded, though exceptionally the shot may pass through the thickness of the organ, or may even be buried close to its root. This last form of injury is generally followed by death from hemorrhage; almost certainly so unless the missile be of small size. Occasionally a bullet, after wounding the pleura, runs over the lung for a variable distance, to be either deflected internally, or to emerge through a rib or an intercostal space. Very rarely, if ever, does a rifle-ball pass from side to side through both lungs, and the patient recover. A lodged bullet, if the wounded individual lives, is very apt to become en- capsulated, though at times it may be found in an abscess cavity, or may enter a bronchial tube, and be coughed up; or the oesophagus, and pass downwards, or be ejected through the mouth ; or, if superficially placed, it may so work its way externally as to make it practicable for it to be readily removed; or,, adhesions not preventing, it may drop down in the pleural sac, where it may either remain free, rolling about upon the diaphragm, or, which is more pro- bable, may rest in the postero-internal angle. A spiculum of bone is more likely to cause the formation of an abscess, and may in this way, or by ulce- ration, find entrance into a bronchial tube ; though it may, especially if small, remain innocuous in the lung tissue either with or without capsular invest- ment. Penetration may occur without lung wound, the missile damaging the pericardium or heart, or lodging in the mediastinum, or even passing directly through without injuring any important structure. In a remarkable case reported by E. S. Cooper, in which, however, the lung was. injured, an iorn breech-pin was lodged “ beneath the heart, upon the vertebral column, just to the right of the descending aorta,” from which place it was successfully removed seventy-four days later. During the Ashantee war, in 1873, there died of dysentery an English naval officer who, in 1860, in New Zealand, had been wounded in the right breast, the resulting symptoms being so .slight as to make it very doubtful if penetration had occurred. Upon post-mortem examination, there were found a cicatrix above the right nipple; evidences of damage to the fourth rib near its cartilaginous junction ; and an encysted round ball, about half an inch in diameter, lying “ outside the pericardium, above the right ventricle, in the triangular interspace between the aorta and the pulmonary artery.” Hernia of the lung is very rare, and, when it does occ ir, is almost always a primary complication, though it may appear at a later period in consequence- of the feeble resistance ottered by a cicatrix. When the missile passes through the seventh, eighth, or ninth intercostal space, especially the latter, and when the diaphragm is wounded, particularly on the left side, omental hernia, or even visceral protrusion, may result. If the diaphragm is strongly arched at the time of injury, it may be wounded in two places, and hernise may occur through both. When the protrusion is recent, and the presence or absence of crepitation in the tumor can be readily and certainly determined, it is easy to distinguish between a pneumocele and an epiplocele,but at a later period, after inflammation and strangulation have occurred, a differential diagnosis cannot usually be made. As the result of the injury of the lung, circumscribed inflammation may be expected to occur along the track of the ball; but ordi- nary pneumonia is rarely developed—never as the direct consequence of the traumatism alone. The inflammation of the pleura may be limited and pro- tective (and in this sense only is it true,as declared by Mouat, that “the inevi- table result of a wound of the lung is pleurisy”), or, as is often the case, may 190 GUNSHOT WOUNDS. be general and purulent, because of the escape of blood, and its admixture with air from the exterior, or from the opened air vesicles or bronchial tubes. When the entrance wound is large, or the pleural effusion abundant, com- pression of the lung takes place—to be subsequently, in cases that recover, more or less relieved by absorption or discharge. Lesions of the pericardium or heart, if not quickly fatal, give rise to pericar- ditis and endocarditis of varying extent and duration, and a lodged shot may become encapsulated. Mediastinal wounds may cause suppurative or gangre- nous cellulitis. Diagnosis of Penetrating Wounds.—The diagnosis of penetration, aside from cases in which an external opening is associated with profuse haemoptysis, is often by no means easy, and is to be based upon an aggregation of symptoms rather than upon any one symptom by itself. Spitting of blood may be pre- sent when the lesion does not directly affect the lung. Shock, perhaps in high degree, may show itself when the lung is undamaged, and is often absent even when a fatal penetrating wound has been received. Severe bleeding may arise from an intercostal or the internal mammary artery, and hcemothorax is not uncommon after a lesion of the former. In pneumothorax, the air may come from without, and in the very rare cases of emphysema which follow a bullet wound, the effused air may have been sucked in from the surrounding atmos- phere, and not forced out of lacerated air-vesicles or tubes. Traumatopncea, while it shows that there is an opening of the pleural cavity, does not prove that the lung has been torn. Dyspnoea from pleural accumulations of blood, air, or pus, cannot be regarded as pathognomonic, since each of these exciting causes may exist independently of lung wound. The late-occurring lumbar ecchymosis of Valentin is very often absent, and is of no special importance in the cases in which it does occur, having really little or no diagnostic value. From the presence of two wounds, perforation cannot be predicated, since the ball may have run around the body, or the patient may have been struck by two shots. Early and persistent, marked reduction of temperature furnishes strong presumptive evidence of visceral lesion. Injury of the heart or peri- cardium is rendered probable by quickly appearing, great shock and precor- dial oppression, with succeeding pericarditis or endocarditis. Prognosis.—The prognosis of these penetrating wounds is very grave. Among the Russian wounded in Sympheropol 98.5 per cent, of those who were thus injured died, as did 91.6 per cent, among the French and 79.26 per •cent, among the English in the Crimea. Of 7929 cases observed during our war 5169 (65.19 per cent.) ended fatally, and if the non-fatal cases in which -errors of diagnosis were made could be eliminated, the mortality rate would unquestionably be carried decidedly higher. In civil life—the missiles, as a rule, being smaller, the cases coming under treatment earlier, and the patients not being subjected to added dangers from transportation—the prognosis is more favorable, but still bad enough. Even in cases which do not terminate fatally, in both military and civil practice, long-continuing or permanent fis- tuhe may remain. Heart wounds, when made by large balls, almost always prove quickly fatal; when made by small bullets or shot, life may be pro- longed for a considerable period of time, and recovery even may take place. In a case which I have elsewhere reported, and which was under my own observa- tion from the time of injury to that of death, three years and two months later, a small pistol-ball, as was proved by an autopsy, passed through three of the four cavities of the heart, and lodged in the root of the right lung—the boy, aged 15, ultimately dying of the effects of the cardiac disease. 191 GUNSHOT INJURIES OF THE CHEST. Pericardial injuries are much less dangerous than heart wounds: four out of the seven cases in Fischer’s table ended in recovery. Treatment.—The treatment of penetrating wounds of the ehest depends upon the size of the vulnerating body; upon whether lodgment within the cavity has or has not taken place; and upon the complications that may be early or late developed. When the missile is small—and such it is likely to be in that large pro- portion of cases treated in civil practice in which the injury is produced by a pistol ball—if the shot has passed through and can be felt lodged under the skin, it should be removed, but should otherwise not be searched for. In wounds by large bullets, or by a fowling-piece charge at short range, the track of the wound should be explored by the finger, and any foreign bodies that are discovered (lead, buttons, clothing, hone fragments), removed. If, as is likely to be the case, the ball has passed beyond the point which can be reached by the finger, shall any probing be done? Hot with a metallic in- strument. An elastic bougie, or a gum catheter, may very properly be used, if guided by intelligence and judgment; since if the lodged substance can he found and removed, either through the wound or through a counter- opening, the patient’s mind will be put much at ease, arid the after local mischief will probably be much less. But the chances of finding the ball, except when it is very superficially located, are not great—much less than the possibilities of doing harm; so that here, as in head injuries, it is, as a rule, safer and wiser for all except the most experienced to rest content with the knowledge acquired by digital exploration, that penetration has probably taken place, and to let the foreign body remain, trusting that it will either become encysted or be spontaneously expelled through the air passages or the oesophagus, or that it will be brought near to the surface by suppuration so as to be easily removed when the abscess is opened, or extracted through a sinus. If at any time during the progress of the case, the bullet can be dis- covered free at the bottom of the pleural sac, it should be taken out, either through an existing opening or through one specially made in the posterior part of one of the lower intercostal spaces. Hemorrhage from, an intercostal artery is to be arrested, as already stated, by plugging ; and if from the internal mammary, by ligation—direct, if pos- sible ; if not, higher up, in the second, third, or fourth intercostal space. This operation was twice employed during our war, though unsuccessfully; but pressure and styptics were equally unavailing in saving life in the four cases in which they were tried. The bleeding from this vessel then when it does occur, which is not often, is to be regarded as a very serious matter. When the hemorrhage, though from neither of the above-mentioned arteries, is yet profuse, it should if possible be checked by rest, by the application of cold, and by the administration of ergot—preferably hypodermically ; the patient meanwhile should be placed in such a position that the blood will flow off* through the wound Pressure upon, and closure of, the external opening will often be found of great service, but “ hermetically sealing,” after the method of Howard, has proved to be far from advantageous. Effusion of blood into the pleural sac, whether from an internal or an external source, if of limited amount, is usually absorbed without difficulty, with relief of the primary symptoms, shock, pain, and dyspnoea. When the extravasation is large, death may take place quickly from the hemorrhage and lung compression, or more slowly from empyema, or, the bleeding having been arrested by the pressure of the clot, absorption may follow, the lung may expand, and the patient may recover. In all of these cases, absolute rest must be enjoined, and cold, opium, and ergot should be employed according to circumstances. The external opening may be closed in order that by compression further 192 GUNSHOT WOUNDS. bleeding may be prevented, but if the dyspnoea becomes extreme, the wound must be reopened and the blood allowed to escape. If the outflow is not sufliciently abundant, aspiration or paracentesis may be practised ; or a free incision may be made in an intercostal space, and, if necessary, the pleural sac may be thoroughly washed out; such an opening of the cavity can do little or no harm, air having already gained access from the first along the track of the bullet. The old time treatment of chest wounds by venesection is not to be adopted, since it will almost certainly but add to already dangerous conditions, that of' “ irrecoverable exhaustion.” Pneumothorax, if producing severe dyspnoea, which is not of common occurrence, should be relieved by tapping. Puru- lent accumulations, whether due to decomposition of blood from the entrance of air either from without or from the wounded lung, or to general pleuritis, may at times be removed by aspiration or by tapping, but are, as a rule, best treated by free incision with or without removal of part of a rib or ribs,, and by subsequent cleansing of the cavity and maintenance of drainage,, which should be as thorough as possible. Very generally, however, though temporary relief is thus afforded, cases of gunshot empyema sooner or later terminate fatally. That recovery may take place in cases of great severity, is well illustrated by a case reported by Schneider of Konigsberg, in which after a pistol-ball wound of the chest smashing the fourth rib, pyo-pneumo-hcemothorax occurred, together with sloughing of the upper lobe of the lung. In order that the ribs might close in upon the unfilled cavity, resection was practised—part of the clavicle and pieces of the second, third, fifth, and sixth ribs, of from two to four and a half inches in length, from the costo- chondral junction outwardly, being removed. The resection wounds healed by first intention, the chest wall collapsed, and the man recovered. The ordinary, limited, pleural and pulmonary inflammation along the track of the wound requires no special treatment. The lung injury may be so perfectly recovered from that auscultation will fail to indicate that any damage has been done, but usually the physical signs of the existence of condensed cicatricial tissue will ever after be present. Tubercular disease has ultimately been developed in a considerable proportion of the patients who have apparently completely recovered from lung wounds; but in what degree this disease lias been really consequent upon the injury, it is impossi- ble to determine. A quickly appearing hernia of the lung, if seen before any inflammation or strangulation lias taken place, should, if the protruding portion is un- wounded, be, if possible, at once reduced, the opening in the chest wall being enlarged if necessary, and a retentive dressing being afterwards applied; at least once (Angelo’s case), such a reduction has been successfully effected. When injured or already inflamed, the protrusion should be left undisturbed. If there has been a wound of the diaphragm, and a portion of the contents of the abdominal cavity protrudes, similar treatment should be adopted. In- juries of the pericardium and heart, which do not quickly cause death, should be treated at first by rest, cold, and closure of the external wound, the latter being subsequently reopened if symptoms of dangerous compression are manifested; in the beginning, however, every effort is to be directed towards preventing or arresting hemorrhage, and favoring speedy cicatrization of the internal wounds. The same principles should govern the surgeon in the treatment of mediastinal wounds attended with much bleeding, but without associated heart lesion. Stimulation if resorted to at all, must be so with great care and judgment. At a later period, if pericarditis and endocarditis are developed—and, while frequent, such inflammations are not necessary con- sequences of the injury—they are to be treated in the usual way. GUNSHOT INJURIES OF THE ABDOMEN. 193 Gunshot Injuries of the Abdomen. As the result of gunshot injury, there may he produced in this region (1) contusion; (2) parietal wound ; and (3) penetration of the cavity, with or without visceral lesion—the missile either lodging in the abdomen, or perfo- rating the cavity to emerge through a second external orifice, or to be arrested at some point beneath the unbroken integument. There may be associated wound of the chest wall or thoracic cavity above, or of the pelvic cavity be- low, or of the spine behind. Contusion may result from the blow oi a nearly-spent cannon-shot or shell fragment, or from a grazing bullet, or from the more direct impact of a musket or pistol ball, the momentum of which is insufficient to overcome the elasticity of the skin. When the missile is large, there may be produced only tearing of the superficial vessels, with resulting extravasation in greater or less amount; or rupture of muscles ; or laceration of the abdominal viscera, especially of the liver or of an enlarged spleen; or even lesion of the great bloodvessels. Parietal Wounds.—When there is a parietal wound, the bullet may lodge at no great distance, or may cut across the wall, or may form a longer or shorter seton track, or being deflected may run around, to emerge or to rest at a point nearly or quite opposite the place of entrance—a round ball, at times, even completely girdling the abdomen. Large vessels may be injured, or the peritoneum bruised, or, though rarely, the kidney or an uncovered portion of the intestine damaged. It is even possible that a pre-existing hernia may be wounded, as in a case reported by Medical Inspector Gihon, U. S. 1ST. In both contusions and non-penetrating wounds, espe- cially when there has been extensive extravasation, parietal abscess frequently results. Fig. 293. Penetrating Wounds.—When the serous mem- brane is pierced, the ball may glide over the con- tained viscera without wounding them. On theo- retical grounds the possibility of such an occurrence has been denied, but the fact that it does take place has been amply established by post-mortem examin- ation.1 (See Fig. 318, page 204.) Ordinarily, in penetrating wounds of the abdo- men resulting from gunshot injury, lesions of the hollow or solid viscera, or both, are produced, and multiple wounds of the intestinal coils are frequent.2 Protrusions of healthy or damaged omentum, or of bowel, may quickly occur, though bullet wounds are not likely to be followed by such complications. Injured portions of even the solid viscera (liver, kidney, rarely the spleen), may appear externally. As the result of early fixation of the damaged intestine, an artificial anus may ultimately be established, either with, or, as is much more usually the case, Loops of ileum with shot-perforsfc- tions. (A. M. M., Spec. 1231, a.) 1 In his address before the surgical section of the American Medical Association, at Richmond, Va., in 1881, Dr. Hunter McGuire reported four such cases that had come under his own obser- vation. 2 Longmore reports a Crimean case in which, upon autopsy, it was found that “ sixteen openings had been made in the small intestines by the bullet,” which “entered near the umbilicus and passed out close to the scrotum,” the man having been hit “ while stooping in the act of defeca- tion.” In the case of the late J. Fiske, Jr., there were “four perforations of the small intestine, two of the large, and fourteen perforations or distinct wounds of the peritoneum.” (Peugnet.) 194 GUNSHOT WOUNDS. without a projecting eperon or spur. A hernia may be found at the opening made for the extraction of the lodged ball. When the diaphragm has been perforated, the protrusion may be into the thoracic cavity, or, as we have already seen, it may show itself through an external chest wound. The bul- let may primarily enter and lodge in the stomach or bowel, to be soon dis- charged per anum (in fourteen hours in one of Lidell’s cases), or may subse- quently, by ulceration and absorption, work its way through the intestinal wall, generally that of the colon, and after a number of days be voided at stool. Encapsulation may take place even in one of the solid viscera. Diagnosis of Abdominal Wounds.—Though the likelihood of penetration having occurred is much greater here than in a wound of the head or chest, the diagnosis cannot certainly be made by the apparent line of direction of the shot, nor even by the resulting shock or the functional visceral disturb- ances. As has already been mentioned, there may have been deflection of the bullet, and thus only a parietal injury may have been inflicted. S'hock, though of more probable occurrence in lesions of the peritoneal, than in those of any other cavity, may be noticed in high degree when only a comparatively superficial abdominal wound has been received, and is, on the other hand, at times absent when a fatal visceral perforation has taken place. The results of hemorrhage from one of the larger secondary parietal vessels may be mistaken for it. Vomiting of blood, or hemorrhagic discharges from the intestinal canal, may be consequent upon a simple and soon-recovered- from contusion, and a similar injury along the course of the urinary track may be followed by the appearance of blood in the urine; though if the hemorrhage in any of these cases is in large amount, the probability of visce- ral wound is very strong. When the diaphragm has been involved in the injury, and hernia has taken place through it, there will generally be little or no contraction of that muscle on the wounded side. If, in a case of contusion, meteorism quickly follows, that symptom very strongly indicates rupture of the bowel. Early and persistent, subnormal temperature renders it very prob- able that there has been grave organic lesion. The only positive evidences of penetration, however, are furnished by the outflow of the contents of the stomach or bowels, of bile, or of urine; by protrusion; or by seeing or feeling the parts within the peritoneum. Prognosis.—The prognosis in the non-penetrating injuries met with in time of war, while of more gravity than in like wounds of the head and chest, is yet favorable,1 though death may result from peritonitis, or, rarely, from hemor- rhage or other wound complication. In civil life, in which, because of the ordi- narily less size and velocity of the missile, peritoneal or bowel injury is very much less likely to be produced, the mortality is much smaller; so much so that, speaking gene- rally, it may be said that, under these cir- cumstances, recovery is almost certain to take place. Penetrating wounds, on the other hand, are most dangerous, 87.72 per cent, of those occurring in our late war having proved fatal (3008 out of 3429 de- termined cases), as did 91.7 percent. (Ill out of 121) of the French, arid 92.5 per cent. (Ill of 120) of the English cases in the Crimea. When involv- Fig. 294. Gunshot perforation of stomach; a, wound of entrance; e, wound of exit. (A.. M. M., Spec. 3749.) 1 Otis reports a mortality-rate of 8.07 per cent. : 253 deaths out of 3134 determined cases. 195 GUNSHOT INJURIES OF THE ABDOMEN. ing the stomach or small intestine, these wounds may always be expected to cause death, generally from peritonitis following extravasation, or from very acute septicaemia. Otis declares that “ the unequivocal recoveries from shot wounds of the stomach, with or without fistula, number only six or seven” —fistula having occurred but twice, in the case of Alexis St. Martin, and in that reported by Baron Percy; and the same authority doubts if during our war there was a single “incontestable instance of recovery” from wound of the small intestine, though in five cases that got well there was more or less “plausible ground for suspecting” that the lesion was of such a nature. The Fig. 295. Jejunum perforated by a pistol ball, showing eversion of mucous membrane. (A. M. M., Spec. 841.) records of military surgery certainly furnish but very few cases of recovery from gunshot perforation of this part of the bowel. If the wound has been made by a small pistol ball, as it is likely to be in cases occurring in civil life, the opening may be so small that escape of fluids may at first be pre- vented by an eversion of the mucous membrane of the gut, aided by the temporary paralysis of the damaged part of the tube, which is produced by the blow, and thus time may be afforded for the formation of adhesions that shall protect the general peritoneal cavity. The prognosis in injuries of the large intestine is much more favorable, particularly when it is the ascending or descending part of the colon that has been wounded. In at least 20 per cent, of the cases of this nature tabulated by Otis, recovery took place, stercoral fistula having been formed in a large proportion, but having, in most instances, become spontaneously closed in the course of a few months. In many of these noil-fatal cases, the wound, it is pro- bable, was in an uncovered part of the bowel, so that in reality the peritoneal cavity was not opened ; and it is in this opening of the peritoneum, with the result- ing inflammation, or, much more rarely, large hemor- rhages, that lies the excessive danger of intestinal wounds. When the liver has unquestionably been wounded, as proved by the escape of bile, or by the protrusion of a part of the organ, though death is very apt to occur, from hemorrhage, from hepatic abscess, or from peritonitis, yet recovery may take place. In at least 14 of the 59 uncomplicated cases analyzed by Otis (23.7 per cent.), and in 18 of the 111 cases in which there were associated lesions of other important parts, and of which the terminations were ascertained (16.2 per cent.), the patients did not die; and it is quite possible that in a number of the thirty other cases of recovery from supposed liver wounds, the organ was really damaged. Even when the gall-bladder has been injured, a fatal result is not inevitable,1 though almost certain to occur from extravasation Fig. 296. Section, of liver showing gun- shot perforation of right lohe. (A. M. M., Spec. 1232.) 1 In at least one case, that of Paroisse, a bullet has been found in the cavity of the gall- bladder, death having occurred long after the receipt of the injury, and from a totally inde- pendent cause. 196 GUNSHOT WOUNDS. and consequent peritonitis. The much more rarely observed wounds of the spleen are at times recovered from, but are usually followed by mortal hemorrhage. As in the case of the liver, protrusion of a part of the viscus does not necessarily prevent a favorable termination. Though it is true that the existence of a wound of the pancreas can generally be ascertained only upon autopsy, and though such a lesion must usually be associated with other very serious if not mortal injuries, yet, if hernia should take place, it need not necessarily add materially to the gravity of the prognosis, since the protruding part of the pancreas may be successfully removed, as was once done during our late war. Kidney lesions, which are often associated with injury of the spine, or of some other of the solid or hollow viscera, though rarely followed by intra- Fig. 297. Fig. 298. Pancreas with conoidal musket hall embedded. (A. M. M., Spec. 2884.) Gunshot perforation of kidney. (A. M. M., Spec. 1773.) peritoneal extravasation of urine, yet generally cause death, from shock, from hemorrhage, or from extra-peritoneal abscess. Recovery however may take place. A number of non-fatal cases have been reported, but in a con- siderable proportion of them there is more or less reason for doubting the correctness of the diagnosis. In a Crimean case, observed by Legouest, in which the bullet had passed through the middle of the kidney from before backwards, it was found upon making an autopsy that “ the organ was much diminished in size, and presented in the centre of each surface a firm, fibrous, depressed cicatrix, to which there were attached like the rays of a star five other irregular cicatrices.” Treatment of Gunshot Wounds of Abdomen.—The treatment of non- penetrating abdominal injuries must be conducted on general principles: foreign bodies are to be removed, when it is practicable to do so; hemor- rhage is to be arrested—by ligation, if the bleeding is from one of the larger vessels; collections of blood, if not duly absorbed, are to be freely laid open, to prevent the formation of abscesses with resulting danger to the peritoneum, either from extension of inflammation by contiguity, or, what however rarely occurs, by the discharge of pus into the cavity; extreme quietude is to be maintained; and a strict diet enjoined. If the kidney has been wounded, free drainage must be secured, and any external collections of urine or pus which result, must be early and thoroughly evacuated. By the judicious administration of opium, by cold applications, and by bandage compression, peritonitis may be prevented or largely controlled. GUNSHOT INJURIES OF THE ABDOMEN. 197 In penetrating wounds, surgeons have until recently been content to apply cold; to put on a bandage—even of plaster of Paris (Neudorfer); to maintain absolute rest; to prescribe a sparing liquid diet, and opium internally, until the inflammation has subsided. The administration of morphia has been pushed to such extremes that in many cases it has become a serious question whether death has resulted from the wound or from the treatment. But the excessive mortality of these injuries from hemorrhage, from acute septicaemia, or from rapidly developed, intense peritonitis, certainly indicates that some- thing more should often be done, and this “something” must be in the way of operative interference. The experience of the last twenty years lias clearly demonstrated that the laying open of the peritoneum is not as dangerous as had previously been thought; that this serous membrane is a great lymph sac that will absorb septic material most readily and rapidly; and that for the prevention of a fatal result from such absorption, drainage must be secured. Whenever then the symptoms clearly indicate that extensive bleeding has recently occurred, or is still taking place; that the stomach or intestine has been opened; or that there has been an intra-peritoneal ex- travasation of urine or of bile — it certainly seems to be proper, a'd the surgeon’s duty, to perform laparotomy, turn out all clots, tie such divided vessels as can be found, sew up the opening or openings in the intestinal tube, thoroughly cleanse the cavity, and provide for the ready outflow of any fluid that may after- wards be poured out. As declared by McGuire, “If it is urged that the means suggested are desperate, it can be said in reply that the peril is so extreme that, as now treated, nearly all die ; and I believe, by the means I have pointed out, in gunshot wounds of the peritoneum, the pa- tient will exchange an almost certain prospect of death for at least a good chance of recovery.” In closing wounds of the stomach or intes- tines, the ordinary continued suture (Fig. 226, page 29) may be employed, or preferably that of Lembert (Fig. 299) or that of Gely (Figs. 300, 301, 302). Whether or not the edges are freshened, is pro- Fig. 299. Lembert’s suture Fig. 302. Fig. 300. Fig. 301. First, second, and third steps of application of G§ly’s suture. bably a matter of little or no importance, since the union must take place between apposed serous surfaces. Silk or catgut sutures may be employed, the latter having the advantage of ordinarily entirely disappearing, but the 198 GUNSHOT WOUNDS. disadvantage of, at times, melting down before the union is sufficiently firm to be permanent. If protrusion of an uninjured portion of omentum or bowel has occurred, and the case is seen when the parts are only congested, the hernia should be re- duced, the parietal wound being enlarged if necessary, and being afterwards firmly closed by compression or with stitches, so as to prevent reprotrusion Fig. 303. Gunshot perforations of ileum closed with sutures. (A. M. M., Spec. 4390.) which is otherwise very likely to occur. If strangulation has taken place, the knuckle of intestine is to be returned within the cavity, or not, according as its vitality is or is not likely to be maintained; the omentum should be left in place, though the great mass of the protrusion may very properly be liga- tured and cut away. This plan of treatment should also be adopted in cases of hernia of portions of the liver, spleen, kidney, or pancreas. When an artificial anus has been formed, an attempt should always be made to close it, since, even if the operation should be unsuccessful, there will generally follow a marked reduction in the size of the opening, and the after condition of “ fecal fistula” will be much less annoying. If necessary, the intestinal ends may be retrenched, and then sutured together,1 or the upper end Fig. 304. Fig. 305. Suture of bowel by Jobert’s method ; the threads are in place, and the mesentery dis- sected preparatory to invagination. Upper end of bowel invaginated within inverted lips of lower end. (Jobert’s method.) may be simply invaginated within the lower, as in Jobert’s method (I igs. 304 and 305). If an fierofi, or spur-like septum, is present, which is much less * 111 a case reported by Kinloch, of Charleston, S. C., in which this was done, half an inch on one side of the opening and two inches on the other having been removed, the continuity of the bowel was in a week later so well re-established, that the patient had a feculent stool per rectum, though this channel had been previously unused for seven months. GUNSHOT INJURIES OF THE PELVIS. 199 likely to be the case than when the artificial anus is due to causes other than gunshot injury, it must generally be destroyed ; and use may then often be advantageously made of some form of enterotome or compressor, such as Du- puytren's (Pig. 306) or Gross’s (Fig. 307). Fig. 306. Fig. 307. Dupuytren’s enterotome. Gross’s enterotome. Gunshot Injuries of the Pelvis. In wounds of this region, damage may be done only to the external soft parts ; or there may be associated injury of the innominate bone or sacrum, with or without penetration of the pelvic cavity; or penetration or perfora- tion may occur without any accompanying bone lesion. Not infrequently, the wound involves also the abdomen or the genitals. Lodgment of the mis- sile often takes place—in the thick external muscular mass, in the bone, some- where in the cavity, or even in the bladder or rectum. As the result of shell injury, great destruction of the overlying soft parts is produced, at times in non-fatal cases; and frequently extensive shattering of the ilium is to be noticed, even in wounds from musket balls. Lesions of the bladder may be expected to be followed by urinary extravasa- tion, intra- or extra-peritoneal according to the location of the vesical open- ing ; a bullet, or a piece of bone, may, however, ultimately work its way by Fig. 308. Fig. 309, Gunshot perforation of left ilium. (A. M. M., Spec. 2217.) Gunshot perforation of bladder. (A. M. M., Spec. 510.) ulceration and absorption into the cavity, without there having been any escape of urine. Contusion of the hypogastrium may cause temporary para- lysis of the bladder, or even permanent incontinence, as in the case reported 200 GUNSHOT WOUNDS. Fig. 310. by Williamson. When the rectum, has been opened, feeal matter may pass into the peritoneal cavity or the connective tissue of the pelvis, or may be discharged externally, according to the position and extent of the wound. Xot very seldom there is simultaneous perfora- tion of both bladder and rectum; or at a later period a communication may be established between these vis- cera by sloughing. Injuries of the male generative organs, which are fortu- nately not very common, may be either superficial and slight, or may involve the testis, penis, or spermatic cord. The testis may be bruised, torn, or completely carried away, and in cases of other than entire destruction atrophy is the usual result of the lesion; much less frequently, severe and long continuing neuralgia is produced. At times, the shot buries itself in the scrotum. The penis may be perforated, or penetration may occur with lodgment of the shot, which, if unremoved, may be- come encysted. The urethra, which is very apt to be involved, may be contused or lacerated, the injury ulti- mately resulting in the establishment of a very trouble- some fistula, penile, perineal, or rectal, or in the forma- tion of a stricture. Occasionally a ball, even of large size, will be found to have passed through the corpora cavernosa or the glans without damaging the urethra. Wounds of the female genitals are rare, and usually associated with other and much more important lesions of the abdominal, pelvic, or femoral regions. The uterus is not often injured; when in the unimpregnated state, but little harm may be done beyond that resulting from the commonly associated vesical and rectal wounds ; but when, on the other hand, pregnancy exists, there is much risk of an early and fatal termination of the case, from the abortion which must almost of necessity occur, or from hemorrhage, shock, or peritonitis. Death, however, may not take place; and even an injured foetus may be born alive, if we can credit such a report as that given by Reichard.1 A more or less perman- ent fistula may remain after an otherwise com- plete recovery from a penetrating uterine wound, through which the menstrual blood may be discharged. The great bloodvessels of the region (iliac, gluteal, sciatic, pudic, or obturator) may be primarily divided, or secondarily opened by ulceration, after contusion; and traumatic an- eurisms are at times developed. The large nerves [the, sciatic within or without the pelvis, the anterior crural, the obturator) may also be injured, with resulting paralysis or neuralgia. Gunshot perforation of penis, dividing urethra. (A. M. M., Spec. 902.) Fig. 311. Gunshot perforation of right common iliac artery. (A. M. M., Spec. 6336.) 1 In this case the child had a wound under the right clavicle, in which there was lodged a piece of the mother’s clothing, and a buckshot of the size of a small pea. 201 GUNSHOT INJURIES OF THE PELVIS. Diagnosis of Pelvic Injuries.—The only doubtful point, as a rule, in regard to diagnosis, is whether or not there has been perforation of the rectum or bladder, or both; and here, as in abdominal wounds, reliable evi- dence is furnished solely by the escape of the contents of the injured viscus —that is, of fecal matter or of urine. Whether or not the bladder is wounded, depends, in great degree, upon its full or empty condition. Prognosis of Pelvic Injuries.—The prognosis in injuries of this region is largely affected, of course, by the presence or absence of fracture or pene- tration. Flesh wounds, though they may cause death from hemorrhage, are, even when very extensive, not likely to terminate fatally, though they are not infrequently followed by decided functional impairment from muscular injury and cicatricial contraction. When fracture has taken place, the gravity of the injury is much increased; since, aside from the effects of the often- associated visceral lesion, the patient is subject to all the risks arising from prolonged suppuration and septic infection. Of the cases observed during •our late war, those of fracture of the ilium were the least fatal—the expanded wing of that bone being at times bored through without serious damage being done—and those of the pubis the most so ; the relative order being: ilium, 24.42 per cent.; coccyx, of which, however, only seventeen cases were reported, 35.3 per cent.; ischium, 42.4 per cent.; sacrum, 43.7 per cent.; pubis, 50 per cent. When the shot passes through the thick gluteal mass, there is often much difficulty in securing free drainage, and, as a consequence, danger to life is proportionately increased. In the cases that recover, healing ordinarily takes place slowly, and extensive necrosis or caries is likely to •occur, especially when the bullet has lodged. When the shot has passed through the pelvic cavity, though it may, particularly if small, occasionally do no serious damage, yet usually visceral lesion is produced ; but the mor- tality of such wounds is very much less than that which attends perforations •of the abdomen, the probabilities of being able to secure free drainage being very much greater. Of 183 cases of bladder wound analyzed by Otis, 96, or 52.46 per cent., ended fatally, as did 44 of 103 cases of wound of the rectum, or 42.7 per cent.; in 34 of the rectal injuries, the bladder was also wounded, 14 of the cases proving fatal, or 41.17 per cent. When the bladder has been so wounded as to cause intra-peritoneal extravasation of urine, death is almost •certain to occur, under the ordinary plans of treatment, from hyperacute peritonitis; and the same is true when fecal extravasation takes place through a rectal wound high up. If recovery takes place after these visceral lesions, fistula, strictures, or functional disturbances often remain. Very troublesome effects are at times produced by the entrance of pieces of clothing, wadding, or bone-fragments into the bladder or rectum, especially the former, or by the late consequences of necrosis. Foreign bodies may, in time, work their way out through the wounds or the natural passages; but osseous spicula, and particularly missiles, projecting into or free in the vesical cavity, may be expected to become in- crusted with phosphates and to form the nuclei of calculi, which, occasion- ally, do not manifest their presence until years after the receipt of the wound. In at least sixteen cases of gunshot injury, stones have been formed upon bone-fragments, and in certainly thirty-three cases, the bladder has been •opened and bullets or shell-fragments removed. In genital wounds, death, when it occurs, is usually due to other associated lesions ; of the cases reported during our war, the mortality rate was: for wounds of the testis, 66 out of 586, or 11.26 per cent.; for those of the penis, 41 out of 309, or 13.27 per cent.; and for those of the urethra, 22 out of 105, or 20.95 per cent. Ex- travasation of urine following gunshot wounds of the urethra, like that following 202 GUNSHOT WOUNDS. injuries of other kinds, may be in large amount, with corresponding exten- sive destruction of tissue, or in limited quantity, with resulting abscess and fistula. When the large intra-pelvic bloodvessels are primarily opened—and this is more likely to happen in civil than in military practice, the wounds being made at shorter range—speedy death generally occurs, and the same- result is very likely to follow similar injuries of the gluteal and sciatic vessels- at or near tlieir points of emergence. Secondary hemorrhage from ulceration may occasionally—though, unfortunately, not very often—be controlled by pressure or ligation, and the patient saved. Treatment.—The treatment of external pelvic injuries is to be conducted on general principles: hemorrhage being controlled by compression or ligation % all foreign bodies, particularly detached bone-fragments, removed if possible *r drainage secured ; pus-collections opened; and rest maintained. Sequestra are to be taken away as they become detached, and carious parts may often be advantageously removed with the gouge. When penetration has occurredr bullets, clothing, wadding, and spicula, driven in by the shot, are to be removed as they can be found. If the rectum has been wounded, much bene- fit will often result from free division of the sphincter, as recommended by Dupuytren. Extra-peritoneal effusions of urine are to be evacuated by perineal incisions, and a catheter should be carried through the urethra into the blad- der and there retained ; all abscesses are to be early and freely opened. When, the vesical wound is so located that the urine escapes into the peritoneal cavity, death, as we have already seen, quickly takes place from peritonitis * and treatment by catheterization, with or without perineal section, cannot be expected, except by the merest good fortune, to avert the fatal result. Vincent has lately shown experimentally that recovery might be hoped for from laying open the abdomen and closing with sutures the wound in the bladder; and such an operation, together with, if necessary, the establishment of a connec- tion with the rectum near the bottom of the recto-vesical pouch, would be certainly justifiable. When the scrotum has been contused, or only superficially torn, no special treatment is required; any resulting inflammatory or purulent collections should be opened early. A wounded testis, even if extensively lacerated, should not be removed, since a portion of the organ may be ultimately saved, and the danger to life from expectant measures is less than that from operation— 11.9 per cent, as against 18 per cent, in the cases treated during our war. When the penis has been wounded, treatment must be directed to the arrest- ation of hemorrhage, the prevention of urinary retention or extravasation,, the preservation of every portion of the organ that can be saved, the con- trolling of the erections (which are, at times, excessively painful), and the correction, at a later period, of cicatricial incurvations arising from unilateral loss of substance. Hemorrhage, much more likely secondary than primary, is to be checked by ligation, if the dorsal artery has been divided, or, under other circumstances, by compression or the introduction of stitches, a catheter being kept in the urethra; or even by styptics. Whatever the part of the organ that is damaged, except when the wound involves only the skin, a soft catheter should for some days at least be kept in the bladder; and especially should this be done when the urethra has been divided, if it is not, as occa- sionally happens, impossible to introduce the instrument. If urinary infil- tration occurs, it must be at once relieved by incisions. Retention, when catheterization cannot be effected, can always and safely be treated by supra- pubic aspiration. Amputation of the penis should not be performed, even if the organ has been almost completely cut through; for by the application of stitches the GUNSHOT INJURIES OF THE VERTEBRAE. 203 parts may be so held together that at times union will result; as in the case reported by Baudens, in which “ the cavernous bodies and the urethra, en- tirely divided, were held only by a portion of the integument.” The always troublesome and often very painful erections must be controlled as much as possible by the usual remedies—opium, camphor, the bromide of potassium, etc. Cicatricial curvatures, which more or less seriously interfere with the functional integrity of the organ, if they cannot be prevented by appropriate dressings during the stage of healing, may be in greater or less measure cor- rected by removal of the cicatrix, if superficial and occupying the dorsum of the penis, or, when laterally placed, by excision of a wedge-shaped piece from the opposite uninjured corpus cavernosum. Urethral fistula and stric- tures should be treated in the usual way. When the abnormal openings are located in the penile portion, particularly near the peno-scrotal angle, or in communication with the rectum, failure is not unlikely to follow any attempt at closure. For the arrestation of primary hemorrhage, if from even the large arterial or venous trunks—should cases of such come under treatment—ligation is always to be employed when practicable; the only exception to this rule is, perhaps, when the wound is of the gluteal artery, in the external part of its course, when properly applied compression may be used instead. Frequently it will be found very difficult, if not impossible, to determine from what source the bleeding comes; for instance, if the ilio-lumbar artery has been wounded, as in cases observed by Hodgen and Despres. If an aneurism has formed, the sac may be opened and the vessel tied above and below, hemor- rhage at the time being prevented by pressure on the vessel higher up, or by the use of an aorta compressor or a Davy’s rectal lever. Secondary hemor- rhage, whenever it is possible, should be treated by the application of ligatures above and below the seat of injury. Unfortunately, neither ligature nor com- press succeeds in the majority of cases in saving life, and this whether the hemorrhage be primary or secondary, ilot once after gunshot injury has a ligature been successfully applied to the common iliac artery. Every case of wound of the sciatic artery, during our war, terminated fatally, as did four- teen out of eighteen of those of the gluteal, two only being saved by ligation and two by compression. Of the sixteen ligations of the external iliac artery, only two ended in recovery. Gunshot Injuries of the Vertebrae. Gunshot injuries of the spinal column may produce contusion, fracture, or penetration of the canal, and are often associated with lesions of important structures in the neck, chest, or abdomen. Contusion may he caused by the' blow of a large missile, with or without accompanying wound of the soft parts, or by a bullet, the momentum of which is so far destroyed that it is unable to break the bone. FracMre may affect either the processes or the body of a vertebra, and in the latter case the shot may either penetrate or perforate, producing very frequently fissures running through to the posterior surface. When the cervical or dorsal canal is penetrated, the cord is usually,, though not necessarily, damaged, and the associated injury to the bony wall may be limited to one of the vertebral laminae. Hemorrhage, either outside or inside of the theca, may be associated with any of the forms of vertebral injury; and the same is true of nervous disturbances, such as pain (near or remote), tingling, reflex movements, and impairment—sometimes extending even to complete though temporary abolition—of motion and sensation. Laceration or division of the medulla must, of course, be followed by paralysis, 204 GUNSHOT WOUNDS. more or less complete, according to the locality and extent of the injury; and similar effects, confined to a limited area, may be due to lesion of a nerve soon after it has left the cord. At times, injury is done not by the missile itself, but by bone-fragments, detached or adherent, driven in by the shot. Fig. 312. Fig. 313. Eighth, ninth, and tenth dorsal vertebrae, with conoi- •dal ball in vertebral canal. (A. M. M., Spec. 2939.) Round musket-ball lodged in second lumbar vertebra, after traversing abdominal cavity without injuring the viscera. (A. M. M., Spec. 3349.) Meningitis, or meningo-myelitis, is the almost necessary consequence of any spinal injury other than the slightest, and is the chief cause of death in cases that survive the first few days after the receipt of the wound. A chronic form of inflammation may result even from contusion; but in most cases of the latter injury, the cord lesion is limited to concussion, which ordinarily is quickly recovered from. Diagnosis of Spinal Injuries.—That a vertebral wound has been received, is indicated by the apparent line of direction of the shot, by the resulting shock, by the development of nervous disturbances, by the discovery upon exploration of broken bone, and by the detection of such associated displace- ment as is pathognomonic of a fractured spine however produced. The first of these indications has no value except as confirmed by the others, since deflection may and often does occur, particularly if the missile is small; and the second is little if any more reliable, since shock may be very slight, as at limes when a spinous process is broken, and, on the other hand, it may be present in an extreme degree when the shot, passing near to but not impinging •on the spine, has wounded important organs in its vicinity. Xor can paralysis •or pain, whatever their character, location, or degree, be accepted as proof positive of fracture; pain may be due simply to contusion, or may be alto- gether absent (except such pain as may follow the receipt of an}’ gunshot wound), particularly when it is a spinous process that has been broken. The existence of the latter form of injury can usually be readily ascertained by manipulation, both preternatural mobility and crepitus being detected. Escape of the cerebro-spinal fluid is usually associated with, and so far indicative of, injury of the cord ; but such an outflow may take place when only the sheath has been opened. Actual lesion of the cord from concussion, from compression, or from lacer- ation by hone or ball, is always, except occasionally when the injury is in the lumbar region, followed by disturbances of sensation and motion, of the same character as those resulting from spinal irritation, inflammation, or disorgan- 205 GUNSHOT INJURIES OF THE VERTEBRAE. ization after ordinary traumatisms. Pain, at times excruciating, may be- present at the seat of injury, girdling the body, following the course of par- ticular nerves, or confined to a limited area in a remote part; the sensation is not infrequently that of burning or tingling, or, on the other hand, there- may be numbness or even complete anaesthesia. Similarly, the motor dis- turbances may be those of excess or diminution of action—twitchings, jerk- ings, tetanic spasms, or, what is much more usually seen, paralysis, partial or complete, below the seat of injury, transitory or permanent according to the condition of the cord—accompanied by muscular atrophy, most strongly marked in the leg muscles after lumbar injury. In cervical and dorsal wounds, the voice, respiration, and circulation are affected, in greater or less- degree, according to the location and extent of the injury. Rectal and vesical paralysis, with subsequent incontinence, are ordinarily present if the cord- lesion has been at all extensive. In the male, priapism is an often-observed,, but not necessary, symptom of injury above the third lumbar vertebra, its- frequency of occurrence increasing as the wound approaches the top of the column. In cervical lesions, high up, seminal ejaculation is apt to take place- at the time of injury, even when the wound causes immediate death. As in all other spinal injuries, bedsores are usually formed in cases that do not speedily prove fatal, and are likely to be developed very quickly.1 Prognosis.—The prognosis of vertebral injuries, aside from the less severe- forms of contusions and fractures of the processes, especially the spinous, is very grave, death usually resulting from lesion of the cord, from septic in- fection, from caries with abscess, or from associated wound of a viscus or large vessel. As was declared by Ollivier, in gunshot cases the accidents are graver, and death generally more rapid, than in those otherwise caused. Of the 32 cases of vertebral fracture among the British soldiers in the Crimea, all proved fatal except four, “ which were either fractures of the transverse processes in the neck, or of the spinous processes only,” and in the French army, 181 died out of 194 (93.3 per cent.). In the war between Prussia and Hanover, in 1866, there were eight cases with six deaths. Of 628 cases- tabulated by Otis, 349 or 55.57 per cent, ended in death, the mortality ac- cording to locality having been : for the cervical region, 70 per cent. (63 out of 90); for the dorsal region, 63.5 (87 out of 137); and for the lumbar region, 45.5 per cent. (66 out of 145); but in almost all, probably, of the non-fatal cases, the fractures affected only the processes. Of the subjects of lumbar injuries, 79 recovered, but it is expressly stated that “there were more than seventy recoveries after gunshot fractures of the apophyses of the lumbar spine.” In Circular No. 6, S. G-. 0., 1865, it is reported that “ of 187 recorded cases of gunshot fracture of the vertebrae, all but seven proved fatal; six of these were fractures of the transverse or spinous apophyses.” Of 54 cases in which it is known that there was an associated injury of the cord, 42 died (77.78 per cent.). In very many of the military cases, death occurs so speedily that the indi- viduals never come under observation. How quickly life may be destroyed is indicated by the fact that in a case of pistol-ball wound between the axis and atlas, the victim, who was asleep, was not startled by the noise of the firing, and never moved a limb.2 The lower down in the column that the wound is, the longer of course the patient may be expected to live. Even when there has been a primary, complete division of the cord, the fatal ter- 1 In a case observed by Guersant, in which the ball passed through the body of the eighth dorsal vertebra, a sacral bedsore formed on the third day. 2 Specimen in Middlesex Hospital Museum. 206 GUNSHOT WOUNDS. mination may be delayed for hours or days, according to the wound’s location. In injuries of less severity, affecting the medulla, its coverings, or the verte- bral bodies, though death is very probable, it is not inevitable, and is less to be apprehended in cases occurring in civil life than in those met with in military practice, since the missiles used in civil life are ordinarily smaller. Complete restoration to health, in cases other than those in which the pro- cesses only are affected, rarely occurs, more or less nervous disturbance (pain, weakness, or positive paralysis) usually remaining during the after-life of the individual, with perhaps caries and abscess, or fistulae communicating with dead bone. When the injury has involved only a spinous process, and there has been no associated damage of the cord—which is frequently, if not gene- rally, the case—the chances of recovery are very good. Even when the body of a vertebra has been broken—and under such circumstances considerable comminution may be expected to occur—if there has been no lesion of the cord or theca, other than perhaps a limited extravasation of blood outside the sheath, or a concussion of the medulla, the individual may not only not die, but may recover, and with very little after-disturbance, organic or func- tional. In a case reported by Keen, a conoidal ball entered through the right upper lip and lodged in the body of the third cervical vertebra, from which place it was extracted six weeks later. The paralysis which had affected all four limbs was rapidly recovered from. Five weeks after the removal of the bullet, there was spontaneously discharged “ nearly the entire body of the third cervical vertebra, including the anterior half of the transverse process and the vertebral foramen.” Nearly eight years afterwards the man was living, having his “right shoulder and arm diminished in size and par- tially paralyzed.” Such a fortunate result, however, occurs only in young persons or in those not beyond middle life. Contusion of the hone may be followed by temporary and quickly recovered from general disturbance, or, after a few days, may give rise to meningo-myelitis, soon terminating in death; but inflammation is much less likely to occur here than in the head after cranial contusions, on account of the greater protection afforded by the subarachnoid fluid. Wounds of nerves close to the intervertebral foramina, will be followed by serious 'effects, motor and sensory, in the parts which they supply; and even concus- sion may give rise to paralysis and atrophy, the latter especially being likely do remain for a considerable time, if not permanently. Treatment.—The special treatment of spinal injuries produced by gunshot has reference only to the removal, when practicable, of foreign bodies, such as balls, bone-fragments, shreds of clothing, etc. The wound should be ex- plored as early and as thoroughly as possible by the finger, if it can be used, if not by the probe, in order that the presence or absence of fracture may be determined. Loose pieces of bone and clothing are to be taken away, and, if detected, the bullet also, provided that its removal can be effected by the exercise of warrantable force and in reasonable time; otherwise the shot is to be left undisturbed. Under no circumstances should any extensive cutting operation be practised in the search for a ball the location of which has not been ascertained by touch. Formal trephining has not as yet resulted favor- ably, but decided benefit has in some cases followed the elevation of de- pressed spinous processes and laminae. At times, the extraction of the missile may be followed by severe hemorrhage, necessitating the plugging of the wound. If an associated injury of an artery is causing troublesome bleeding, the vessel should if possible be found, and ligatures should be ap- plied on either side of the opening. This complication is however a rare GUNSHOT INJURIES OF THE EXTREMITIES. 207 one: in only seventeen cases of spinal injury during our war was there hemorrhage of any importance—but fourteen of these terminated fatally. In all other respects, the treatment of gunshot spinal injuries is the same as that of like accidents produced by ordinary traumatisms. The maintenance of rest, as absolute as possible, is very essential; and much benefit will without doubt be often secured by immobilization of the spine, preferably by plaster-of-Paris. Dry-cupping, in cases of concussion, and wet-cupping in those in which meningo-myelitis has supervened, have been regarded with much favor by many military surgeons. The bladder should be regularly •catheterized; the bowels relieved at proper intervals; and bedsores prevented if possible by the use of the water-bed, by change of position, and by mildly stimulating local applications. Blood-poisoning, so much favored by the nature of the injury of a vertebral body, may perhaps be largely prevented by an antiseptic dressing. Paralysis, not disappearing speedily and spon- taneously, should be treated in the usual way. Gunshot Injuries of the Extremities. By far the larger part of the gunshot wounds coming under treatment in time of war,1 and a very considerable though decidedly less proportion of those met with in civil life, are of the extremities ; injuries of the lower, are about one-half more numerous than those of the upper extremity, and the general mortality is between 20 and 25 per cent, for the former, and about 12 per •cent, for the latter. The left side is more often wounded than the right. As in other regions, the injuries may involve the soft parts only, or the bones .and joints may also be damaged—the gravity of any wound being, as a rule, proportionate to the extent of the existing osseous or articular lesion. Jcfint wounds have already been considered. (See page 155.) Upper Extremity. Flesh Wounds of this region, though very frequent,2 and liable to be fol- lowed in large proportion by more or less disabling cicatricial contractions and adhesions, are, when there is no associated wound of the neck or trunk, dangerous to life only as they are very extensive (as for instance when caused by heavy shot, shell fragments, or fowling-piece charges at short range), as they involve the main vessels, or as they are attended by the graver wound- complications. The treatment therefore, aside from that proper for all gunshot injuries—• the discovery and removal of foreign bodies, maintenance of rest, moderation of inflammation, relief of tension, drainage of the wound, etc.—has reference to the arrestation of hemorrhage, the meeting of special symptoms as they may arise, and the exercise of such care in dressing as shall prevent or lessen as far as possible cicatricial deformity and false anchylosis. Divided arteries, if other than small ones, should be ligated above and below the point of injury; but even when thus treated, the probabilities of such cases terminat- ing fatally are very great. 1 Of over 130,000 eases tabulated by Longmore, nearly 67 per cent, were of tlie extremities— 28 per cent, of the upper, and 39 per cent, of the lower ; and Otis’s table, including nearly twice as many cases more, 360,000 in all, shows that one-third of the entire number were of the upper extremity. 2 “ Over fifty thousand cases, or about a fifth of all the wounded reported by name, were returned as shot flesh wounds of the upper extremities.” (Otis.) 208 GUNSHOT WOUNDS. During our late war, there were 15 ligations of the axillary in cases of flesh wound,, with 12 deaths (80 per cent.) ; 76 of the brachial, with 21 deaths (27.6 per cent.) ; 20- of the radial, with 4 deaths (20 per cent.) ; and 10 of the ulnar with 3 deaths (33.33 per cent.). The large nerve trunks are, fortunately, not very often injured (about once- in every 600 cases perhaps), but when wounded, though the results are not serious as respects life, they are very grave as regards the after comfort of the individual and the usefulness of the limb. Occasionally, because of extensive laceration of the soft parts (by shell frag- ments usually), of sloughing or gangrene of large extent, or of lesion of a main vessel, amputation, primary or late, has to be performed. Of fourteen such operations at the shoulder-joint, during our war, eight resulted fatally, or 57.14 per cent.; of fifty-four of the arm, twenty-seven, or 50 per cent. ; and of fourteen of the forearm, three, or 21.43 per cent. In civil practice, re- moval of the limb can only be required when a load of shot has been driven through the axillary space, so destroying the vessels and nerves as to render it certain that even if saved the- arm must be useless, or because of the super- vention of gangrene, or of secondary bleeding that cannot be otherwise con- trolled. Gunshot Fractures.—Occurring much less frequently, but still often, and producing greatly increased risk to life, and far more ulti- mate interference with the functional utility of the ex- tremity, are cases of bone injury, almost always fracture. Bone contusion has but rarely been observed in this situa- tion, either because actually not present, or more probably because overlooked, the effects produced being of a mild character, and being attributed to the injuries done the soft parts. All the varieties of fracture heretofore referred to- are met with in this region ; fissures, comminutions, crush- ings, penetrations, perforations, etc.—but the results of such lesions are not as grave as those of similar injuries in the lower extremity. At times both arms are wounded, or even carried away, by a shot that does not touch the body. After the battle of Antietam, I saw a young infantryman who,, when in the act of firing, was struck by a shell that crushed the left arm and right forearm, necessitating double primary amputation. Similar injuries have been not infrequently observed. Associated wmunds of the neck or trunk are very com- mon, and in such complications are often to be found the- causes of death. Nerves, especially those passing in close relation with the broken hone, and when the fracture is near an articulation, are frequently damaged, with resulting paralysis, atrophy, muscular contractures, pains, or numbness; and in the majority of' non-fatal cases, a large part of the- functional impairment met with after these injuries is due to such nerve lesions. In many cases, especially when the nerves distributed to the hand have been wounded, severe and quite persistent causalgia has sooner or later manifested itself. Tetanus is not very likely to supervene, even in hand injuries, having been met with in but 24 of the over 11,000 cases of this nature reported during our war. Primary, and still more often secondary, hemorrhage gravely complicates many of these cases, and traumatic aneurisms are at times developed; the vas- cular lesions, too, are often, but much less frequently than in like wounds in Fig. 314. Shell-fracture of hu- merus treated by exci- sion. (A. M. M., Spec. 1738.) 209 GUNSHOT INJURIES OF THE EXTREMITIES. the thigh and leg, the cause of gangrene. Suppuration of the sac is more apt to occur in traumatic aneurism of the axillary artery than in that of any other vessel. Sometimes, when the shot has produced great destruction of the humerus, or after an extensive exsection in continuity, a flail-like condition of the ex- tremity has resulted ; but such a “ dangle-limb” may yet be quite serviceable, the individual being able, by muscular contraction, to bring up the lower against the upper fragment, and afterwards to execute many movements of the forearm. Pseudarthrosis is very seldom met with ; but in the rare cases of simple gunshot fracture of the humerus, false-joint seems very likely to result: there were but five such cases recorded during our war, and in two of these there was non-union. Prognosis.—The prognosis of gunshot fractures of the arm, though affected, of course, by the character and extent of the osseous lesion, and by any asso- ciated injury of the neck or trunk, may be said, in general, to be moderately favorable, and to become less grave in proportion as the wound is located further away from the body: humeral fractures are the most dangerous, while those of the bones of the hand are the least so. Of nearly twenty-five thousand (24,200) cases analyzed by Otis, the numbers and death-rates were as follows :— Cases. Deaths. Mortality per cent. Clavicle 44 8.46 Scapula 177 12.44 Clavicle and scapula . . 103 24 23.3 Humerus . 7888 1639 20.7 Radius . 1450 115 8.0 Ulna .... 126 8.0 Radius and ulna. . 1288 142 11.0 Bones of liand . . 9960 316 3.17 As shown by the above table, though injuries of the clavicle or scapula, separately, are less dangerous than those of the humerus, yet those of the two bones together are decidedly more so. In scapular perforations, much trouble and some danger are likely to be caused by collections of blood and pus, internal to and, from gravitation, below the bone; even lumbar ecchymosis is some- times thus produced. The chief causes of death are hemorrhage, exhaustion, and septic infection. In those non-fatal cases in which the limb is saved, recovery is tedious, and may be expected to be associated, in greater or less degree, with deformity, adhesions and contractions of the muscles and fasciae, atrophy, weakness, and true, or more often false, anchylosis of the joints. The amount of impairment of functional value will, however, in very many cases, depend greatly upon the treatment adopted, and upon the time at and during which passive and active movements of the injured parts are made, and the extent to which they are carried. Treatment.—In the treatment of these cases, the first and most important question to be settled is, shall it be by amputation, by excision, or by expec- tancy? Primary amputation of a part or the whole of at least the right upper extremity, should seldom or never be adopted for a bullet-wound, no matter how extensive the shattering caused by the ball; this operation should, in military practice, be reserved for the severer shell injuries, and in civil life, for the similar lacerations produced by shot-charges fired at close range. Even if the brachial artery has been torn, amputation is not imperatively demanded. Though undoubtedly lives will, at times, be lost in attempts to save limbs, the importance of the arm is so great that it is often permissible to take the increased risk. Amputation at a later period may be necessitated, 210 gunshot wounds. of course, by wound complications ; but, with the exceptions already referred to, the operation should be held in reserve as the complement of expectancy. As based upon a far larger number of cases, and for every reason giving a nearer approximation to the legitimate death-rate of amputations in the upper extremity than the tables compiled chiefly from the Crimean returns, Otis’s statistics are here presented. Table showing Results of Amputations for Gunshot Injuries of the Upper Extremity. Shoulder .... Arm—upper third Arm—middle “ Arm—lower “ Arm—location not stated . . Elbow Forearm—upper third Forearm—middle “ Forearm—lower “ Forearm—location not stated. . Wrist f—' t—' tO CO tO to Oi H1 CO 45. Ox CO CD OO CO CO 4.. >—‘050000 W 03 4x- HJ 05 tO -T fcO tO CO On Cases. Primary. t-1 to to to 77 o^ooh Ox 00 CO On 05 tO O 05 CO CO -T Deaths. Ci tO 1—1 h-* bO JOO ppcopco Otc -1 COC bOOJMOl W 0 0—14-^ Mortality per cent. H tO H H W WM t—1 OOtO vfc. 05 45- Ux —7 —I OWCCOl® t—1 OO —J —1 Cases. Intermediary. h-1 t-j bo co co h-» CO h-» r-» h-» O CO 00 bO Deaths. 45.86 31.12 '26.72 41.61 73.91 0 24.22 20. 21. 76.47 14.28 Mortality per cent. hJ t—• co cjx h-i Oi a Deaths. bO CC uj m H CO bO bO tO 0 05 W00500 JO H p. CO cs co * oo as b\ as O co co Mortality per cent. ZJt h-» ci h-j h-» co bo yi oo m -a -a «d o m boootoco Cases. Unspecified Date. h-» CO h-i to bO 00 o CO H CO Deaths. 23.53 25.61 22.41 0 • 36 14.28 0 11.11 5.88 14.03 Mortality per cent. (—* H-* l-> rfi.0545. CO —T —7 50 00 OS Hi Ox -J 00 45. 45. Ox CO 45. tO —I CO M ox 50 ® be adopted, and not the simple fact that in so many thousand cases, collected 1 In a case reported by Despres, of ligation of the femoral vein near the apex of Scarpa’s tri- angle for secondary hemorrhage, “neither oedema nor pain followed, the ligature separated in six days, and the man rapidly recovered.” 2 Of Beck’s 124 leg amputations, the mortality rate of the 66 primary operations was 33.33 per cent., of the 6 intermediary operations 66.67 per cent., and of the 52 secondary operations 40.38 per cent. 216 GUNSHOT WOUNDS. from numerous wars in different years and various countries, expectancy has yielded a higher percentage of recoveries than amputation. Gunshot wounds of the foot, not involving the ankle-joint, are frequently met with in military practice, and occasionally—almost always as the result of accident—in civil life; and in a relatively large proportion of cases, frac- ture of one or more bones is present. The prognosis of these injuries as respects life is not grave, though death may result from hemorrhage, from tetanus, or, much more generally, from septic complications. As respects, however, the after-usefulness of the limb, the gravity of these cases is quite considerable, for even if amputation, com- plete or partial, is not necessitated, muscular atrophy, tendinous adhesions and contractions, osseous deformities, or tender cicatrices, one or more, are very liable to seriously interfere with locomotion. As a general rule, the treatment should be by expectancy, primary amputa- tion being performed only when a part or the whole of the foot has been very extensively damaged. In toe-injuries, if amputation becomes necessary, it should be complete—at the metatarso-phalangeal articulation—except in the case of the great toe, of which any uninjured portion should be saved. In operating through the metatarsus or tarsus, no more should be removed than is absolutely necessary, and the skeleton of the foot may, with reference to amputations, be regarded as constituted of but a single bone. Amputa- tions in contiguity are to be practised only when those further distant from the trunk, and in continuity, cannot be substituted; Cliopart’s operation is very likely, because of retraction of the tendo Acliillis, to be followed by an unsatisfactory result as far as the comfortable use o*f the stump is concerned. The death-rate of amputations in front of the ankle-joint is not great, and that of amputations at the joint itself was, during our late war, but 13 per cent.—9 out of 69 cases. Of 790 cases of toe-amputation, tabulated in Circular No. 6, S. G. O., only 6 or 0.76 per cent, terminated fatally; and of 119 partial amputations of the foot, only 11 or 9.24 per cent. Legouest’s statistics, here as elsewhere, give a much higher mortality percentage, viz., 18.9 for the toe-amputations, 38.0 for partial removals of the foot, and 23.2 for disarticulations of the ankle. During the Crimean war, more than one-half (51.35 per cent.) of the cases of ankle-joint amputation among the French ended in death, while the proportion among the English was only about one-sixth (15.38 per cent.). Expectant treatment in these cases must be conducted on the same general principles as in wounds of other regions. Lodged missiles, if of large size, should always if possible he found and removed, since their presence is almost certain to develop and maintain bone-inflammation.1 When the in- jury, however, has been caused by a small pistol bullet, if the location of the shot cannot be determined by the use of the probe, no extensive incisions should be made in the hope of finding the ball. The ends of divided nerves and tendons, especially those upon the dorsum of the foot, may very pro- perly be united with sutures. Hemorrhage, whether primary or secondary, if from any of the larger arteries, should be arrested by ligation, at the seat of injury, and not at a distance. Bleeding of a severe character is of frequent occurrence in these cases, and, if not properly treated, is very apt to produce most serious results. The dissection that may be required in order to find the wounded vessel will be much facilitated by the preliminary application 1 Stromeyer declares that “ injuries of the tarsus generally are not very dangerous, and heal with unexpected facility, and without perceptible exfoliation, after extraction of the bullet.” GUNSHOT INJURIES OF THE EXTREMITIES. 217 of the Esmarch bandage. Free drainage must be secured, and suppurative teno-synovitis—which is quite likely to occur, as it is also when amputation has been performed—must if possible be prevented. The foot should be immobilized in a proper position, and much attention should be directed to the prevention of cicatricial deformities. If tetanus should be developed, and it is relatively frequent in these cases, early neurectomy might prove of great benefit. Carious bone should be gouged out, or the affected bone or bones removed. Even the entire os calcis has in a number of cases been taken away, and recovery with a useful foot followed ; and judging from the results of extensive, and even complete, excisions of the tarsus for caries consequent upon other causes, similar operations might very properly be substituted for amputation in cases of bone disease following gunshot injury. VENEREAL DISEASES: GONORRHOEA. BY J. WILLIAM WHITE, M.D., CLINICAL PROFESSOR OF GENITO-URINARY DISEASES IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA ; SURGEON TO THE PHILADELPHIA HOSPITAL, PHILADELPHIA. The word Gonorrhea, although etymologically inaccurate as a designation of the disease in question, is still so universally employed and so well under- stood, that it has been retained in this article for the sake of convenience. The old English but now vulgar term “ clap” is no better, lacking even the slight descriptive force of its French and German congeners, chaude-pisse and tripper. For reasons to be presently stated, urethritis will be used inter- changeably with gonorrhoea, as the term that most precisely and compre- hensively describes the most common manifestation of this malady, which, exclusive of the diseases of childhood, has probably affected at some time in their lives a larger proportion of the males of the community than any other single ailment. This extreme frequency—which will not be ques- tioned by those who have had much opportunity of observation in this direc- tion—of itself renders the disease of sufficient gravity to entitle it to careful consideration, even if the harmful consequences commonly attributed to its direct or indirect influence be denied. History of Gonorrhoea. As to the history of gonorrhoea, which may he briefly dismissed, there is quite sufficient evidence to show that inflammation of the urethra, attended with purulent discharge appearing at the meatus, and capable of being trans- mitted from person to person by contagion—that is to say, of “ gonorrhoea” precisely as we now know it—is a disease which has existed from the remotest periods of antiquity, the writings of Moses, of Herodotus and Aristophanes, of Celsus and Hippocrates, of Rhazes, Avicenna, and Albucasis, all containing more or less accurate descriptions of such a urethritis, which affected their cotemporaries, and which was then, as now, accompanied or followed by numerous complications. The disease may be tracked across the middle ages with even greater facility, although it was then confused with the various manifestations of syphilis, and was not definitely separated from that affection until the early part of the present century, since which time the non-identity of these two diseases has been but rarely and feebly disputed. The only debatable ground in the con- sideration of gonorrhoea at this time is the question of its specificity, or invariable dependence upon a virus which is said to constitute the contagious element, and to impart to the disease such distinctive—“ specific”—characters as clearly to separate it from other affections. 219 220 GONORRIKEA. Nature of Gonorrikea. As this subject is not only of theoretical interest but of great practical importance, the views held influencing both prognosis and treatment, and sometimes important medico-legal opinions, etc., it will be ussti x to look care- fully at both sides of it. Those diseases which are called “ specific,” and which are recognized as distinct clinical or pathological entities, or as depending upon definite and in- variable sources of origin, have, as a class, certain peculiarities which more or loss accurately characterize them; they have a period of incubation inter- vening between the time of exposure to infection and the outbreak of the first symptoms ; they cannot be caused by traumatic influences or by anything except tlie essential virus of the disease, which through some channel must find its way into the general circulation ; they usually protect from a second attack; they are, in the majority of cases, accompanied by distinctive patho- logical changes or processes, which distinguish them from diseases the result of mere irritative action; they run a definite course, and, after their termina- tion or subsidence, cannot be reawakened at will by any known agency. In gonorrhoea, not one of these conditions obtains. There is no definite period of incubation—indeed, none at all, except that which always inter- venes between the contact of an irritating foreign substance and the produc- tion of a sufficient degree of inflammation to excite subjective symptoms. A large number of widely dissimilar causes are capable of developing the disease in its greatest intensity; authentic cases are recorded of well-marked urethritis following accidental or experimental exposure to leucorrhceal dis- charges ; to the pus from a healthy abscess, or from a purulent bronchial catarrh ; to the secretion from an endo-cervicitis or endo-metritis ; to the dis- charge resulting from ulceration or malignant disease of the uterus ; to the menstrual fluid or acrid vaginal discharges; to powerful injections; to the passage of gravel; to catheterism ; and to many other undoubtedly non-spe- cific causes. The condition thus evoked is in no wise distinguishable from that following sexual intercourse with a person already having a similar dis- ease, some of the most severe and most complicated cases of gonorrhoea which have fallen under the notice of the writer having been derived from one or the other of these sources. The assertion that in so-called “ true” gonorrhoea the disease has a peculiar tendency to become chronic or to run into obstinate gleet, while on the other hand “ simple” gonorrhoea, or urethritis, tends to ■subside spontaneously, cannot be admitted as an argument based upon clinical facts. It may be positively stated that no sound inference as to the cause, in any particular case, can be drawn from its course or symptoms, and that the variations observed in the different grades of urethritis are no greater than those which prevail among inflammations of other mucous passages, and which are due to individual idiosyncrasy, or to differences in the power of the original irritant. So far from exercising any protective influence against subsequent attacks, gonorrhoea, like tonsillitis, laryngitis, bronchitis, enteritis, cystitis, etc., pre- disposes to them, often, especially if it has been protracted, leaving the ure- thra in an atonic, relaxed, or catarrhal condition, or else roughened, granular, .and congested. It is exceedingly common to have patients remark that, although frequently exposed to contagion, they went many years without ■contracting the disease, but that since the first attack they acquire it every few months, which circumstance they usually attribute to “bad luck,” or, not infrequently, to an imaginary necessity for conforming to a general average. In observing the course of gonorrhoea from a pathological standpoint, NATURE OF GONORRHCEA. 221 nothing whatever is found to occur, either as to the manner of attack or the tissue or tissues invaded, which separates it from ordinary catarrhal diseases nothing, for example, analogous to the induration of the chancre, the ulcera- tion of Peyer’s patches, the dermatitis and pustulation, which, by their almost unvarying presence in syphilis, typhoid fever, and variola, are entitled to be- called specific characters in those diseases.1 The occasional occurrence of articular disease, “ gonorrhoeal rheumatism,” and of a sclerotitis, “gonorrhoeal ophthalmia,” as complications of urethritis,, has been frequently attributed to some peculiar property supposed to belong solely to gonorrhoeal pus, and never originating apart from contagion. Since, however, it has been found beyond dispute that these inflammations of fibrous tissue may complicate urethritis due to traumatism, and that they are in all probability mild pyaemic manifestations following the absorption of purulent products through the delicate urethral mucous membrane (see p. 240), this argument has lapsed. The term “ urethral sypovitis” has been proposed as a substitute for the former, and is in every way preferable. The intense form of conjunctivitis following contact with pus resulting from a urethritis, has also been shown by experiment to be in no sense a specific process, pus from an eye affected with ophthalmia neonatorum having pro- duced a characteristic urethritis, which in its turn proved transmissible, and gave rise to a typical conjunctivitis. After gonorrhcea has apparently subsided, any indiscretion in diet, any sexual or alcoholic indulgence, any local irritation, may, and frequently does,, serve to reproduce it in all its original intensity, and this may be repeated an indefinite number of times. Nothing at all analogous to this occurs, during the course of any of the diseases with which we are comparing it. Unless the peculiar virus is supposed to be generated anew in each case of traumatic urethritis, an untenable theory, it becomes impossible in the light of clinical observation to explain these peculiarities and variations in the cause of gonorrhcea on the supposition that it is truly specific in its character. The facts which have thus been stated may be briefly presented in a tabu- lar form:—■ Gonorrhcea. Specific Diseases. No period of incubation. Caused by a variety of agencies, chem- ical, traumatic, and infectious. Predisposes to a second attack. Associated only with ordinary processes of inflammation. May be re-awakened or reproduced at will and indefinitely. Definite period of incubation. Caused always by the absorption of a definite virus or morbid product. Protect from a second attack. Have distinct and almost unvarying peculiarities as regards their pathology. Run a definite course, and cannot be made to return after its completion. Dr. Fordyce Barker speaks of a peculiar form of urethritis which has associated with it a leucorrhoeal discharge, that in repeated instances has produced a purulent ure- thritis in the male. Dr. Otis records the case2 of a gentleman who had been married 1 “ Chiefly affecting mucous membranes, gonorrhoea has all the characters of ordinary inflam- mation of mucous membrane; it begins near the surface where the contagious secretion is first applied, and thence spreads towards the interior of the body ; it is attended by redness, with scattered or more general hypersemia, swelling of the mucous membrane, considerable increase in the secretion of mucus, with the addition of many wandering leucocytes, and, in severe inflam- mation, also of red corpuscles; subsequently the swelling, hypersemia, increased mucous secre- tion, and escape of leucocytes diminish, the superficial epithelium desquamates, and the secretion of mucus gradually abates. Such are the anatomical characters, and they are those of any ca- tarrhal inflammation.”—Prof. H. Lebert (a strong advocate of the doctrine of specificity), in Ziemssen’s Cyclopaedia of Practical Medicine, vol. viii. p. 752. 2 Medical Record, June 8, 1878. 222 GONORRHOEA. one year, and in whom a urethritis had appeared soon after his marriage. This disap- peared under treatment, but subsequently redeveloped three or four days after each sexual congress with his wife. Upon examination it was found that she suffered from retroversion of the uterus ; that the surface of the external os was eroded, and covered with a thin layer of muco-purulent material. The uterus was restored to its normal position and retained by a pessary. The lady made a prompt recovery, and from that time the gentleman suffered no more from his urethral trouble. Mr. Milton, an ardent supporter of the theory of specificity, admits1 that “ ure- thral discharges do appear in men as the result of connection with women laboring under leucorrhoea,” but says that such a discharge is “ usually much milder than gonorrhoea in its symptoms,” which we have no doubt is true. We may also agree with him that “ even a slight amount of gonorrhoea is more likely to excite the same disease in another person, than a pretty high degree of leucorrhoea is to bring on a simple urethritis.” Leucorrhoeal discharges are sometimes almost entirely mucous, and in such cases are probably innocuous. Gonorrhoea, in the sense in which he uses the term, always contains pus, which is undoubtedly the most active and most frequent source of urethritis, only it need not be in any sense “ specific.” Unquestionably the strongest argument urged in favor of the specificity of gonorrhoea, is the fact that those married men who refrain from intercourse with other women than their wives, enjoy comparative immunity even although the latter are the subjects of leucorrhoea. There can be no doubt that in the vast majority of cases such men either escape all forms of urethral inflam- mation, or at the most suffer from a catarrhal urethritis, and rarely or never develop an acute, inflammatory condition. This as a clinical fact is denied by no one, but was explained by Ricord on the theory of “ acclimation the husband is said to become “ seasoned” or accustomed to the discharges of the wife, so that they have no effect upon him, although at the same time, as is shown by many authentic cases, they may give rise to a violent gonorrhoea in a third person. This is doubtless also true to a great extent, yet it hardly seems to me entirely satisfactory, or to explain, for instance, the escape of those men who marry women already affected with leucorrhoeal discharges, and who, of course, are not already “ acclimated.” Great numbers of such mar- riages continually occur, and yet it is very rare, at least among well-to-do people, to find the husband developing gonorrhoea, even although the predis- posing influence of the sexual excesses not uncommon in early married life be added to the possible exciting causes existing in the woman’s condition. In dispensary practice, however, it is not so exceptional an occurrence, and is occasionally a source of domestic discord. I have seen several such cases within the last year. Here again it must in fairness be admitted that the women concerned are hardly above suspicion; and although it is the duty of the physician under the circumstances to give the woman the benefit of any doubt as to the precise character and cause of her ailment, it cannot be denied that the doubt frequently exists. The only explanation of these facts which seems in accord with the various powerful arguments in favor of the non-specific character of gonorrhoea, is that which attributes the production of the disease to the combined influences of neglect of personal cleanliness and hygienic precautions on the part of both the woman and the man, together with sexual and possibly alcoholic intemperance. Fournier lias shown that of 387 women known to have been the source of gonorrhoeal infection, only 56 were prostitutes, the other 331 being made up of married women, kept women, shop girls, and domestics, or, in other words, of women with whom illicit intercourse was often of necessity clandestine, hurried, or performed under circum- stances which did not admit of thorough ablution. Such women are of course more apt to be the subjects of uterine or vaginal catarrh, the secretions from which, if 1 Pathology and Treatment of Gonorrhoea, p. 6. 223 NATURE OF GONORRHOEA. retained as a consequence of neglect, are much more likely to be purulent and contagious than in women who live a regular and well-ordered life, and who are careful about their personal condition. If these factors be duly considered, the escape of married men, the infec- tion of “ lovers,” the comparative harmlessness of prostitutes (who learn to attend to cleanliness as a matter of business), and the great frequency with which the disease is contracted from certain classes of women, all become comprehensible, and may be said, in resume, to depend upon the generally ad- mitted facts, that in the female a purely mucoid discharge, or one with but slight purulent admixture, is contagious only to a very moderate extent;1 that regularity in the performance of the sexual functions, absence of excesses of all sorts, and attention to personal cleanliness—circumstances usually existing in married life—tend to preserve the non-purulent character of such discharges; and that these conditions are usually reversed when intercourse is illicit, and particularly when it takes place with women who do not prac- tise it as a profession. Consequently, we are not compelled to depend upon “acclimation” as the sole explanation of the immunity of married men, while at the same time we may maintain the original proposition, that gonor- rhoea may be contracted from all forms of uterine and vaginal discharges. The importance of having well-grounded and clearly defined views upon this subject, becomes evident upon reflection. If we assert or believe in our ability to recognize by certain symptoms a specific gonorrhoea, which could only have been obtained, except in instances so rare that they might practi- cally be excluded, by contact or intercourse with an individual of the oppo- site sex having the same disease, we shall frequently be compelled either to prevaricate or actually to falsify, or else in many cases to put an end to domestic happiness or cause infinite misery and suffering. If a man with all the symptoms, presently to be detailed, of a typical case of gonorrhoea, asks the point-blank question as to the cause of his disease, and if, true to the “ viru- lent” theory, and careless or ignorant of his sexual or matrimonial relations, we reply that it has almost certainly resulted from a similar discharge pro- duced in its turn by a similar cause, we may possibly—indeed, taking the average of a large number of cases among the better classes, it is safe to say we will probably—do some innocent woman a great injustice, and, as in one instance of which I am personally cognizant, may even indirectly cause her ruin and death. It is never safe or proper to say that a given urethritis, vaginitis, or vulvitis, has resulted from impure sexual intercourse, although we may admit that the latter is the most frequent cause of these diseases. There is a marked difference between the sexes as regards susceptibility and exposure to contagion, which we should remember for our own instruc- tion, observing, however, the same caution as to expression of opinion. A man with a urethritis may have derived it from any one of the sources which have been mentioned, the woman, if it follow sexual intercourse, having been quite free from any truly venereal disease. In the majority of cases in which I have been asked to examine women suspected under these circumstances, I have failed to find any evidence of gonorrhoea in any of its forms. On the other hand, in the absence of traumatic or mechanical irritation, if a woman develops gonorrhoea—that is, a vulvitis, vaginitis, or urethritis—it is strong presumptive evidence that she has been exposed to contact with the secretion from a similar inflammation affecting the male urethra. The possible infect- ing or exciting causes of gonorrhoea in women are obviously much fewer 1 Mr. Milton’s rule, already quoted, that “ even a slight amount of gonorrhoea is more likely to ■excite the same disease in another person than a pretty high degree of leucorrhoea is to bring on ■even simple urethritis,” is a statement of this same fact, possibly a little exaggerated. 224 gonorriicea. than in men, as the genital and urinary apparatus in the male is neither so extensive in surface nor so subdivided functionally as in the female, and her chances for contact with morbid secretions, other than that from a purulent urethritis, are correspondingly limited.1 [See page 299.] Varieties of Gonorriicea. Gonorrhoea may then be defined as an inflammation of the urethra in the male, of the vagina, vulva, or urethra in the female, depending upon some local irritation for its development, the most common cause being con- tact during sexual intercourse with purulent or disordered secretions from the genito-urinary tract. In practice we meet with three distinct varieties of the disease, which are of definite clinical importance, and which may be described as:— I. Typical or acute inflammatory gonorrhoea; II. Subacute or catarrhal gonorrhoea; III. Irritative or “ abortive” gonorrhoea.2 Distinctions based upon minor variations in the form or seat of the inflam- mation have been made, chiefly by those observers who have employed that very unsatisfactory instrument, the urethral endoscope. They have thus de- scribed a membranous urethritis with inflammation of the dorsal lymphatics- of the penis ; a granular urethritis, with numerous punctiform elevations of the mucous membrane; a suppurative urethritis, with the formation of ab- scesses in the submucous connective tissue; and an ulcerative urethritis, noticed in persons predisposed to herpes. I have never been able to distinguish these different forms with any degree of accuracy except when they have given rise to well-marked symptoms, such as follicular or peri-urethral abscess in the “ suppurative” form, hemorrhage after urination in the “ ulcerative” variety, etc.3 For practical purposes they may safely be ignored, and the division or classification above suggested may be adhered to. 1 At intervals of a few years the doctrine of the dependence of gonorrhoea upon the presence and growth in the urethra of vegetable organisms—bacteria and micrococci—is revived and dis- cussed. Neisser, Salisbury, Bokai, and lately Mr. Cheyne, Assistant Surgeon to King’s College Hospital, have claimed to base their diagnosis and treatment of the disease upon the existence of these organisms. As their observations have never been confirmed, except as to the discovery of micrococci such as are found in pus under all circumstances, and whencesoever derived, and as the antiseptic plan of treatment is usually a conspicuous failure in cases of gonorrhoea, it will not be necessary further to allude to these theories. [See page 299.] 2 Lebert classes the two latter forms together under the name of “ slight, superficial, sero-puru- lent and mucous gonorrhoeo-catarrh.” 3 J. Griinfeld (Cbl.f. Chir., 1878, No. 21; from Wiener med. Jahrb.), as a result of his expe- rience with the endoscope, describes the following forms of urethritis, which closely resemble those above given : (1) Urethritis blennorrhoica, acute blennorrlioea of the urethra, without com- plication. The field of vision of the endoscope is filled with greenish pus, the mucous mem- brane underneath markedly reddened, greatly puffed out, and showing erosions here and there. The so-called lacunae of the mucous canal are wanting, or their depth is reduced to a minimum. (2) Urethritis membranacea, characterized by striated layers of grayish-white membrane, the re- moval of which gives rise to slight bleeding. This form of disease is ordinarily complicated by inflammation of the dorsal lymphatics of the penis. (3) Urethritis simplex, a less marked variety of U. blennorrhoica, the mucous membrane being somewhat red and swollen, with injected blood- vessels ; the lacunae decidedly evident. (4) Urethritis granulosa. The mucous membrane is- evenly colored ; no isolated bloodvessels can be seen ; wrinkles are for the most part wanting, but numerous punctiform elevations can be perceived, which are distinguished by reflecting light from their surface. (5) Urethritis with the formation of abscesses, which occasionally originate in herpes blebs, occasionally are chancrous sores, and sometimes proceed from badly treated strictures. A form of gonorrhoea known as “gonorrhoea sicca,” or “dry gonorrhoea,” and unattended with discharge, is discussed by some authors. I have never seen a case of this disease, and am disposed to agree with Van Buren and Keyes, who attribute the symptoms—pain, ardor urinae,. SYMPTOMS OF FIRST OR INCREASING STAGE OF GONORRHOEA. 225 Acute Inflammatory Gonorrhoea of Male Urethra. Taking up the subject of gonorrhoea in the male, we may begin with a description of the acute inflammatory variety, which is the one most fre- quently encountered, particularly in those persons who are for the first time atfected. The interval which elapses between exposure to irritation and the develop- ment of noticeable urethral symptoms, is a variable one, extending from a few hours to twelve or fourteen days. In the great majority of cases, however, the disease appears during the first week, and intelligent or observant patients usually discover indications of its presence within two or three days. Such persons will often tell you that they have experienced an obtrusive conscious- ness of the possession of a penis, an involuntary turning of the thoughts in that direction, a disposition to search or examine the organ, although no pain is felt, and no discharge can be seen. In a short time, however, one or the other of these symptoms makes its appearance, or they occur simultaneously. The patient notices a drop of milk-and-watery fluid at the meatus, which is slightly red and puffed or everted; a tickling sensation is often felt in this locality, and the next act of urination is attended with a feeling of warmth at the end of the canal, or with actual scalding. After this, the symptoms increase rapidly in number and severity, so that within forty-eight hours, or even sooner, the disease may be described as having gotten well into its first or “increasing” stage, the characteristic phenomena of which, with their respective causes, may be enumerated as follows:— Symptoms of First or Increasing Stage of Gonorrhoea. Changes in Meatus.—There are redness, eversion, and often erosion of the lips of the meatus ; sometimes, but rarely, so much swelling as to constitute a distinct obstacle to the passage of the urine, which escapes only by drops. Ardor Urinje.—Scalding at each act of urination, or ardor urince, is the symptom which gives the disease in French its popular name of chaude-pisse. This is due partly to the distension of the inflamed and swollen mucous folds of the urethra during the passage of the stream, but chiefly to the contact with the inflamed surface of the salts of the urine. That this latter is the principal cause, is shown by the favorable influence which diluent and alka- line diuretics have over this symptom, although they actually increase the size of the stream, and consequently the amount of distension. Chordee.—Painful erection, or chordee, is present to a greater or less extent in all such cases. It may occur at any time during the twenty-four hours, but is most frequent after the patient has become warm in bed. He is awakened or kept awake by an intractable, persistent priapism, which is associated with pain felt along the under surface, or often along the sides of the penis. In well-marked cases the organ is bent or curved, usually in a downward direction, more rarely upward or laterally. The corpus spongiosum, situated beneath and between the corpora cavernosa and surrounding the etc.—to urethral neuralgia, and assert that the malady is not in any sense a gonorrhoea. Jullien thinks, however, that it is not illogical to consider the mucous membrane of the urethra as affected, in such cases, by an inflammation analogous to that of cutaneous erysipelas, the pro- ducts of which in “ hlennorrhagie seche” may be so slight as only to he detected by a careful examination of the urine. (Maladies Veneriennes, p. 35.) 226 GONORRHOEA. urethra, is more directly involved in the inflammatory process than the other portions of the penis. The urethritis is not confined solely to the mucous layer of the canal, hut extends by contiguity to the submucous connective tissue, and thence continuously to the trabeculse of the erectile tissue of the spongy body. The lymph, which is exuded in these localities, blocks or fills up the inter-trabecular spaces or meshes containing the intricate venous plexus which, by its engorgement and distension, furnishes the essential mechanical element of normal erection. When, either in response to sexual desire, or as a result of the local irritation of the urethritis, or induced by the contact of accumulated urine with the neck of the bladder, or suddenly occa- sioned by spasm of the muscles controlling the return of blood from the penis, the organ becomes erect, the corpora cavernosa expand normally and fully, but the blood is unable to find its way into the partially obliterated erectile tissue of the corpus spongiosum, which remains rigid and inflexible. The pain the sides is produced by the pressure on nerves caused by the unnatural position, and that along the under surface by the attempted distension of the inflamed tissue of the spongy body. There is an analogous condition, con- sisting of a chronic circumscribed inflammation of the corpora cavernosa, in which erections are equally painful, but in which the curve is upward; or, if only one cavernous body is involved, the bend is lateral, and toward the affected side. One explanation of the mechanism of chordee attributes the bending of the penis to spasm of the layer of longitudinal muscular fibres said partially to encircle the urethra.1 These, however, are very scanty, are sometimes almost entirely absent, and have no normal functional activity. It is hardly con- ceivable that, even under persistent irritation, they should exert sufficient force to produce the severe and often long-continued bending of the penis found in chordee. Then, too, the characteristic pain in erection is frequently experienced without the least curving of the organ. According to Hilton,2 when the erection occurs suddenly, the cause is spasm of the muscles which control the blood supply to the penis, the spasm being due to irritation of branches of the pudic nerve, which are distributed to the inflamed mucous membrane of the urethra. The sudden and severe erections which occur during sleep are attri- buted by the same author to excito-motor action roused in the spinal cord when it is deprived of the control of the brain. Mr. Hilton also suggests that the greater disten- sion of one side of the penis than of the other, which often occurs, may depend upon a greater amount of irritation on the corresponding side of the urethra. The variety of chordee which is produced by the effusion of inflammatory products into the corpus spongiosum, is considered by him to be quite distinct from the preceding forms.3 This explanation seems as far removed from the truth as that of Mr. Milton, mentioned above. At least, I have never seen any cases which could be distinguished as being due to muscular action. Doubtless erection is prolonged by the tendency of the erectors and compressors to spasm, but that this is in any sense the cause of either the pain or the deformity of chordee cannot, I think, be admitted. Frequent Urination with Vesical Tenesmus is another symptom which occurs about this time in many cases. It generally indicates an extension of the inflammation to the deep urethra, but may exceptionally be due to reflex influence from a disturbance as yet localized at or near the meatus. In either event, the irritability of the neck of the bladder is shown by the inability of that organ to retain more than very small quantities of urine, and by the urgency >of the calls to evacuate it, the difficulty in starting the stream, and the bear- 1 Milton, op. cit., p. 184. 2 Lectures on Rest and Pain, 2d ed., p. 255. 3 Hill and Cooper, Venereal Diseases, p. 497. PLATE XV [.limit’ amwi'Sxma Mulli jttuluit \JunwAid. c2. I a 110 -|u-uj It i t b ui {li JteiJu’lijeutu 2). wilia wtuctjumlMlcesuxtwsn. 4'. x iluua vvv wo mem/ „ 227 COMPLICATIONS OF FIRST STAGE. ing-down, expulsive efforts which accompany or follow the dribbling of the last few drops. The discharge during this period has been growing more and more profuse. At first thin, and of a bluisli-white hue—like city milk—it has become white, then yellow, and then greenish or streaked with blood-stains. If actual ulceration has occurred, it may contain a considerable admixture of blood, a few drops of which will follow each urination, produced by the rupture of minute capillaries during the contraction of the circular muscular fibres which takes place at the end of that act. We have, then, certain conditions—ardor urinse, profuse purulent discharge, chordee, and frequent urination—which characterize the increasing stage of inflammatory gonorrhoea, and all of which occur with so much frequency that they should be regarded as symptoms of that stage, and not classed, as is sometimes done in the case of the two latter, with the complications. Under this head, however, and observed during the same period, some annoy- ing and troublesome results of inflammatory action may be described. Complications of First Stage. Balanitis.—When the inflammation, instead of remaining within the ure- thra or involving only the lips of the meatus, extends over the surface of the glans penis, we have the condition known as balanitis. This is usually caused by a neglect of cleanliness, the urethral discharge being permitted to remain in contact with the head of the penis, or allowed to accumulate under the foreskin, but it occasionally occurs, as has been said, from a simple extension of inflammatory action by continuity, and in spite of the greatest care. As in the case of gonorrhoea itself, some patients seem to be peculiarly subject to the development of this form of inflammatory action, and it has been noted that persons who have been troubled with erythema intertrigo are usu- ally sufferers from this complication. In dispensary and hospital practice it is seen in about one-fourth of all cases, in private practice not nearly so often. The susceptibility to irritation of the mucous membrane of the glans is, for obvious reasons, much less than that of the urethra. Pus which would in- stantly excite an active urethritis, may often be permitted with impunity to bathe this region; astringents, such as nitrate of silver, which, when injected per urethram, give exquisite pain, have little or no effect on the thicker epi- thelium of this part, which, in circumcised persons or those with short or retracted foreskins, closely resembles epidermis in density and insensitiveness. If it were not so, the most scrupulous cleanliness would not prevent the large majority of patients with the variety of gonorrhoea under consideration from having this complication. Symptoms and Diagnosis of Balanitis.—Its symptoms are those of super- ficial inflammation, heat, redness, burning or itching, and finally exfoliation of epithelium, leaving an eroded or sometimes a superficially ulcerated sur- face. Hot infrequently little crops of herpetic vesicles (see Plate XV. Fig. 2) appear, and may remain discrete until they desiccate, or they may pustulate, coalesce, and leave an ulcer which is sometimes mistaken for a chancre or chancroid. Between the balanitic ulcer and the chancroid, the differences seem to me chiefly those of degree, a more intensely irritating or corrosive pus causing deeper and more intractable ulceration. Indeed, I have on more than one occasion seen balanitic ulcers subsequently removed from treatment by the 228 GONORRIKEA. occurrence of phimosis, and at a still later period disclosed by operation, in which all the so-called specific characters of the chancroid—the abrupt or undermined edges, the tendency to spread, the profuse discharge, etc.—were present. The diagnosis here is of no great importance, as treatment should be applied in either event on the same principles. Mild local measures suffice in both cases to cure the majority of sores; in those which continue to ex- tend or which remain intractable, cauterization with nitric acid is indicated both theoretically and empirically. The form of the initial lesion of syphilis known as the chancrous erosion, may be mistaken for a superficial balanitis. The period of incubation, the absence of urethral discharge, the abrupt limitation of the erosion, the pres- ence at its base of “ parchment” induration, the enlargement of the inguinal lymphatics, and the lack of inflammatory element, are symptoms of the former condition which should render it easily distinguishable from a solution of continuity due to balanitis. Balano-Posthitis.—An extension of the inflammation from the surface of the glans to the inner or mucous layer of the prepuce gives rise to what is known as balano-posthitis, which has no special clinical significance, except that it is almost invariably followed by, or associated with, an inability to retract the foreskin, so as to uncover the glans penis. This is due to an extension of the inflammation to the loose cellular tissue uniting the two surfaces of the foreskin, which rapidly becomes oedematous, and in some cases is the seat of an effusion of plastic lymph. Phimosis.—The phimosis thus produced is an extremely objectionable com- plication, as it interferes with treatment, necessitates most vigilant and unremitting care as to cleanliness, and obscures diagnosis and prognosis. If the case has not been watched from the beginning, and the patient comes under observation for the first time with a vague history and with an oede- matous, swollen prepuce (see Plate XY. Fig. 1), from the orifice of which pus or pus and blood exude, it is not always easy to determine the exact under- lying condition. An indurated chancre can generally be discovered without trouble by its hardness, and is moreover not often complicated in this manner. A soft or chancroidal sore, however, or a balanitic ulceration, may not be so readily recognized. The main points of distinction may be tabulated as follows:— Phimosis from Gonorrhcea. Phimosis with Sub-Preputial Chancroid. No history of sore on glans or prepuce. Swelling in foreskin at first almost en- tirely oedematous. Discharge usually purulent. No definite area more tender or harder than the rest. Chordee often present. Ardor urince extends along whole length of canal. Vesical symptoms not infrequent. Bubo very rare. History of sore. Swelling often due to presence of plastic lymph around ulcer. Discharge often sanguinolent. A distinct spot usually discoverable by palpation. Never any true chordee. Ardor urinse only when the urine comes in contact with the inflamed or ulcerated foreskin. No vesical symptoms in uncomplicated cases. Bubo common. It is not at all uncommon for patients who have had no experience in venereal disease to assume that a balanitis originating in uncleanliness, and SYMPTOMS AND COMPLICATIONS OF SECOND OR STATIONARY STAGE. 229 due to the retention and decomposition of smegma, is a gonorrhoea. In dis- pensary practice, such patients are usually seen after having passed through the hands of an apothecary who, prescribing, as is usual with such persons, without making an examination, has administered a course of copaiba, sulphate of zinc, etc., in place of the soap and water which were all that was requisite. Of course no such mistake can he made by a careful prac- titioner; but even he may be temporarily in doubt when the balanitis is complicated with a phimosis so tight as to prevent any view of the meatus. In these cases, however, subpreputial injections are the first essential of treatment in any case, and will soon allay the swelling, so as to permit of sufficient retraction of the prepuce to resolve all uncertainty. Paraphimosis, a condition in which the prepuce, retracted and caught be- hind the projecting corona gland is, cannot be brought forward, is a less frequent but more annoying and dangerous complication. The tense and rather inelastic edge of the preputial orifice constitutes the cause of the constriction, which grows tighter and tighter as swelling increases. The neighboring parts, at first cedematous, soon become infiltrated with inflammatory lymph, the re- turn of blood from the glans is interfered with, and, in extreme cases, ulce- ration or even extensive sloughing of the head of the penis has occurred, and would doubtless be more frequent were it not for the extraordinary blood supply of the glans, and the anastomosis between its vessels and those of the corpora cavernosa. The line of constriction (see Plate XV. Pig. 3) is situated a short distance behind the glans, immediately back of which is a furrow due to the normal depression existing there, intensified by the sur- rounding oedema. Back of this is a swollen fold of mucous membrane, which is the part of the inner layer of the prepuce, normally in contact with the posterior face and edge of the corona. Then is found a second and very deep furrow, which is the actual seat of the trouble, and behind this another prominent collar of swollen integument. It is attended with severe, sometimes excruciating pain, which does not disappear until either the pre- puce has been replaced, or the constriction has been relieved by division or by ulceration. It is often productive of deformity from cicatricial con- traction in those cases in which surgical interference has been delayed or ineffective. These complications—balanitis, balano-posthitis, phimosis, and paraphimosis —are by far the most frequent which make their appearance during this early period of the disease, and have accordingly been described in their usual clinical order. The first stage, or that in which there is a progressive increase in the severity of the symptoms, is of variable duration, but under well- directed treatment commonly terminates in from five days to a wTeek, after which, for a short time, the condition appears to remain stationary. Symptoms and Complications of Second or Stationary Stage. The discharge is still profuse, and the ardor urinfe and chordee marked, and in some cases agonizing. Patients will complain bitterly that their com- fort during the day is interfered with by urgent calls to urinate, which they resist to the last possible moment, in a vain endeavor to avoid the pain occa- sioned by it; and that their rest at night is disturbed by frequently recurring erections, which are no less painful, and which often will not subside until some means be adopted for their reduction. During this period, which may be said to extend on an average from the seventh or eighth day to the 230 GONORRHCEA. end of the second week, the inflammation is gradually extending backward, and may give rise to other complications. Follicular and Peri-uretiiral Abscesses.—Dipping down from the urethral membrane into the little mucous follicles which empty upon its sur- face, the inflammation of gonorrhoea occludes their mouths by causing swelling of their lining membrane, and converts them into little bags or pockets of pus —-follicular abscesses—which appear as small, round, tender tumors along the under surface of the urethra. They very often open internally, but now and then adhesion to the skin takes place, pointing occurs outwardly, and they dis- charge upon the cutaneous surface. Fortunately they are not followed by urinary hstulie. If the suppurative . process involves the loose connective tissue around the urethra, a peri-urethral abscess is formed. This is most fre- quent at precisely the points which on a priori grounds would have been selected —those at which gonorrhoea is most persistent, the fossa navicularis and the anterior part of the membranous urethra. It is accompanied with localized tenderness and swelling, but on account of the easily distensible nature of the structure in which it is situated, is not very painful. It is a more dangerous complication than the folliculitis, just described, as in rare instances its spon- taneous evacuation into the urethra has permitted of extravasation of urine with all its attendant dangers. It is also much more apt to be followed by persistent fistuhe. I have now under my care several cases in which pin- point communication exists between the urethra and the external surface, in the neighborhood of the frsenum and near the peno-scrotal junction. Lymphangeitis.—In a certain proportion of cases of gonorrhoea, a simple lymphangeitis occurs as a result of absorption of purulent matter. It affects most commonly the lymphatics of the dorsum of the penis, and has been in my experience almost invariably associated with neglect of cleanliness and retention of the discharge between the prepuce and the glans. This is what might be expected on anatomical grounds from the group of lymphatics- involved, those directly connected with the urethra itself belonging to the deeper set, and running beneath the pubic arch to join the deep lymphatics of the pelvis, and to terminate in the lumbar glands. The symptoms consist in a thickened, cord-like line of induration, extending from the prepuce to the root of the penis, usually tender to the touch, easily isolated from the surrounding structures, and often traceable upon the surface by a faint red linear blush. The dorsal phlebitis which is said sometimes to occur, is described as associated with more cedematous swelling, and is said to be without the distinct line of induration separable from adjoining parts, and to be unassociated with any enlargement of the lymphatic glands of the groin, which is rarely absent when the lymphatics are involved. I have never seen a case of this character, and believe it to be an exceedingly rare complication of gonorrhoea. The lymphitis of syphilis is unassociated with tenderness, has for its point of origin the initial lesion, and is accompanied by multiple painless indurations of inguinal glands. Bubo.—Either with or without this condition as a forerunner, adenitis of one of the glands of the groin may be the result of gonorrhoea—or, in other words, we may have a gonorrhoeal bubo. The gland affected is usually one of the superficial set, lying just below Poupart’s ligament, imbedded in the sub- cutaneous cellular tissue, and above the fascia lata. A small, painful tumor makes its appearance in the groin; it is at first freely movable beneath the skin, but afterwards contracts adhesions to the latter and to the surrounding parts, becomes doughy in feel, and reddish or purplish in hue. In the SYMPTOMS AMD COMPLICATIONS OF SECOND OR STATIONARY STAGE. 231 majority of cases, after reaching this condition, it will subside under appro- priate treatment, disappearing by resolution. In others, however, particularly in individuals of scrofulous tendencies, or in those broken down by vicious habits or by overwork, suppuration ensues, the connective tissue which surrounds the gland liquefying first. Indeed, very often the glandular struc- ture itself is not involved in the suppurative action. Another group of complications may be mentioned as possible occurrences towards the end of the third week, some of them, however, often appearing much later. They are Cowperitis, Prostatitis, and Cystitis. Cowperitis.—Inflammation of one or both of Cowper’s glands, or Cowperitis, is a result of extension of the urethritis by continuity along their ducts, which empty into the posterior portion of the spongy urethra—that part incorrectly described as the “bulbous” portion. The first symptom usually developed is pain in the perineum, much increased by pressure, and rendering sitting or walking markedly painful. The inflammatory swelling of the glands is resisted by the two layers of the triangular ligament between which they are situated, and by the deep perineal fascia, and this resistance, associated with the determination of blood to the part by gravitation, imparts, as in other inflammations where the same conditions exist, a throbbing element to the pain, which renders it peculiarly distressing. The glands may often be felt as two small hard tumors, situated just back of the scrotum, one on either side of the median line; or may be recognized by pressure made in an upward and forward direction by the finger inserted just within the external sphincter. Urination is difficult if the swelling be great, and is always painful, particu- larly at its termination, as the glands are surrounded by the transverse fibres of the compressor urethrse muscle—which, contracting to expel the last drops of urine, compresses their inflamed and tender structure. Suppuration in the peri-glandular tissue sometimes occurs, in which case the usual signs of the formation of pus are present. Prostatitis.—After gonorrhoea has crept or spread backward as far as the prostatic urethra, it may, and in some cases unavoidably does, in spite of the best directed treatment, involve the prostate gland. The follicles and the glandular element of this body are primarily and chiefly affected, the muscular tissue which composes the larger portion of its mass remaining in moderate cases uninvaded. Harrison, in a paper on acute prostatitis, read at the Medical Society of London, April 11, 1881, divides this affection into two varieties, follicular prostatitis and general or parenchymatous prostatitis, the former attacking the glandular structure, but remain- ing limited to it, and attended with the symptoms above described ; the other more rare, much more serious, and developing as if the whole gland within the capsule were at once involved in the inflammatory action. Suppuration usually supervenes, and unless treatment is prompt and decisive, on the first appearance of fluctuation as revealed by rectal examination, the most serious results both as to structure and life are likely to follow. The persons in whom this variety is said by Mr. Harrison to occur most fre- quently, are those of deteriorated constitutions, or with urinary organs more or less damaged by long-standing obstructive disease. The anatomical and physiological relations of the gland (see Fig. 317) fur- nish at once a key to the symptoms produced by its inflammation, the earliest of which will probably be a feeling of weight and distension in the perineum and rectum. This is soon followed by frequent urination, due to the inability of the bladder completely to empty itself, the exit of the urine being inter- fered with by the engorged gland. The end of the act is painful, but is not 232 GONORRHCEA. accompanied with the degree of tenesmus which is noticed when the bladder itself is involved, nor with any marked discharge of pus and blood. Defe- cation also is painful, markedly so if the feces are inspissated, and the finger inserted into the rectum feels the anterior wall pushed into the centre of the bowel, hot, unnaturally firm, and tender to the touch, while through it the indefinite outlines of the greatly enlarged prostate can be felt. Fig. 317. Relations of the prostate to the neck of the bladder and the rectum. As the disease progresses the pain increases, becomes throbbing, particu- larly when the patient is erect or in the sitting posture, radiates along the cords of the hypogastric plexus to all the neighboring regions, and is very greatly aggravated by any evacuation of the bladder or rectum. The fre- quency and difficulty of micturition both increase, the latter sometimes pro- ceeding to complete retention. The disease may terminate by resolution, the most frequent way, or by suppuration. In the former event, the symptoms gradually subside, and the urethral discharge, which has been replaced during this period by the albu- minoid secretion of the prostate, reappears and is often profuse. If suppura- tion occurs, it is usually due to the coalescence of several inflamed follicles, which, lying in proximity to one another, have broken down into a common cavity. The pus is frequently discharged into the urethra, but occasionally pointing takes place in the direction of the rectum. In either event, evacua- tion gives great relief. In most cases, the prostate is left with some fibrous thickening—a hyper- plasia of its cellular tissue—which is often the groundwork for future trouble, but which should not be confounded with the hypertrophy of the same tissue SYMPTOMS AND COMPLICATIONS OF SECOND OR STATIONARY STAGE. 233 and of the muscular elements, which so frequently takes place in advanced life.1 An acute prostatitis may run into a chronic condition which is very annoy- ing and intractable. The same symptoms exist in a modified and much subdued form; the pain is replaced by a sense of weight and fulness; mic- turition is rather too frequent, and is feeble, the last drops dribbling from the meatus; a mucoid discharge like the white of raw egg, but occasionally milky, may be squeezed from the urethra by deep pressure from behind for- ward, and the same discharge appears at the meatus after every evacuation of the rectum. By examination through the latter, the gland is found to be somewhat enlarged, and slightly tender on firm pressure. As it is desirable in this as in some other cases, hereafter to be described, to ascertain the character of the discharge and also the exact locality of the inflammation which furnishes it, it may be well to have recourse to a bulbous bougie, it being remembered that in this condition the acute symptoms have subsided, and that there is but little danger of re-kindling the urethritis. The bougie, the head of which should be large enough comfortably to fill the urethra, should be passed down to the junction of the spongy and membra- nous portions, and then withdrawn. If it bring with it, as it probably will, some muco-pus from the anterior part of the urethra, this should be wiped ofi, and the instrument again inserted as far as the neck of the bladder. On removing it, a quantity of the prostatic secretion will usually be found upon the shoulder of the bulb. Pain is generally excited by the contact with the instrument, and the degree of sensitiveness will furnish a valuable indication for treatment, and should be carefully observed. The mental symptoms associated with this trouble are often the most dis- tressing. They will be alluded to again when we come to consider the sequelae of gonorrhoea. Cystitis.—A greater or less involvement of the neck of the bladder is often :a concomitant of acute prostatitis, and is indicated by increased urinary trouble and by the appearance of a drop or two of blood at the end of micturi- tion. This prostato-cystitis, which is the form of bladder trouble usually ■encountered in gonorrhoea, may subside under treatment, or may pass into a well-developed inflammation of the mucous membrane of the vesical neck. In this case (Gonorrhoeal Cystitis), we have certain well-marked symptoms, chief among which are very frequent urination, the patient not being able to retain liis water for more than a few moments, and the ■desire to expel it becoming intense and irresistible on the slightest delay ; •excessive vesical tenesmus at the end of the act, which is characterized by severe burning pain instead of a sense of relief; blood and pus following the stream of urine, the latter part of which is turbid or milky. There are few constitutional symptoms, little or no fever, no rigors, and but slight deterioration of the general health unless the disease runs a protracted course. The diagnosis between prostatitis and cystitis, which are the only complica- tions of gonorrhoea likely to be confounded, may be made by attention to the following points:— 1 “Zeissl believes that in every case of chronic gonorrhoea there is moderate tumefaction of the prostate. Individuals who have very frequently had gonorrhoea, or in whom gonorrhoea has persisted for a long period, are said to be the subjects of a considerable enlargement of the pros- tate in their thirty-fifth year or even younger, the growth being due to the persistent liypersemia of the part during the prolonged urethritis.” Among 2041 cases of gonorrhoea admitted into the Antiquaille Hospital of Lyons, under the care of Dron, prostatitis occurred only three times. .{Hill and Cooper, op. cit., p. 530.) This is certainly an unusually small number, and in all probability must have been due to a failure to recognize the disease, or to its classification under ■.some other name. 234 GONORRIKEA. Prostatitis. Cystitis. Not as frequent a complication of gon- orrhoea as a mild form of cystitis. Perineal and rectal pain. Pain violent and throbbing, aggravated during defecation. Pain not markedly severe at the end of urination. Tenesmus not always present. Stream of urine diminished in size. Retention of urine common. Urine not much changed in appearance. Rectal examination shows enlargement and great tenderness of the prostate. Occurs in its lower grades in perhaps one-fourth of all cases of gonorrhoea. Possibly a little tenderness of perineum on pressure, but no rectal pain. Pain burning, not especially affected by defecation. Much pain in passing the last drops of urine. Tenesmus constant and severe; very characteristic. Size of stream not always affected. Retention of urine rare. Urine turbid and ropy, last drops mixed with blood. No prostatic enlargement or tenderness recognizable by rectal examination. Two conditions are said by Mr. Reginald Harrison closely to simulate acute prostatitis, the first being inflammation and suppuration around the membranous portion of the urethra as a consequence of urethritis; and the second, inflammation and plugging of the veins constituting the prostatic plexus. The diagnosis between the former condition and prostatitis should he made chiefly by the situation of the swelling, which here will be peri- neal, while in inflammation of the prostate it is difficult to imagine how the tumefaction can invade the region of the perineum. It certainly does not become apparent there when the prostate is hypertrophied in old age. When suppuration occurs, the pus may be discharged by a perineal opening, wdien it arises from a peri-urethritis; it never is so in prostatitis.1 The other disordered condition is said to be rare. Mr. Harrison, who has only seen two cases of it, describes the primary lesion as oedema of the pre- puce dependent upon plugging of the dorsal vein of the penis. In both cases a feeling of perineal weight, frequent micturition, and uneasiness referred to the neck of the bladder, come on in a few days. Rectal examination is said to have determined that these symptoms were not due to any inflamma- tion of the gland, but to the extension of the vein-blocking to the prostatic plexus. I have never seen such cases, and do not believe that digital examination per rectum.will disclose with any definiteness the condition of the veins said to be involved. On the other hand, a follicular prostatitis not extending to any depth from the urethra, will often give rise to no general tumefaction of the gland, and to little or no tenderness on rectal pressure, while at the same time it would produce all the above-mentioned symptoms. Probably autop- sies alone can determine the existence or non-existence of this alleged pro- static phlebitis. These complications belong in the majority of cases to the latter part of the stationary period of gonorrhoea, which extends over from one to two 1 The points of similarity between the two conditions are very marked : “In both there is a cessation or alteration in the character of the urethral discharge ; in both there is a feeling of weight and uneasiness about the perineum ; in both there is some difficulty in micturition, per- haps amounting to retention ; and in both there is some tumefaction to be felt, and much distress, is occasioned on introducing the finger into the rectum. So painful is the latter to the patient that it often leads to an imperfect examination being made, and hence an error of diagnosis- arises in exactly fixing the position of the tumefaction, which might have been avoided. ’ ’ (Medical Times and Gazette, July 2, 1881.) SYMPTOMS AND COMPLICATIONS OF THIRD STAGE. 235 weeks, rarely longer, and during which the acute symptoms of the first stage, the ardor urinse, chordee, etc., remain, as has been said, nearly or quite unaltered. . At the termination of this stage that of subsidence begins, and in uncom- plicated cases progresses rapidly until complete recovery has taken place. Symptoms and Complications of Third Stage, or that of Subsidence. Urination becomes painless and less frequent; the discharge grows thinner, becomes watery and scanty, or dries up altogether; erections no longer occur with abnormal frequency, and do not give rise to curvation of the penis or to pain. If any of the complications which have been described has existed, the last vestiges of it fade away, and perfect health is restored. But until this stage is actually completed, as long as any of the symptoms of urethritis are still evident, there are yet certain dangers to be avoided,, and serious difficulties which may present themselves. Epididymitis.—Chief among these, in respect to frequency of occurrence, is epididymitis, or swelled testicle, which is a complication usually super- vening in the fifth or sixth week of the disease, sometimes coming much earlier, and rarely as late as the end of the second month, or even in the third month. In the great majority of instances it is obviously the result of the extension of the urethral inflammation along the ejaculatory ducts and spermatic canal to the epididymis itself.1 In others this connection between the original inflammation and the epididymitis is not apparent, and various theories have been adduced to explain the phenomenon.2 The sympathy existing between the various portions of the genito-urinary system, metas- tasis, reflex nervous agency, and other hypotheses, are all unsatisfactory, and, as it seems to me, unnecessary. The absence of conclusive post-mortem or clinical proof that the vas deferens is the medium of transmission in almost every case is readily understood when we remember, on the one hand, that the deaths which occur during this stage are from intercurrent diseases, and are very rare, and, on the other hand, that it is not at all uncommon for inflammation to travel rapidly, leaving behind it no foot-prints, over extensive mucous surfaces.3 If the disease were metastatic in its origin, or the result of “sympathy” or of reflex irritation, it is difficult to see why it should stop at the epididy- mis, which is an excretory duct and a comparatively unessential part of the testicle, and should spare the secretory portion of that gland. The early symptoms usually indicate more or less clearly the course of the disease, and, indeed, the clinical evidence, and the period at which the affection develops 1 M. Terrillon asserts (Le Progres Medical, Jan. 29, 1881) tliat in swelled testicle the inflamma- tion is principally in the cellular tissue around the epididymis, rather than in that organ itself. 2 Dr. Otis, in a clinical lecture on epididymitis (Boston Medical and Surgical Journal, Nov. 28, 1878), after calling attention to its association with strictures of large calibre, adds : “ Such strictures are capable of producing recurring epididymitis of every grade, from that which causes slight swelling and tenderness to the most acute form of the trouble. My own observa- tion leads me to believe that the ligliter forms of trouble, such as chronic sensitiveness and occasional slight swelling, also various grades of hydrocele, are the result of reflex irritation transmitted from a point of stricture, and that the attacks of acute epididymitis are due to the extension of the inflammation—the urethritis associated with stricture—along the track of the vas deferens, as in epididymitis accompanying ordinary gonorrhoea.” 3 In 1871, MM. Grombault and Terrillon made an autopsy in the case of a young man, aged 19, who died of an intercurrent disease during an attack of gonorrhoea. They found the vas defe- rens, in its entire extent, filled with the products of catarrhal inflammation, red, swollen, and injected ; no epididymitis had yet developed. 236 GONORRHOEA. in the great majority of eases, when taken in conjunction with the evidence ■obtained by experiment, are quite sufficient to explain the production of the epididymitis in the manner indicated. The first symptom which attracts the attention of the patient is an aching, occasionally a neuralgic pain, along the line of the groin, more frequently on the left side.1 It the cord be taken between the thumb and finger at this time and rolled gently so as to separate its constituents, the vas deferens will be found enlarged usually to but a slight degree, but sometimes to three or four times its normal diameter; it will also be tender on pressure.2 Sometimes, but rarely, it will be insensitive, and in this event, in many cases, the inguinal pain will prove to be simply neuralgic in its character, and no further trouble will result, If the inflammation progresses, however, and the epididymis is involved, this preliminary pain is soon followed by a feeling of weight and a dull ache in the aflected testicle, which begins to increase in size and rapidly becomes of great bulk, purplish in color, and exceedingly painful.3 (See Plate XYI. Fig. 1.) The nauseating quality possessed by this pain is peculiar to it, and serves greatly to aggravate its unpleasantness. The patient, particularly if the testicle be not supported so that its weight is withdrawn from the cord, will walk in a slightly stooping posture, with the legs apart—a straddling, constrained attitude which is almost pathogno- monic of this ailment. The dragging of the heavy tumor upon the spermatic vessels prevents the free return of blood from the testicle and serves to in- crease the tension, and by additional pressure upon the nerves to add to the pain, which in some instances spreads by reflex agency to the loins, abdomen, 1 Jullien has collected 2158 cases of epididymitis, of which 1011 were on the right side, 982 on the left, and 165 double. (Maladies Veneriennes, p. 104.) “ Of 1342 cases observed by Sig- mund, of Vienna, the left testicle was affected in two-thirds.” (Bumstead and Taylor, Treatise •on Venereal Diseases, p. 133.) 2 M. Terrillon (Bull, de la Soc. de Chirurgie, 1881, No. 2) details four different degrees of in- flammation of the vas deferens observed when the disease is experimentally excited : (1) Mucous membrane alone attacked ; (2) More frequently muscular walls also involved ; (3) Cellular tissue of spermatic cord affected ; (4) General connective tissue and scrotum inflamed. He thinks that the sole theory of epididymitis which is at all tenable is that which ascribes it to propagation of the inflammation along the ejaculatory ducts and the vas deferens. 3 In exceptional cases, a patient with gonorrhoea having a complete inguinal hernia, or having .accidentally received a blow on the scrotum, may develop a painful tumor of the scrotum, about 4he diagnosis of which some difficulty will exist. The following table of Mr. Christopher Heath very well represents the differences between the gonorrhoeal complication and the other diseases for which it may be mistaken :— Strangulated Hernia. produced, or, if pres- ent before, suddenly strangu- lated ; Pain in groin and about abdo- men, with considerable con- stitutional depression and anxiety of face; Tumor tense, and giving the sensation of intestine when manipulated ; skin normal; Impulse on coughing to be felt along the groin, in which there is more fulness than usual, but ceases abruptly at the point of strangulation ; Percussion over tumor gives a clear sound unless the pro- trusion is omental; Vomiting probably present, continuous, and eventually stercoraceous. Hematocele. Suddenly produced by some external violence; Pain in scrotum and consti- tutional disturbance, slight after the first few minutes ; Tumor tense and heavy, globu- lar in shape, and not trans- lucent ; skin often bruised ; No impulse in groin, which is perfectly normal. Percussion gives a dull note ; Vomiting immediately follow- ing the accident, but not continued. Orchitis or Epididymitis. Developed a few hours after a blow or following gonorrhoea; Pain in scrotum and along the cord to the loins ; feverish disturbance of system ; Tumor excessively tender to the touch ; cord thickened ; skin reddened ; No impulse on coughing ; Percussion gives a dull note ; Nausea and faintness, but sel- dom vomiting. PLATE XVI !. C9j^1 nltd111nilij . 2J3. (|c»1u?iilie)ml Ctuijmu‘liiT.lu». ( vv - a’ aoi i n Chancroid seen 1st day after coitus in 5 cases. «i u 2d “ “ “ 4 “ a a 34 a a a 2 “ a a a a “ 5 “ a a 5th « « « 6 “ “ “ 6th “ “ “ 4 “ it it ii a a 12 “ ii a gtll « « “ 9 “ “ “ 9th “ “ “ 5 “ “ “ 10th “ “ “ 10 “ “ “ 11th “ “ “ • 1 case. “ “ 12th “ “ “ • 2 cases “ “ 14th “ “ “ • 8 “ u n lgth l< (« « • • 2 “ No positive data could be obtained in • • • • • 20 “ Total • • • • • • 95 “ Table XIV. (Debauge, op. cit., p. 21.) The chancroid seen in less than 24 hours in • • • 6 cases. “ “ “ “ two days in • • 5 “ “ “ “ “ three “ • 10 “ “ “ “ “ four “ • 5 “ ff ft U ff fiyg ff • 5 “ i t ii ii ii six • 3 “ «( << u “ seven “ • • 1 case. «« (< “ “ eight “ • 24 cases. “ «< «< if ten fi • 2 “ tf if “ “ twelve “ • 11 “ if it it f« fifteen “ • • 7 “ “ “ “ “ seventeen “ • • 1 case. “ “ “ “ three weeks in • 1 “ Total • 81 cases ResumL Total number recorded 429 cases.. Of these, positive dates are given in ....... 381 U Data are uncertain in .......... 48 u Of these 381 positive cases, the chancroid was seen within 8 days after coitus in 310 u After that time in 71 it Of the 310 cases seen within 8 days after coitus, the chancroid appeared within 3 days after infection in 111 u. Or, expressed in percentages, the chancroid appeared within 8 days after coitus in 81.3 per cent, of the cases in which the data are positive. 318 THE SIMPLE VENEREAL ULCER OR CHANCROID. Varieties of the Simple Venereal Ulcer. According to the appearances which the chancroid presents during the different stages of its progress, it has received a variety of names, to wit: the follicular, the herpetiform, the ectliymatous, the ulcus elevatum, and the exulcerous. This multiplicity of names is to be regretted, as liable to pro- duce confusion, and to obscure the fact that the lesions to which they are applied are accidents in the course of the disease, rather than well-defined varieties of the ulcer. Thus, when the matter of a chancroid is deposited within a follicle, its first appearance is as a small nodule surmounted by a slight depression, with a grayish floor. This nodule is due to the distended follicle, and the depressed apex corresponds to the mouth of the duct of the follicle. It should be borne in mind that the small ulcer does not represent the real extent of the chan- croid, inasmuch as the destructive action has been advancing more rapidly in the interior of the follicle than appears externally, and that hence these fol- licular chancroids should be laid open prior to cauterization, so as to allow of a thorough destruction of the ulcer. The herpetiform chancroid is simply one which is seen very early in its course, before the contents of the vesicle have become purulent, and is apt to lead to error by causing the chancroid to be mistaken for a simple attack of herpes. Its subsequent course differs in no respect from that of an ordinary chancroid. The ectliymatous chancroid is simply one which has been covered with a crust by the drying of the secretion from exposure to the air. Removal of the crust reveals all the usual characteristics of the ulcer. The ulcus elevatum has been a source of much confusion, owing to its simu- lating the initial lesion of syphilis. It is due to causes which have already been discussed in a previous portion of this article. This ulcer is usually attended with marked inflammation and exudation about the base, which cause an elevation of the tissue upon the apex of which the ulceration is seated; hence the name. As the inflammation subsides the elevation becomes flattened, and the ulcer in its subsequent course exhibits all the characteristics of the chancroid. The exulcerous chancroid is a superficial chancroid, in which from the feeble- ness of the inflammation the destructive action is very slight, the edges are hardly undermined, and the secretion is scanty instead of being abundant. Indeed, to all intents and purposes this ulceration is a chancroid which is incapable of extension, and which resembles in many respects an acute erosion of balanitis. It is hardly deserving of the separate classification accorded it by M. Clerc. Locality of the Simple Venereal Ulcer. Until within a few years it was believed that certain regions of the body were exempt from being the seat of the simple venereal ulcer. Indeed, Ricord, as lately as in 1860, taught the following doctrine: “Up to the present there is no well-authenticated case of a soft chancre [that is, a chancroid] developed upon the face, or, to put it in more general terms, of a cephalic soft chancre.”1 Later experience, however, proves that cephalic chancroids do occur in suf- ficient number to demonstrate their existence, and to permit us to take exception to Ricord’s formulated teaching given above. 1 Lefons sur le Chancre, p. 18. PLATE XVII C jlttlUUtHtl.). 319 LOCALITY OF SIMPLE VENEREAL ULCER. But before taking up this question of cephalic chancroid, let us see upon what portions of the body the simple chancre is most likely to occur. Upon turning to the tables bearing upon this point, we observe that out of a total number of 1271 cases in the male, 1194 occur upon the genitals, and of these, 826 are recorded as occurring upon the glans penis, upon the prepuce, upon the fossa glandis, and upon the sheath of the penis; 24 at the meatus urina- xius; 9 within the urethra ; 9 upon the scrotum ; 3 about the anus ; 3 on the finger; 5 upon the leg; 1 on the anterior thoracic region ; and 1 on the nates. In the female we have the following record: the external genitals were the ;seat of the simple venereal ulcer in 185 cases; the meatus urinarius and its vicinity, and the urethra, in 26 cases ; the vagina in 68 cases. The lesion was situated at the margin of the anus in 33 cases; at the inter-crural angle in 5 cases; on the perineum in 7 cases; on the inner aspect of the thighs and upon the hypogastrium in 7 cases; on the cervix uteri alone in 1 case, and on the fourchette and cervix uteri together in 58 cases. Expressed in percentage, the extra-genital chancroids are only 6.05 per cent, of the total number of •chancroids recorded, while of these none are cephalic (that is, occurring upon the head and face). Localities of Simple Venereal Ulcer and of Initial Lesion of Syphilis. Table XV. (Ricord, op. cit., p. 364.) Indurated chancre. Simple chancre. Patients affected with chancres of the glans and prepuce . . 314 296 it a a “ of the fossa glandis . . 60 15 16 u a multiple chancres of the penis, that is, seated upon the prepuce and the fossa, the fossa and the glans, etc. . . . . . .11 17 a it a multiple chancres of the meatus urinarius . 32 9 u it a intra-urethral chancre .... . 17 3 a a a chancres of the scrotum . 7 0 a a u “ of the peno-scrotal angle . . 4 0 a a a “ of the anus .... . 6 2 a a “ of the lips .... . 12 0 a a a “ of the tongue .... . 3 0 it a a “ of the nose .... . 1 0 it u a “ of the nasal mucous membrane . 1 0 a a a “ of the eyelid .... . 1 0 a u a “ of the fingers . . 1 1 a it a “ of the leg .... . 1 471 0 343 Table XVI. (Fournier, op. cit., p. 72.) Simple chancres. Chancres of the glans and prepuce .... tt 1t fossa glandis . 21 tt tt penis, that is, occupying at the same time the furrow, or the furrow and the glans prepuce and the . 24 tt tt penis, no more precise designation . . 25 tt u meatus urinarius .... . 11 u a urethra ...... . 5 a u scrotum ...... . 3 tt tt pubes ...... . 3 tt tt internal and upper aspect of the thighs . 2 tt tt anus ...... it a fingers ...... a it anterior thoracic region . . 1 445 320 THE SIMPLE VENEREAL ULCER OR CHANCROID- Table XVII. (Debauge, op. cit., pp. 62-63.) Simple chancres Chancres of the fourchette, or of the fossa navicularis . . . . 78 ll ll “ or of the labi majora .... . 19 n “ “ “ minora .... . 16 n ll meatus urinarius (19 of these invaded the urethra) . 1 n ll vicinity of the meatus ...... . 2 n ll vestibule ......... . 4 n ll clitoris ......... ll n introitus vaginae st outside of the carunculae myrtiformes, be- tween these and the labia minora . 17 n ll vagina posterior to carunculae ..... . 7 it It cervix uteri ........ n ll margin of anus n ll intercrural angle ....... it It perineum ........ ll ll internal aspect of thighs ll ll hypogastrium ........ 206. Table XVIII. (Males.) (Sturgis, Records of Third Venereal Division, Charity Hospital, Blackwell’s Island, New York, 1879-80.) Simple chancres. Chancres of the prepuce ...... “ “ “ and glans penis . “ “ penis (so stated in records) • . • . . 5 “ “ meatus ...... “ “ sheath of penis .... “ “ glans penis only .... “ “ frsenum ...... “ “ neighborhood of the meatus • # • . 2 “ “ meatus extending into the urethra . . • • . . 1 “ “ inner aspect of thigh • • # . 5 “ “ nates “ “ scrotum 96 Table XIX. (Females.) (Sturgis, Records of Third Venereal Division Charity Hospital, Blackwell’s Island, New York, 1879-80.) Chancres of the labia majora ..... Simple chancrea. . 22 “ “ “ minora ..... . 17 “ “ vulva, so stated in records . . 5 “ “ anus . . 8 “ “ neighborhood of the meatus . . . 1 “ “ vagina inside of ostium vaginae . • • • . . 9 “ “ vagina outside of ostium vaginae • • • . 7 “ “ perineum ..... • • • . . 2 “ “ fourchette ..... . . 12 83 Table XX. (Sims Perondi, quoted by and taken from Debauge, op. cit., p. 63.) Simple chancres. Chancres of the fourchette and cervix uteri # . 58 U a “ alone . 8 u n meatus urinarius . , • . . 2 it u anus ..... it a vagina ..... 98 LOCALITY OF SIMPLE VENEREAL ULCER. 321 (1) Total number of chancroids recorded . 1271 “ “ seated on genitals ....... “ “ extra-genital ........ . 77 Of these latter none were found upon the head and face. (2) Total number of initial lesions recorded . 471 “ “ seated on genitals ....... . 434 “ “ extra-genital ........ . 37 Percentage of genital chancroids to total number .93.95 “ extra-genital chancroids to total number .... . 6.05 “ cephalic chancroids to extra-genital ..... . 0.00 “ genital initial lesions to total number .... . 92.20 j “ extra-genital initial lesions to total number . 7.80 “ cephalic initial lesions to extra-genital .... .54. Resume. On turning to the initial lesions, although we find the percentage of the extra-genital" ulcers to be only slightly in excess of that of the chancroids (7.8 per cent, as compared with 6.05 per cent.), the percentage of cephalic to extra-genital lesions is very large, 54 per cent. Still, although I have been unable in my statistics to come across any cases of cephalic chancroid, it would be unwise to conclude that they never occur, as several such have been reported. I do not here mean to include cases in which artificial inocu- lation of chancroidal matter has been successfully performed in the cephalic region; the only examples which I shall now consider are those which have been observed clinically. The first positive case of the kind which I know of, is one given by Ricord,1 with a plate, the history of which is a curious commentary upon the quota- tion on page 424, taken from his “ Lemons.” It is quite short, and I give it here in full:— “ Primary and non-indurated ulceration of the upper gum. Here is a virulent and primary ulcer of the gum, contracted by the application of the mouth to the genital organs of a woman affected with chancre. “ It is the only example that we have met with, which proves that chancres of the gums are much more rare than virulent ulcerations of the lips and of the tongue, which we have had occasion to observe several times. “ This ulceration, of which the duration has not been very long, followed the ordi- nary course of the non-indurated chancre. It healed up under the influence of fre- quently repeated cauterizations with the nitrate of silver and of lotions of aromatic wine- “ Our object in calling attention to this case is to prove that the virulent, inoeulable syphilitic pus has not, as its seat of predilection, any particular organ, but that it acts always at first locally, wherever it meets with the conditions favorable for its develop- ment. Moreover, the fact that in this patient there has been no constitutional infec- tion, as we were able to determine long after the period at which it ought to have developed itself, proves that the gravity of syphilis does not depend, as has been said, upon the seat of the primary lesion.” It should be remembered that, at this period of Ricord’s teaching, he had not yet distinguished between the chancroid and the initial lesion of syphilis, and that hence, in speaking of this lqsion being syphilitic, he was in error, as he subsequently acknowledged. Although no auto-inoculation was prac- tised, the history of the case and the appearance of the lesion in the plate leave no reasonable ground for doubting that the case was one of chancroid of the gum. Still, Ricord is unwilling to admit that it was such a lesion, for he says, on the fifteenth page of his “Lemons sur le Chancre” (Paris, 1860):— “ These chancres (cephalic) always belong, and I might say inevitably, to but one spe- cies, the indurated. They are always accompanied by the symptoms of constitutional 1 Clinique Iconographique, etc., pi. 21. 322 THE SIMPLE VENEREAL ULCER OR CHANCROID. syphilis. Not one of them is exempt from induration, not one of them is confined to a local lesion without reaction upon the entire system, nor without phenomena of general infection. I shall not speak here of a case which I have published elsewhere. This case, which relates to a non-indurated chancre of the gum, would appear as a most con- clusive exception, were it not for the fact that I have become more exacting in drawing conclusions than I was when 1 published the case. I repeat, that this case referred to a non-indurated chancre of the gum, which was not followed at the proper time by constitutional symptoms, and this chancre was derived from a woman wdio also had a chancre ; but 1 ought to add that I did not see the woman, and that a knowledge of her disease was derived from the patient. I should also state that no artificial auto-inocu- lation was performed, hence the correctness of the diagnosis and the value of the case may very properly be doubted.”1 Fournier2 gives the following case from Puche:— A young man applied to Puche on the 17th of November, 1861, wTith an ulcer of the lower lip near the median line, which was chancrous in appearance, and had lasted three or four days. This ulcer came eight days after a connection, “ the nature of which,” as Puche says, “ the patient did not attempt to deny.” There was a slight adenitis of the submental gland. The patient was taken to Cullerier for an opinion, which was “ indurated chancre.” Puche, dissatisfied apparently with this diagnosis, practised auto-inoculation with the secretion of the ulcer on the man’s abdomen. While the inoculation was being made, the patient, attempting to restrain the surgeon’s hand, pricked himself on the finger with the instrument. The result in both places was posi- tive in a few days. Local treatment was now instituted, and all three ulcers healed without induration, and the patient passed from observation on the 31st of December, 1861, without any constitutional symptoms of syphilis. The history of this case it would be hard to controvert, and unless we are prepared to entirely abandon the value of auto-inoculation in diagnosis, we must be willing to admit that this was an undoubted case of chancroid of the lip. I know that the experiments that have been made with simple pus would seem to rob this case of many of its distinctive features in a diagnostic point of view, but when we consider that these ulcers have been artificially inoculated upon the face by many trustworthy observers, it would, I think, be a refine- ment of criticism to deny that this case was one of true chancroid of the lip. Diday3 gives two separate cases of what he calls “ chancrelles de la bouche,” and MM. Boys de Loury and Costilles4 give two more cases, one of the eyelid and one of the ear, but these cases are so imperfect as to be worthless, and I shall make no further mention of them. Millet, in his thesis, gives a curious though somewhat imperfect account of a man who on the 12th of July, 1865, went bathing in a forbidden locality, was chased by the police, and was in the water for two hours. When he came out he was very much exhausted and had violent lumbar pains. On the 13th, he went to the Hopital St. Antoine, where he was confined to bed for fourteen days, during which time he saw no outside friend but his mis- tress. On the 28th, the day after leaving the hospital, he noticed a smarting of the lower lip, on the skin and mucous membrane of which were some small yellow pimples. The next day these pimples were covered over with a crust. Thinking he had some venereal affection, although he declared that his mistress was perfectly healthy, he went to the Hopital du Midi on the first day of August. 1 Ricord, in his “Traite pratique des Maladies VSneriennes,” published in 1838, gave in his tables of inoculations seven cases of primary syphilis on the lips, and three in the throat, all of which produced the characteristic pustule of inoculation, as among the cases which occurred in his wards in 1831 and 1837. As no details are given, the cases are worthless in a scientific point of view. 2 Nouveau Dictionnaire de MSdecine et de Chirurgie Pratiques. Art. Chancre. 3 L’Union Medicate, 1858 ; and Annales de Dermatologie et Sypliiligrapliie, 1872, No. 2. 4 Gazette M6dicale de Paris, 1845, 1847. LOCALITY OF SIMPLE VENEREAL ULCER. 323 On liis entrance the following condition of things was observed. Smarting of the lower lip which was found swollen, patulous, and devoid of induration. The mucous membrane was deep red in color, and glistening. On the mucous surface of the lower lip, near the gingivo-labial fold, was a chancrous-looking ulceration, and on the cuta- neous surface covered by the beard, were two small ulcers covered with crusts. His teeth were good, but dirty and uncared for. (He was a great smoker.) The mouth and pharynx were sound. A submaxillary lymphatic gland, in the median line, was enlarged to the size of a pigeon’s egg, and painful on pressure. Abundant salivation was present, but the breath was not fetid. There was no pain in the lip except on mastication. The last coitus, according to his statement, had taken place on the 10th of July. On the 2d of August, inoculation was made with matter taken from the ulcer on the inside of the lip, and this inoculation was positive in result. The resulting sore lasted for fifteen days, and disappeared without treatment, while the ulcers of the lip healed under the local use of chlorate of potassium. The submaxillary ganglion did not suppurate. Millet himself seems to doubt whether this lesion was really a chancroid, and he says that its value is impaired by two circumstances: the first is that he did not have permission to examine or even question the man’s mistress ; and the second, that the pus of ulcerative stomatitis has been proved auto- inoculable in several instances by M. Bergeron, of the Hopital Sainte Eu- genie.1 The next case'is one reported by Labartlie.2 It occurred in a man who applied for treatment on the 4th of December, 1870, with three chancroids of the penis and a right inguinal adenitis attended with fluctuation. The bubo was opened on the same day, and local treatment was pursued for both sets of lesions. On the 8th of December, the patient called the doctor’s attention to his lower lip, which pained him. There, at a point midway between the median line and the left commissure, was a longitudinal ulceration which had the appearance of a deep fissure. The edges, however, were punched out and a little undermined; the floor was grayish in appearance, and furnished a purulent secretion. Upon questioning the man, it appeared that he was in the habit of placing the pin which confined the dressing of his bubo between his lips. Labartlie believed that he had to do with a chancroid of the lip, but to make assurance double-sure, he inoculated the matter from the ulcer on the man’s lip, above his abdomen, and in four days the result was positive. The next cases are those of Profeta, of Palermo, which are translated from the Italian in the fifth volume of the Annales de Dermatologic et de Syphili- graphie. The first case was that of an Italian musician, whose chancroid, of two years’ dura- tion, began at the right commissure of the lips, and extended over the cheek and fore- head. It was phagedaenic in nature, and was seated upon an engorged but not indurated base; it secreted an abundant purulent matter; its edges were livid and undermined; in short, it presented all the aspects of a phagedaenic chancroid. No evidences of con- stitutional syphilis were present, but the patient had a vesiculo-pustular eruption due to the presence of the acarus scabiei. Auto-inoculation was practised with the pus of this ulcer, with a positive result. The second case was one of a barber who had multiple chancroids of the penis, writh a suppurating bubo. Attempting to open this bubo with a razor, he cut his finger, soil- ing the wound with pus and blood from the bubo. He then promptly put his finger in his mouth to stanch the bleeding, and the following condition of things ensued. He had a chancroid of the index finger of the left hand, with lymphatic engorgement of the arm of the same side; besides this, he had two chancroidal ulcerations of the upper and lower lips, which invaded both the skin and mucous tissues of these parts. He appa- rently declined treatment, but Profeta saw him from time to time for a year, and states that his face was peppered (parseme) with chancroids. 1 De la Stomatite ulcereuse. Paris, 1860. 2 Le Chancre simple, These, p. 53. 324 THE SIMPLE VENEREAL ULCER OR CHANCROID. The third case was one of pliagedsenic chancroid of the penis, this latter being almost entirely destroyed by the ulceration. There were also a chancroid of the scrotum, and an ulceration seated upon the right ala nasi which bore all the characteristics of a chan- croid. This latter chancroid inoculated the tissues about the nose, and finally became phagedsenic and produced great destruction of those parts. Although this ulcer im- proved under treatment, the patient disappeared from Profeta’s sight before cicatriza- tion was complete. Iii this third case, auto-inoculation was not resorted to, and hence doubt might arise whether this were not an ulcerating serpiginous syphilide of the face and of the body, although no history of syphilis is given; but with the first, two cases, I think no reasonable doubt can exist, if we concede the ex- istence of such a thing as a chancroid. Profeta’s fourth case is reported in the Gazette Medicale de Lyon, for 1867, and was a serpiginous chancroid of two years’ duration, which was seated upon the face. Profeta inoculated himself with the pus of the chancroid in live places, producing five chancroids which were not, in the space of eighteen months, followed by constitutional syphilis. I)r. R. W. Taylor,1 of New York, reports a case which occurred in his own practice at the New York Dispensary. A man with chancroids of the prepuce inoculated himself over the outer margin of the left supra-orbital ridge with the pus from his chancroids, producing an ulceration which had all the appearances of a chancroid. Matter from this supra-orbital ulcer was inoculated upon the man’s abdomen, care being taken to prevent contamination with the matter from the chancroids of the penis, and in four days afterwards a positive result was obtained. Apart from these cases of accidental inoculation, artificial inoculations have been resorted to by Bassereau, Puche, Rollet, Ilubbenet, and others, which conclusively prove the possibility of inoculating chancroidal pus upon the face. It has been stated that one peculiarity of cephalic chancroids is that they are short-lived, but upon reviewing the cases on record this point is not to my mind satisfactory proved. Enough cases have been reported to show that the cephalic region is not exempt from being the possible seat of a chan- croid. Such ulcerations are, it is true, not common in this region, and hence we may lay down the general law that ulcerations of this portion of the body should be regarded with suspicion, and should be considered as syphilitic, unless the contrary can be distinctly proved. Origin of the Simple Venereal Ulcer. As already stated, Clerc, in 1854, considered that the chancroid was the result of inoculation of the matter of an indurated chancre upon a person who either was suffering or had suffered from constitutional syphilis. ISince Clerc’s time, however, this doctrine has fallen somewhat into discredit, and until within a short period it has generally been believed that the chancroid and the chancre were produced by two distinct kinds of virus, and that it was not possible to produce a chancroid by any other means than by contact of a chancroid or a chancroidal bubo. Here is another instance of the error produced by this word “ virus,” a term which I trust will be expunged in time from the vene- real vocabulary. We have already seen that it is possible to produce a sore corresponding in many points with a chancroid from the inoculation of simple pus, and if these experiments be trustworthy, then it is the pus-cor- puscle which is the cause of the ulcer (chancroid), and not any supposititious 1 Archives of Practical Medicine, 1873. ORIGIN OF THE SIMPLE VENEREAL ULCER. 325 virus. Let us see if the same thing can be done with the secretion of syphi- lis, and under what conditions success is obtained. In 1854, M. Maratray (de Severs) published a case1 which is very interest- ing and instructive. “ During September, 1852, one of my friends, who was syphilitic at the time, con- sulted me as to the nature of an ulceration situated upon the fraenum, dependent, so he said, upon a coitus dating twelve days hack. At a glance I recognized a specific ulce- ration with a tendency to become phagedenic. He informed me that another young man who upon the same day had had connection with the same woman, was suffering with a less painful and less extensive ulceration. Upon examination of this young man, I recognized upon him an indurated chancre accompanied with a perfectly well charac- terized inguinal adenitis, one of the most certain signs of constitutional infection. I asked if it were possible to see the presumed cause of the trouble. Frightened by the word “pox” she consented to an examination. My attention was attracted at first to the fourchette, the seat by predilection of chancres in the woman, and this the more on account of the strange coincidence of the ulcer of the fraenum in the man. I at once discovered a specific ulceration in process of repair ; palpation showed a hard, carti- laginous, elastic nodule, which by compression blanched the neighboring tissues.' All the characteristics of the indurated chancre were present; there was no possibility of mistake ; the inguinal ganglia, although somewhat difficult to recognize, were yet per- ceptible by comparison with those of the unaffected side. In spite of great care, fur- ther research failed to reveal in any portion of this woman’s genitals, whether in the vagina or the neck of the uterus, any reason for the existence of the phagedaenic chan- cre. As the good hygienic conditions under which the first patient was placed com- pensated somewhat for the debilitating influence of the syphilis, a local dressing of aro- matic wine led to a pretty prompt cure. As to the two indurated chancres, as already stated, cicatrization had commenced, and went on to completion. I learnt subsequently that secondary symptoms appeared in the man and in the woman notwithstanding a mercurial treatment of some duration.” This case was followed, in 1856, by the two following, mentioned by Ricord and quoted by Fournier.2 Case I—One of my old patients, whom I had treated several months during my ser- vice in 1843 for an indurated chancre, followed by constitutional manifestations—rose- ola, mucous patches of the mouth, posterior cervical adenitis, alopecia, etc had con- nection with a woman of the town during May, 1856. It was at least two months before this time since the patient had seen another woman. Some days after this con- nection, two chancres appeared upon the prepuce, one upon the cutaneous, the other upon the mucous, surface. The patient at first pursued no treatment. When I exam- ined him, the chancres were of ten days’ duration, the size of a ten-cent piece, without any induration of the base—indeed, they were quite supple and exempt from inflam- mation. The glands of the left groin were slightly swollen and painful. The diagnosis was beyond question. I had to deal with simple chancres, at least as far as their external characters were concerned. They healed up, without complications, under simple dressings of aromatic wine. The adenitis rapidly disappeared. No internal treatment was used, but the patient, kept under careful observation, has not presented any new symptom of syphilis. While this patient was being treated at the Midi, my interne looked up and found the woman who was pointed out as the source of the man’s disease. What do you suppose was found ? A typical indurated chancre of the labium majus, with an enormous ehondroid induration. This chancre, according to the patient, had existed for several weeks. It was accompanied by a well-marked adenitis, and was followed by subsequent constitutional manifestations. Case II L., a girl seventeen years of age, was infected in June, 1856, with an indurated chancre, accompanied by an inguinal adenitis, in which the glands were mul- tiple, hard, and indolent. She followed a mercurial treatment for only a few weeks’ time. In September, a confluent roseola covered her body, the hair began to come out, and a double cervical adenitis showed itself. There could be no question as to the dis- 1 Op. cit., p. 49 et seq. 2 Recherches sur la Contagion du Chancre. 326 THE SIMPLE VENEREAL ULCER OR CHANCROID. ease in this case. During the last of June, one of my former patients, whom I had treated in 1842 for an infecting chancre followed by constitutional symptoms, had con- nection with this girl, and contracted two chancres on the penis, one at the fraenum, the other on the prepuce. These two chancres were entirely devoid of induration ; their bases remained supple. The inguinal ganglia were not affected, and, although no specific treatment was employed, constitutional manifestations did not appear. Ricord considered both these cases as simple chancres (that is, chancroids), produced by the secretion of an indurated chancre (initial lesion of syphilis) upon a person previously syphilitic. But another explanation of these two cases may be given. A double infection (what Rollet called a mixed sore) may have existed in the woman; she may have had both a chancroid and syphilis at the same time. Each following the laws of its existence, the chancroid would appear first. The men, having coitus at that time—and there is nothing in the histories to disprove this supposition—before the syphilis made its appearance, would naturally contract only a chancroid ; the woman, seen when her chancroid had gone, and when the initial lesion had appeared upon the scene, would be unquestionably syphilitic; and the deduc- tion being drawn that the secretion of the initial lesion had produced a chan- croid, error and confusion would follow. Let us see if any other cases have been reported which will assist us in our search. II. Rey1 reports a most extraordinary case, which is briefly as follows:— Two young men, A. and B., free from any previous syphilis, have connection on the same day with the same woman, C. From ten to fifteen days (sic) after, A. calls upon M. Rey, and shows him an indurated chancre with inguinal adenitis. A few days subse- quently B. calls upon M. Rey, and shows him four chancroids of the penis, with an in- flammatory mono-glandular adenitis. C. is then examined. She has an indurated chancre at the fourchette, with double syphilitic adenitis. The sequel in the three per- sons is, that A. has cervical adenitis and mucous patches in the throat; B. has a sup- purating bubo, this and the chancroid finally heal under local remedies only, and no constitutional manifestations appear within six and a half months after cicatrization of the chancroid ; C. has a macular syphilide. What shall be said of this case of M. Rey ? Let us run over the points: Two men, A. and B., entirely free from syphilis, cohabit on the same day with the same woman, C. She has Uun chancre indure magniftque.” What is the result? One, A., contracts syphilis—just what we should expect; but the other, B., contracts chancroids—what we should not expect. Why? Inexplicable, unless this happened: B. followed A. directly in coitus; the excitement and stimulation of A.’s coitus caused the woman’s initial lesion to suppurate, and the pus thus produced was inflammatory and capable of inoculation, not as syphilis, but as a local ulcer (chancroid). This is pure hypothesis, because, although we have the records of many cases of auto- inoculation of irritated initial lesions, there are none, as far as I know, of inoculations with such matter of irritation on subjects free from syphilis, and until this is done the problem must go unsolved.2 But though we have not any cases exactly corresponding to the conditions above named, there is one, published by Robert,3 which presents us with a very interesting experiment indirectly bearing upon this subject:— Madame J. was affected with two cancerous ulcerations of the nose, the largest of which was the size of a franc piece (quarter dollar). 1 Annuaire de la Syphilis, 1858. 2 In this connection, consult Lee, Lectures on Syphilitic and Vaccino-Sypliilitic Inoculations.. London, 1863; Boeck, Becherches sur la Syphilis. Christiania, 1862; Danielssen, Deutsche Klinik, No. 33, 1858, etc. 3 Nouveau Traite des Maladies V6n6riennes. Paris, 1861. This case has been given more- fully on page 305, to establish another point. ANATOMY OF THE SIMPLE VENEREAL ULCER. 327 October 14. The more extensive ulceration was dressed with a dossil of lint soaked in the pus taken from a recent chancre of inoculation practised upon a syphilitic patient; this chancre was derived from a simple ulceration. October 16-25. The peripheric inflammation has increased; the ulceration has extended. The floor of the ulcer is gray ; its scalloped borders are undermined. Sup- puration is very abundant, and the patient complains of a decided heat and tingling in the part. No glandular enlargement. November 1. Ulcer is evidently transformed into a chancre. December 15. The wound which was inoculated and partially cicatrized was dressed with aromatic wine. No signs of adenitis and no signs of infection. December 27, The ulcer of inoculation, as well as the second cancerous ulceration, had both entirely healed. There was no sign of any constitutional infection. The dressings had been diachylon at first, and afterwards aromatic wine. So far, then, no cases have been published, or are known, which prove the direct descent of the chancroid from syphilis, as those which I have presented (the only cases I can find upon this branch of the subject) are all open to serious question. Of course, it would be idle to speculate upon the possibility of future ex- periment proving this derivation, so that we must at present content ourselves with saying that the simple venereal ulcer (chancroid) is derived from the secre- tion of another chancroid, or of a virulent {chancroidal) bubo, and from nothing else. Nor does the possibility of simple pus being auto-inoculable deprive this fact of any of its importance. Anatomy of the Simple Venereal Ulcer. But little has been written upon this subject, and most of our knowledge of the pathology of the chancroid is derived from the works of German Fig. 331. Section made through a soft chancre [chancroid]. Hartnack, oc. 3, obj. 4. (Kaposi.) 328 THE SIMPLE VENEREAL ULCER OR CHANCROID. observers. Kaposi1 and Casparj2 are the most recent writers upon this sub- ject, and as Kaposi’s description is the best, I shall give it in full Microscopical examination of a perpendicular section, including the margin, the inflamed parts in the neighborhood, together with a portion of the floor and the inflamed base of the ulcer, shows that a portion of the skin occupied by the chancroid consists of two parts, which have evidently undergone different anatomical changes. (Fig. 331.) From the floor of the ulcer, c d, to a considerable depth in the corium is a uniform and uncommonly thick cell infiltration which terminates sharply at the line f g. This infiltration is continued beneath the intact papillae of the margin of the ulcer, e /, and laterally far beyond the limits of its floor. The tissue bordering on the infiltrated Fig. 332. Section made through a soft chancre [chancroid]. Hartnack, oc. 3t obj. 7. (Kaposi.) mass, f g h i, is composed of loose meshes, and exhibits scattered cells with a large nucleus, which is well brought out by carmine. In the swollen margin, a b, a number of papillae, e, lying nearest to the Hoor of the ulcer are thickened and closely infiltrated with cells. The layer of Malpighian cells between these papillae is thickened. These, b, overhang (undermining) the walls of the ulcer. The floor of the ulcer, c d, is formed by the exposed cell-infiltrated corium and is destitute of papillae. Both the corium and * Syphilis der Haut und der angrenzenden Schleimhaute. Wien, 1873. 8 Zur Anatomie des Ulcus durum und molle. Vierteljalirsschrift fur Dermatologie und Syphilis, 1876. COMPLICATIONS of the simple venereal ulcer. 329 papillae, wherever infiltrated Avith cells, exhibit numerous enlarged vessels, most of which are bloodvessels. A few, however, are lymphatics. With a higher power (Fig. 332), the cell-infiltrated portion, a b d, consists of a close network of partly narrow, and partly broad bundles of fibres with faint contours, in which is deposited an abundance of nucleated and evenly distributed cells, some of them very large and resembling lymph corpuscles, others smaller. The cells lying near the floor of the ulcer and the neighboring parts are for the most part small and irregular in outline, with scattered nuclei. Free nuclei and nucleoli are also found in large numbers. In the deeper tissues, the cells have generally the appearance of in- flammation-corpuscles, but there are also many smaller ones. Of great interest is the remarkable thickening of the walls of the vessels, e d g, which appear to be embedded in an abundant netw’ork of tissue-proliferation, due to adventitious fibrous deposits running parallel to them. In this network, cells with large nuclei are found. The openings of the vessels are everywhere apparent throughout this cell-infiltrated tissue, inasmuch as they are kept dilated by the surrounding oedema. The degeneration of the tissues and of the infiltrated cells takes place only in the upper portion, and to an extent wdiich is only limited by the extent and depth of the infiltration. Interstitial abscesses do not exist. We have not found any characteristics which would enable us to distinguish the cell-infiltration of the corium and the papillae, or the subsequent de- generation of the same, from similar processes of simple origin. Complications of the Simple Venereal Ulcer. The complications which occur with this variety of ulcer are numerous, and the aeuter the inflammation the more likely are they to occur. Bubo.—That most frequently met with is the bubo, and this is of two kinds, the “ simple,” which is sympathetic in nature, and is really nothing but a glandular or peri-glandular abscess, which secretes healthy pus and heals up rapidly as soon as its contents are evacuated; the other the “virulent” which is always serious, depending upon the absorption of the chancroidal matter by the lymphatics, and its arrest and retention in the nearest chain of glands, there to produce an inflammatory and. contagious ulceration of the gland similar to that which gave rise to the bubo. As showing the relative frequency with which various complications occur in cases of simple venereal ulcer, I refer the reader to the annexed table, in which will be found the figures bearing upon this subject. In 200 cases Frequency of Complications in Simple Venereal Ulcers. Table XXL (Sturgis, Records of N. Y. Dispensary for the last four months of 1879, Division F.) Patients with chancroids recorded ....... . 200 i i without complications with “ ....... . 135 it . 65 buboes (non-suppurating) . 22 phimosis ......... . 21 gonorrhoea ......... . 17 balano-posthitis 5 taken from the records of the New York Dispensary for the last four months of 1879, it will he seen that complications occurred in 65, or in about one- third of the cases, and that of these 65 patients who presented complications, 22, or nearly one-third, suffered from buboes, while phimosis, gonorrhoea, and balano-posthitis made up the remaining two-tliirds. The bubo then we may accept as the most frequent complication found with chancroids, and the next question for consideration is whether buboes are usually mono-lateral or 330 THE SIMPLE VENEREAL ULCER OR CHANCROID. bi-lateral. On looking at the first of the appended tables, we observe that 71 patients were the bearers of buboes, 54 having but a single bubo, while 17 had bubo on both sides; this is accounted for by the fact that the bubo is generally mono-lateral unless the ulcer is seated .upon, or close to, the frsenum of the penis, when both groins are attacked, and that chancroids of the thenum are not as often met with as chancroids of other portions of the geni- tal mucous membrane. (See Table XVIII. page 320.) Frequency of Bubo in Cases of Simple Venereal Ulcer. Table XXII. (Sturgis, Records of Third Venereal Division Charity Hospital, B. I., N. Y., 1879-80.) Patients affected with simple venereal ulcers . , # . . . 24& Without bubo ....... 178 With buboes 71 Of these—with single bubo , # . 54 with double buboes . • 9 . 17 Table XXIII. (Ricord, op. cit., p. 40.) Patients affected with simple chancres • • • . 207 “ “ “ buboes . . 65 “ without buboes Table XXIV. (Sturgis, Records Third Venereal Division, Charity Hospital, B. I., N. Y., 1879-80.) Total number of buboes ...... 71 Suppurating buboes Non-suppurating buboes Total number of patients recorded “ “ with buboes “ “ without buboes Percentage of patients with buboes to total number, almost . 30 Total number of buboes (see Table XXIV.) . 71 Percentage of suppurating buboes to total number of buboes (Table XXIV.) .42.2 Resnmb. As regards the pathology of this kind of bubo, it may be repeated that there are two kinds, viz., the sympathetic bubo, and that resulting from ab- sorption. The first symptom noted by the patient is a feeling of pain and uneasiness in one or both groins, aggravated by motion, and upon examina- tion the surgeon readily detects a swollen and painful gland or glands. This enlargement differs materially from the adenitis found in syphilis, in that the gland is not felt distinct and separate from the surrounding tissues, but is sunk into and matted together with the material of inflammation, infiltra- tion and cell exudation; that the outlines are indistinct; and that the swell- ing interferes with motion. At first, redness is absent, but in a short time this symptom supervenes, and invades the entire swelling. After lasting a longer or shorter time, a point of softening declares itself at the apex of the swelling, and fluctuation is apparent on palpation. Up to this point, both kinds of bubo run the same course, and there is no means of deciding to which class the swelling belongs. As soon as fluctuation is certain, the wisest course is to open the bubo, and for these reasons: it is a good, fundamental rule in surgery to evacuate pus wherever practicable; the bubo, if simple, heals more rapidly if it be opened, while if it is “virulent,” it becomes of decided importance to open it—in the first place, to prevent burrowing, and in the next, to check the destructive action which is always present in these COMPLICATIONS OF THE SIMPLE VENEREAL ULCER. 331 lesions, and which constitutes a very dangerous element. These buboes, when left to themselves, always sooner or later slough, but sometimes not until they have undermined the skin to an alarming extent; hence it is good sur- gery under any circumstances to open a bubo in which fluctuation is evident. The bubo after it is opened diverges widely in its future course according to its nature. The simple bubo reveals itself as an ordinary abscess with a clean, healthy-looking floor and edges; it secretes laudable pus, the granula- tions are red, and bleed easily upon handling, and the wound heals rapidly. The bubo by absorption, on the other hand, presents the appearance of a chan- croid, which, indeed, it is ; the floor is uneven, irregular, unhealthy-looking, covered with a dirty-grayish or yellow pultaceous layer, which is adherent to the ulcer; the edges are undermined for some little distance from the edge of the ulcer, and the overlying skin is dead and shrivelled; the discharge, which is copious, is grayish or brown, sanious, and irritating, differing widely from healthy pus, and healthy granulations are absent. Unless checked by proper treatment the ulceration extends rapidly, destroying tissue and bur- rowing deeply in the groin, down the thighs, and even up the abdominal walls, not infrequently giving rise to alarming hemorrhage from erosion of the superficial epigastric and femoral arteries. The other complications liable to occur with the simple venereal ulcer are Phimosis, Paraphimosis, Balanitis, and Phagedsena. • Phimosis and Paraphimosis.—These complications are only serious if ag- gravated by intense inflammation, when they produce gangrene from impedi- ment to the proper nutrition of the part. In 'phimosis the skin of the penis becomes enormously oedematous, the prepuce cannot be retracted, and the discharge from beneath the foreskin becomes often so abundant as to give rise to doubt whether the case may not be one of gonorrhoea instead of chancroid. Auto-inoculation here comes to our rescue, and if the experiment be success- ful, all doubt will be ended as to whether the surgeon has a gonorrhoea or a chancroid to deal with, for the secretion of gonorrhoea is incapable of auto- inoculation. If, on the other hand, the experiment is unsuccessful, the pro- babilities will be in favor of the concealed disease being simply a clap, and this point is of importance in regard to treatment, inasmuch as in the latter event incisions may be resorted to for the relief of the phimosis, which the surgeon would hesitate to use if the concealed disease were chancroidal. In paraphimosis the diagnosis is much easier, as the parts are more exposed to view, and the only question to occupy the surgeon is the prevention of gangrene. Balanitis is not an infrequent concomitant of chancroids, and is more annoying than serious, the abrasions becoming converted into chancroidal ulcers, which have a tendency to run together into one large sore. Phagedena.—Besides tlie complications hitherto considered there is one other, by far the most serious which can befall. I mean Phagedcena. This occurs in consequence of some constitutional defect, such as Tuberculosis or Scrofula, or from a vitiated condition of the system—as, for example, aleohol- lsmus—and not from any inherent vice in the ulcer, or in the inflammation attendant upon the chancroid itself. When this is attacked by phagedeena, a notable change occurs in its character and local aspect. The pus, which for- merly was abundant and fairly purulent, now becomes scanty and thin; its color changes from yellow to brown, sometimes even to black, from the detritus of tissue; the floor of the ulcer becomes of a leaden-gray, brown, or black 332 THE SIMPLE VENEREAL ULCER OR CHANCROID. hue, and is converted into a thick, grumous, pultaceous mass ; the undermined edges of the sore collapse, while simultaneously fresh burrowing goes on, extending the area of the wound to an alarming extent. Sometimes an attempt at cicatrization takes place at one end of the ulcer, while rapid pro- gress is being made at the other; and when this assumes a sinuous course the affection is known by the name of the “Serpiginous Pltaged.cenic Chancroid.” At other times, the floor of the ulcer is overspread with a grayish flocculent membrane, not unlike the diphtheritic membrane, which is closely adherent to the sore. This goes by the name of the “Diphtheritic Chancroid.” The odor emanating from such ulcers is sickening, and the patient, exhausted by this constant suppuration and necrosis of tissue, assisted sometimes by hemorrhage as bloodvessels are eroded by ulcerative action, is often reduced to an alarm- ing condition of debility. Under appropriate treatment the phagedsena sometimes disappears, when the ulcer assumes the appearance of a simple granulating wound, and finally heals, but often at the expense of serious loss of' tissue, leaving as a reminder of its presence an indelible scar. But this happy result is not always attained, for sometimes the ulcer obstinately refuses to heal under the most approved treatment, and remains in an indolent, unhealthy condition, the floor being covered with a grayish exudation, and the few granulations that spring up being flabby and easily destroyed. In this condition the ulcer will sometimes remain for a longer or shorter time, until excited into action by some acci- dental cause, when suddenly the activity of the disease will he renewed, the phagedenic ulceration will extend with frightful rapidity, and severe loss of tissue will ensue. This renewed activity will after a while subside, and the ulcer will then relapse into its former indolent condition, until again excited into activity. These “ Chronic Chancroids” are practically incurable, and the patient finally succumbs from exhaustion, and, as I believe is often the case, from an associated phthisis. I have observed during my hospital experience many such eases, and although I am not yet prepared to say absolutely that phthisis was the cause of incurability of the ulcer, I believe that it played an important part in that direction. Mixed Chancre.—There is another condition of things occurring with the chancroid which can hardly be called a complication, but which is full of interest and worthy of mention. I allude to the so-called “mixed chancre” of Rollet, the invention of which was a happy stroke of genius to account for -certain ulcers which, although undoubtedly chancroidal in the beginning of their career, in due time became converted into initial lesions, and were fol- lowed by other symptoms of syphilis. In consequence of the name, much confusion arose from the belief that a real admixture of the two kinds of virus took place, and that the secretion of this ulcer would by inoculation produce a sore which, although chancroidal at first in all respects, would become syphilitic, and be followed by the subsequent manifestations upon the skin and mucous membranes. Such, however, has been found by experience not to be invariably the case; and in those instances in which the occurrence did take place, it was due to the period at which the sore whence the matter for inoculation was taken had arrived. Thus, if the matter was used when the sore was still young, that is, within the first fourteen days of its existence, the inoculated ulcer was and remained throughout a chancroid; if, however, the matter was taken between the four- teenth and the twenty-first days, then the resulting ulcer would often start as a chancroid and end as an initial lesion; but when the matter was not taken until the sore was twenty-one or more days old, then no chancroid would appear, but the resulting inoculation would be from the beginning an initial 333 diagnosis of the simple venereal ulcer. lesion. In other words, there was a commingling of two kinds of poison; what did occur was a double infection at the same spot—possibly, not neces- sarily, at the same coitus—and, each disease following its own natural course, the first to appear would be the chancroid, and after that, at the proper time, the syphilis embodied in the initial lesion. Each disease, to parody the well- known maxim in the old Roman policy, “divide et impera,” pursues its own course undisturbed by the other, as far as it is possible to do so, but the syphilis, as the more chronic aflection, naturally outlives the chancroid. Diagnosis of the Simple Venereal Ulcer. To repeat what was said before when discussing the gross appearances of the chancroid, the diagnosis of this variety of ulcer is based upon the follow- ing points:— (1) An absence of incubation. The chancroid appears usually within the first eight days after the infecting coitus, and probably in a large proportion of cases even earlier. (See Ilesume of Tables XI.-XIV., page 317.) (2) The property of auto-inoculation. This consists in a capacity for repro- duction within certain limits from the secretion of the original ulcer. Owing to this property, this variety of sore is more often multiple than single. (See Ilesume of Tables V.-X., page 315.) (3) The absence of induration of the base. This point, it is true, has lost some of its significance since the discovery of the fact that the initial lesion of syphilis is occasionally met with devoid of induration. Xevertheless,. should this point be doubtful, other symptoms must be appealed to in order to establish the diagnosis. The pseudo-induration of the simple venereal ulcer must also be rated by the same standard. (4) The copious purulent secretion. This is due to the inflammatory and destructive nature of the sore. (5) The punched-out and undermined edges of the sore. (6) The irregular and eroded appearance of the floor. (7) The grayish-yellow layer covering the floor of the ulcer. These three last are all due to or result from inflammation. Relative Frequency of Simple Venereal Ulcer and Initial Lesion of Syphilis. Table XXV. (Ricord, op. cit., p. 10.) Total number of patients ...... . . . .10, ,000 “ affected, with simple chancres .... ,045 “ “ “ infecting chancres .... . . . . 1, ,955. Table XXVI. (Fournier, ibid., p. 9.) Total number of patients .... • • • • . 341 “ affected with simple chancres • • • • . 215 “ “ “ infecting chancres . • . 126 Table XXVIL (Chabalier, Historique de la plurality des Maladies Veneriennes. These. Paris, 1860.)> Total number of patients # . 208 “ affected, with simple chancres , , . • • . . 118 “ “ “ infecting chancres . . . . . 90 334 THE SIMPLE VENEREAL ULCER OR CHANCROID. Table XXVIII. (Belhomme et Martin, Traite theorique et pratique de la Syphilis et des Maladies V4neriennes, p. 129, 1876.) Total number of patients .... “ affected. with simple chancres • • • . . 105 “ “ “ infecting chancres . 45 Table XXIX. (Nodet, quoted by and taken from Labarthe, Le Chancre Simple, p. 110. These. Paris, 1872.) Total number of patients “ affected with simple chancres .... “ “ “ infecting chancres .... Table XXX. (Millet, op. cit., p. 53.) Total number of patients .... “ affected witli simple chancres • • , . 201 “ “ “ infecting chancres . Table XXXI. (Belhomme et Martin, op. cit., p 477.) Total number of patients “ affected with simple chancres .... “ “ “ infecting chancres .... Table XXXII. Total number of patients “ affected with simple chancres 77 “ “ “ infecting chancres . 54 Table XXXIII. (Labarthe, op. cit., p. 10.) Total number of patients . 167 “ affected with simple chancres “ “ “ infecting chancres . Table XXXIV. • Division B. (Sturgis, Records of the Male Venereal Division B, New York Dispensary, from Sept. 1, 1878, to Sept. 1, 1880.) Total number of patients “ affected witli simple chancres 389 “ “ “ infecting chancres . 230 Table XXXV. Division F. (Sturgis, Records of the Male Venereal Division F, New York Dispensary, from Sept. 1, 1878. to Sept. 1, 1880.) ’ Total number of patients 786 “ affected with simple chancres ........ 640 “ “ “ infecting chancres 146 For the permission to consult the records of their divisions, I am much indebted to the courtesy •of the attending surgeons, Dr. Bronson and Dr. Fox. Total number of patients recorded .... . . . . 13,572 “ affected witli simple chancres .... .... 10,337 “ “ “ infecting chancres .... . . . . 3,235 Percentage of simple chancres to total number, is . . . . . 76.1 “ of infecting chancres to total number, is . . . . . 23.9 ResumL TREATMENT OF THE SIMPLE VENEREAL ULCER. 335 Prognosis of the Simple Venereal Ulcer. Generally speaking, this may be said to be favorable, the large majority of chancroids healing rapidly without leaving any bad results behind, either in the way of systemic infection (for the disease is purely local, never consti- tutional), or from serious destruction of tissue. But to this, as to all rules, there are exceptions, and these usually occur when the chancroid is attacked by phageclsena. In such a case, the destruction is often frightful, and the in- curability of the ulcer, the exhaustion which it induces, and the serious hem- orrhages to which it gives rise, not infrequently tend to a fatal termination. Such cases are happily rare, at least among our white population, the fatal eases which I have seen having occurred in the dark-skinned races: indeed, I have often been struck with the peculiarly rebellious and alarming course which venereal diseases, particularly chancroid and syphilis, pursue among the negroes and Chinese. The same peculiarity I am told exists among the Mexicans, especially in those persons who have an admixture of negro or of Indian blood. Treatment of the Simple Venereal Ulcer. Under this heading, I shall first consider the treatment of the uncompli- cated chancroid, and shall afterwards take up the various complications. In the treatment of all chancroids, two indications must be steadily kept in view: the first is to prevent the extension of the ulceration and to relieve the in- flammation ; the second, to prevent the conveyance of the matter to adjacent or to distant tissues, and thus to obviate the production of fresh sores. JSTow, as to the first point:—to prevent the extension of the ulceration and to relieve the inflammation. The best method of bbtaining this result is the destruction of the ulcerated surface, and especially if it be large and pro- gressive, by some active cauterizing agent which shall so change the nature of the ulcer as to cause it to heal up instead of extending—what in ordinary parlance is known as “ destroying the virus.” The best agent for this pur- pose is the actual cautery, the iron being heated to a white heat, the galvano- eautery, or the Paquelin cautery, either one of which is sufficient to change the character of the sore. This form of cauterization is best adapted to ser- piginous, diphtheritic, and phagedsenic sores, where extension is rapid and destruction serious ; for the milder varieties, some less powerful caustic is sufficient. Of these, chemically pure sulphuric acid takes the lead for the thoroughness with which it destroys the ulceration ; next to this come caustic potassa, chemically pure nitric and carbolic acids, then iodine and bromine, and, last of all, the nitrate of silver, which cannot properly be called a caustic, its action being so superficial as to give it the character of a stimulating rather than that of a destructive agent. Many surgeons of the present day deprecate the use of caustic or destruc- tive agents for the treatment of the majority of chancroids met with in prac- tice, declaring that milder and less heroic measures suffice for the cure. Undoubtedly this is perfectly true, a large proportion of the simple venereal sores met with at the present day being of the mild and superficial variety, which will heal up under the use of iodoform or some such simple remedy. But the advantage of using a cauterizing agent, as long as the sore retains the appearances of inflammation and unhealthy action, is that for this condi- tion of things it substitutes a healthy action, and obviates what not infre- quently happens in chancroids, viz., a supervention of inflammation in what 336 the simple venereal ulcer or chancroid. originally was a superficial and mild ulceration. Besides this, a proper use of the cautery hastens the cure, and any means which does this should be used, no matter though it may not appear absolutely requisite. Application of Caustics.—If caustics are to be applied, certain points should be carefully attended to in order to make their use effective. Selecting the one which is most active, it should be applied not only to the apparent surface of the sore, but should be carried beneath its edges, and into sound tissue to the extent of from an eighth to a sixth of an inch, or further, if the undermining process is extensive ; in other words, the entire extent of the ulceration must be thoroughly destroyed, else the healthy ulcer left after the cautery is apt to become contaminated with the matter from those portions which have not felt its action, and the inflammation then commences anew, and spreads over a broader area. The old remedies known as Bicord’s and Canquoin’s pastes have lately fallen into disuse, and their employment pre- sents no advantages over simply cauterizing the ulcer with the liquid caustic, and applying cold water dressings, while it has the decided disadvantage of concealing the chancroid from view, and thus preventing the surgeon from knowing what is going on beneath the crust which is formed. The simpler and more effective is the agent employed, and the more accessible is the ulcer to the inspection of the surgeon, the speedier will a cure be brought about, inasmuch as the applications may then be made with sufficient frequency to insure the substitution of a healthy action for the morbid inflammation. Subsequent Dressings.—The subsequent dressings are those which are continuously used in the intervals between the cauterizations. Of these the dry are infinitely to be preferred to the wet dressings. Iodoform is the agent most deserving of praise in this connection, the only objection to its" use being the pungent and penetrating odor which it possesses. Many sub- stances have been suggested for the palliation of this defect, the last agent for this purpose being chloral-hydrate, but none of them can claim a great degree of success. Perhaps the best manner of correcting the odor is to instruct the patient not to scatter the powder upon his hands or clothing; if due attention be paid to this point, this disagreeable feature of a valuable drug may be materially modified. Besides the iodoform, the impure oxide of zinc, and powdered tannin, mixed with some inert powder like bismuth or lycopodium, in the proportion of one part of the active agent to three of the inert, is often of service. These dressings should be applied several times during the day, the ulceration being carefully bathed in hot water before each fresh application. After the preparation is dusted on, the part may be protected by the super-position of charpie or of Davison’s prepared absorbent cotton, which makes an excellent dressing. Of the wet dressings, solutions of carbolic acid are the best, but the objection to their continued use is that they are apt to macerate the epithelium of healthy tissues sur- rounding the sore, to harden circumjacent parts, and to render the sore indo- lent and flabby. Another excellent dressing, and perhaps on the whole prefer- able to carbolic acid, is what is known at Charity Hospital, Blackwell’s Island, as the “ nitric acid wash,” which is simply a fluidrachm of the chemically pure nitric acid dissolved in a pint of water. Should this produce burning and pain in the ulcer for more than three or four minutes after its applica- tion, it may be diluted; otherwise it should be kept up to the standard prescribed. Under its use, the surface of the sore loses its grayish look and becomes covered with healthy granulations; the purulent discharge ceases; and the edges of the wound fill up. When this point is reached, the wash may be discontinued, and dry dressing substituted. In the treatment of this TREATMENT OF COMPLICATIONS. 337 variety of ulcer, special care must be taken to persevere faithfully with the use of the remedies until complete cicatrization has occurred, inasmuch as some chancroids become freshly inflamed, and break down anew, even when they are apparently on the high road to recovery. The use of hot-water baths, general and local, has been recommended as another means of treatment for these ulcers, and undoubtedly in those cases which are attended with much inflammation, benefit accrues from this plan. But for the cure of chancroids I cannot speak in the same terms of approba- tion which some writers employ when speaking of the “ hot-water treat- ment ;” the utmost that I have obtained has been relief of inflammation, and this has been notably the case in phagedsenic ulcers, in which, after the sub- sidence of the acute symptoms (the swelling, redness, and pain), the condition of the ulcer has remained stationary, requiring more active measures for its cure; and this, too, although the bath treatment had been diligently and carefully pursued. Treatment of Complications. Bubo.—Buboes, according to their stage, require an abortive or a stimulat- ing method of treatment. When tirst seen, and before any breaking down has occurred, the attempt should be made to cause absorption and disappear- ance of the swelling. For this purpose, local applications of the tincture of iodine (simple or compound) should be made to the enlarged gland, together with compression, if the condition of the swelling will admit of it. Besides this, applications of nitrate of silver—thirty, forty, or even sixty grains to the fluidounce—and of collodion, either alone or holding iodoform in suspen- sion, have been used with varying success. The internal administration of the sulphide of calcium, in doses varying from one-tenth to one-half a grain,, has in my hands not produced satisfactory results, although some writers speak highly of its use in these cases. The application of ice is occasionally of benefit in diminishing pain and reducing inflammation. As soon, however, as is apparent, the remedies mentioned above must be abandoned, and an opposite course of treatment pursued. Every- thing must now be done to favor suppuration, for the reasons which I have already given, and which will perhaps bear repetition. As already men- tioned, when a bubo threatens to break down, it is impossible, until after the bubo has been opened, to declare whether it is of the kind known as “ simple,” or whether it is “ virulenthence it is important to favor suppu- ration, and to settle this point. If the bubo be “simple” the mere evacua- tion of the pus will be almost all the treatment requisite, if we except the dressing of the wound with lint and cold-water bandages. But if the bubo prove to be what is known as the “virulent bubo,” then the condition of things is materially altered. The ulcer which is left after the evacuation of the pus is to all intents and purposes a chancroid, and requires active measures for its cure.1 The flrst thing to be done is to destroy the inflammatory and destructive character of the ulcer, and this is best done, if the bubo be at all large, by the actual cautery in one of the methods already advised. Any glands which are not yet destroyed should be removed, either with the knife or ecraseur, and whatever hemorrhage there may be should be checked with the white- hot iron. In making cauterizing applications to these, as well as to other 1 Aspiration of the bubo in these cases is of no service; a free incision is the best method of treatment. 338 THE SIMPLE VENEREAL ULCER OR CHANCROID. chancroids, care should be taken to include all portions of diseased tissue. The subsequent dressings should be detergent and stimulating, and the best articles are the nitric and carbolic lotions. These should be applied upon the absorbent cotton, well packed into all portions of the wound until it assumes a perfectly healthy appearance, when they may be discontinued in favor of a dry dressing, usually of iodoform. Phimosis.—In phimosis, the attempt should be made to relieve the swelling and oedema of the prepuce by frequent and continuous, hot, local baths, carried to the point of producing slight faintness. Associated with these, sub-prepu- tial injections of the nitric or carbolic lotions should be made, conjoined with strict attention to cleanliness; as soon as the oedema subsides and retraction of the foreskin is possible, the concealed sore should be treated in the manner already advised. It is better surgery in such cases not to attempt to relieve the phimosis by incision, unless gangrene threatens to supervene, as the cut edges of the wound almost invariably become inoculated, and a large and troublesome sore results. If, however, it becomes necessary to operate, the incision had better be made double instead of single, by making one at each side of the foreskin, instead of the time-honored single cut along the dorsum of the penis. The double incision admits an easier and more thorough exposure of the glans penis and fossa glandis, and a more perfect application of the necessary remedies. The concealed chancroids, as well as the edges of the wounds, should then be cauterized in the manner and with the means already detailed. Paraphimosis is usually a less serious accident than the complication we have just been considering, although even here the constriction may be so great as to produce gangrene of the glans penis. If this threatens, it must, of course, be relieved by a timely division of the constricting portion of the prepuce; under other circumstances, the same rule as regards incisions must be observed here as in phimosis. Antiphlogistic treatment by hot-water local baths, leeches to the abdominal rings, multiple punctures of the cede- matous prepuce, and the ice-pack, are the remedies which hold out the best and most speedy means of relief; destruction of the chancroids must be always carried out as quickly as possible. Balanitis.—In balanitis the principal danger arises from the auto-inocula- tion of the abraded points, and hence these should be cauterized and treated in the same manner as though they were already chancroids. Concealed Chancroids (Chancres larves, of the French), if seated just with- in the meatus, can generally be treated by cauterization and the dressings already advised, without any great difficulty. If seated further within the canal, the applications must be made through a speculum, for which purpose there is nothing better than a Gruber’s ear-speculum. As a matter of fact, I do not believe that these ulcers are ever seated further than one inch with- in the canal, and the celebrated case of Ricord, described in his “ Clinique Iconographique,” is open to question as regards diagnosis. In many respects it loots as though it had been a case of tuberculosis, and not of chancroid. Phagedena.—The most serious of all complications to treat is phagedsena, and the main point to be remembered is, that it is due much more to some constitutional defect than to any local property of the chancroid; hence a twofold method must be adopted, namely, local destruction of the ulceration, and an internal treatment to alter the underlying diathesis. The only cautery TREATMENT OF COMPLICATIONS. 339 which is of any service in these cases is the actual cautery, and this should be thoroughly and mercilessly applied wherever the disease shows itself. Tlio subsequent dressings are best made with the nitric acid lotion, and these should be carefully applied over the entire extent of the sore, the cauterizations to be repeated as long as the floor of the ulcer shows its purulent grayish hue, or the sore exhibits any tendency towards extension. The use of the potassio- tartrate of iron, so much vaunted by Ricord as the “ born enemy of phage- dena,” does not seem to be as etflcacious in this country as abroad, and it has the decided disadvantage of depositing the metallic tartrate of iron over the surface of the sore. Internally, as a tonic, it is sometimes of benefit. The internal treatwxnt of phagedena must be directed to building up the patient’s general health, and, of the various tonics recommended for this pur- pose—besides the preparations of iron—quinine, cod-liver oil, and phosphoric acid may be used with advantage. Care must be taken not to confound these phagedenic chancroids of the genitals and of the inguinal region with ulcer- ating gummata and serpiginous syphilides of the same regions, as those require an entirely different treatment. In chancroids, mercury and iodide -of potassium not only are of no advantage, but often do positive harm, and I believe that many cases of serpiginous chancroids, which are reported as having been benefited by the “ mixed treatment,”1 are examples of serpigi- nous syphilides, and not of true phagedenic chancroids. In the large majority of cases, chancroids do not need any internal treatment; it is only in those oases in which the patients are debilitated that constitutional remedies are required, and even then tonics, such as iron or quinine, are all that are requisite. In the phagedenic variety of chancroid, tonics are, of course, a necessity. Mixed Sore.—As regards the so-called “ mixed sore,” the treatment is two- fold, and must be changed as soon as the character of the local ulceration is altered. As long as the chancroid exists, the case must be treated as one of chancroid; but as soon as the ulcer assumes its syphilitic characters, the remedies applicable to the chancroid must be abandoned, and those remedies adopted which are appropriate for the treatment of the initial lesion ot syphilis. 1 [This name is applied to the combined use of mercury and iodide of potassium.} VENEREAL DISEASES: SYPHILIS. BY ARTHUR YAN HARLINGEN, M.D., PROFESSOR OF DISEASES OF THE SKIN IN THE PHILADELPHIA POLYCLINIC ; CONSULTING PHYSICIAN TO THE DISPENSARY FOR SKIN DISEASES, PHILADELPHIA. IIistory of Syphilis. The origin of Syphilis1 is involved in obscurity. Whether the disease has everywhere and at all times existed, or whether it has originated at one period or another de novo, are questions which, in spite of the vast amount of laborious erudition which ha3 been brought to bear with a view to their solution, cannot at present be regarded as satisfactorily answered.2 Our earliest positive knowledge of the disease dates to the year 1495, at which time it appeared, of a malignant type and epidemic in character, in the armies of France, led by Charles VIII. against the kingdom of Naples. The disease not only attacked the invaders but also the defenders of the Italian kingdom, and almost simultaneously overran the whole of Europe. The earlier writers on syphilis differentiated it with accuracy from the other venereal affections, but later authors confounded the various diseases due to sexual intercourse, until, at the end of the last century, confusion everywhere prevailed.3 The identity of gonorrhoea with syphilis was, however, denied even in the last century by Astruc, Balfour, and Benjamin Bell, but John Hunter, who published his work on venereal in 1786, when at the height of his great reputation, maintained this identity, and taught that the only difference between the two diseases depended upon the nature of the surface to which the poison was applied; that it caused ulceration when it acted upon a cutaneous surface, but only a purulent discharge, without breach of continuity, when applied to a mucous membrane; and that the morbid secretion in either case might give rise to one or the other set of symptoms according to the struc- 1 As the limits of an article like the present, preclude the full discussion of many points, and necessitate the concise treatment of nearly all subjects included, I have made numerous refer- ences through the text to monographs and papers which contain a fuller exposition, or which take different views, of disputed questions. The reader desirous of working out any particular topic will find in the abstracts of current literature published in the Archives of Dermatology, a complete bibliography of syphilis during the past seven years, with an epitome of the more im- portant papers. 2 The best recent works on the history of syphilis are, Hirsch (Handbuch der historische- geograpliischen Pathologie, 1860—4), and Haeser (Geschichte der epidemischen Krankheiten, zweite Auflage, Jena, 1853 und 1865), in favor of the ancient origin of syphilis, and Geigel (Geschichte, Pathologie und Therapie der Syphilis, Wurzburg, 1867) against it. An excellent and full summary is contained in Lancereaux’s Traite historique et pratique de la Syphilis, 2me ed. Paris, 1874. 3 See Bassereau, Affections de la Peau symptomatiques de la Syphilis. Paris, 1852. A book well worthy of the title “epoch making,” and one of the most important works ever written upon syphilis. 341 342 SYPHILIS. ture with which it came in contact. With this belief, he inoculated himself on the glans and prepuce with the discharge from a gonorrhoea; the result was the development of primary sores, followed after some months by secondary manifestations from which he was not completely cured for three years. This naturally made a great impression on his mind; he appears to have considered the experiment conclusive, and not to have repeated it upon others.1 Hunter’s great name and the influence of his writings caused the doctrine of the identity of gonorrhoea and syphilis to prevail extensively, and, indeed, it is only within the last score of years that this view has entirely ceased to be held.2 The treatment of gonorrhoea by means of the internal employment of mercury, even to salivation, was not uncommon in the first thirty years of this century, and it was not until 1838 that Ricord in his work on the sub- ject3 finally disproved the identity of gonorrhoea and syphilis. Ricord, while clearly differentiating chancre and gonorrhoea, failed to distinguish accurately the two kinds of sore confounded under the former name, and moreover committed the lamentable mistake of denying the com- municability of syphilis by the secretions of its generalized lesions.4 His. pupils, who founded the modern French school of syphilology, proceeded in Ricord’s footsteps and pushed the investigations of the Master still farther,, disproving some of his assertions while confirming others. Bassereau, a pupil of Ricord, first put forward, in 1852, the theory that the two kinds of sore indicated two entirely distinct contagious diseases, having no relation to each other and each invariably only transmitting its like. lie arrived at this conclusion by the confrontation of a large number of patients with the individuals from whom they had contracted, or to whom they had communicated, their disease. He found that in every case those affected with chancre followed by secondary infection, had derived their disease from per- sons similarly affected, with secondary infection. On the other hand, those affected with chancres not causing symptoms of general syphilis, had, without exception, derived their disease from persons who, like themselves, were the subjects of sores whose action was limited to the point first infected.5 Ricord had observed that the “indurated” sore could only be inoculated with difficulty upon the individual who bore it, while sores not indu- rated could be inoculated indefinitely. Moreover, when the indurated sore was inoculated upon its bearer, it gave rise to a sore precisel}" similar to that caused by inoculation from a non-indurated or “ soft” sore. Therefore it was argued by Clerc,6 that it was not necessary to imagine, with Bassereau, the existence of two poisons, but that the soft sore was the product of the hard sore when conveyed to a person already syphilitic; that it had permanently lost its infecting property, so that if transmitted further to a person who had never had syphilis, it would still be transmitted as a soft sore without any power of conveying general infection. To this hybrid or degenerated sore,. Clerc gave the name of “ chancroid.”7 Other observers confirmed Clerc’s asser- 1 J. R. Lane, Lectures on Syphilis, delivered at the Harveian Society, December, 1876, page 6. 2d ed. London, 1881. 2 Bumstead says that it was taught as lately as in 1860, in one of the most prominent medical schools of this country. 3 Traits des Inoculations appliquees a l’Etude des Maladies VSneriennes. Paris, 1838. 4 Although doubts as to the non-inoculability of “secondary” lesions existed in the minds of various writers previous to Ricord’s time, yet his advocacy of this view silenced or convinced his contemporaries, and it was not until the inoculation experiments of Waller, of Prague (Prager Vierteljahrsschrift, 1851), and others, that the contagiousness of these lesions was generally acknowledged. 5 Lane, op. cit. 6 Du Chancroide Syphilitique. Moniteur des Hopitaux, etc. Paris, 1854. 7 Lane, op. cit. GENERAL PATHOLOGY. 343 tions, and it was also found that the “ indurated sore,” which under ordinary circumstances was inoculated upon the bearer with so much difficulty, could readily be inoculated if it were first irritated by powdered savin or by a seton, and made to produce pus, and that the sore thus arising resembled in every way the soft sore, the “ chancroid” of Clerc. By this means an unfortunate step backward was taken, and the two poisons which had been so carefully differentiated by Bassereau were once more con- founded together, and regarded as essentially one. But these experimenters had proved too much, for others following their lead inoculated simple non- venereal matter of inflammatory origin upon syphilitic subjects, with the result of producing pustules and ulcers identical with the chancroid, and capa- ble of reinoculation through a number of generations. The result of these various observations and speculations regarding the nature of venereal sores has been the gradual evolution of the following theory, which is held by a majority of the most distinguished syphilographers of the present day, and which is accepted by the writer of this article:— The virus of venereal sores is of two distinct kinds. Some venereal sores are due to the inoculation of the syphilitic virus, others are due to the inoculation of a distinct specific virus known as chancroidal. These two poisons may he inoculated simultaneously} General Pathology. Syphilis is a virulent, contagious, inoculable disease, having a sluggish evolution, and manifesting itself, in the acquired form, first by a chancre, then by eruptions on the skin and mucous membranes, subsequently by chronic in- flammations of the cellulo-vascular tissues and the bones, and finally by special productions in the form of small tumors or nodules called gummata.2 There are two forms of syphilis, the acquired and the hereditary. Both originate in the same virus, but their course, the lesions by which they are expressed, and the symptoms to which they give rise, are so different that they require a separate description. Acquired syphilis is the disease communicated by an infected person to one free from syphilis. It first shows itself, precisely at the point of inocula- tion, by an initial lesion or chancre. Hereditary syphilis is the disease derived from one or both parents, either by conception, or through the blood of the mother after conception. In this form of syphilis the initial lesion or chancre is wanting.3 Is chancre the first symptom of a generalized infection, or is it in the be- ginning merely a local lesion? Observers are not all agreed upon the answer 1 The other prevailing views represent the virus of chancroid either as, according to Clerc’s view given above, a sort of degenerated syphilitic virus, or as nothing more than purulent infec- tion, and the chancroid as in no way distinguishable from the product of the inoculation of pus from simple sores upon persons of peculiar constitution. Among the upholders of the latter view may be mentioned the late Prof. Freeman J. Bumstead, whose opinion justly carries great weight. I cannot, however, admit the identity of the chancroidal virus with that of simple purulent matter, for I believe that the clinical appearance and course of the chancroid are se peculiar as to establish its existence as a morbid entity. Two excellent papers by Dr. Bum- stead may be referred to in this connection, viz. : “ On the present state of the question of the unity or duality of syphilis,” Am. Journ. Med. Sci., April, 1873, and “The virus of venereal sores, its unity or duality,” Transactions of the International Medical Congress of Philadelphia, Pliila., 1877. See also a review by Dr. Frederick Zinsser : “ The doctrines of unicism and dualism of the syphilitic contagion.” Am. Journ. Syph. and Derm., vol. i., 1870, p. 220. 2 Cornil, Lemons sur la Syphilis. Paris, 1879. 3 Bumstead and Taylor, The Pathology and Treatment of Venereal Diseases, 4th ed. Phila- delphia, 1879. 344 SYPHILIS. to this question, but the weight of evidence, I think, lies in favor of the first view, and against the local character of chancre. Those who favor the local view of chancre, point to the period of so-called “ second incubation,” the space of time which elapses after the chancre has appeared, and during which it lies dormant, so to speak, for several weeks before any signs of general infection occur. In opposition to this view, how- ever, it may be remarked, that a period of incubation follows the inoculation of the virus, and that it is during this first “ incubation” that the poison is penetrating the system. The chancre is, in fact, the first outward sign of the constitutional infection; the “second incubation” being indeed only a halt between two outbreaks. The fact that auto-inoculation of chancre cannot he effected (see p. 354, note), shows, I think, most conclusively, that the entire system is already saturated with the poison. This question is of practical importance, for if indeed chancre were only a local manifestation, its prompt excision might prevent infection of the system, while if it is only the first symptom of general infection, such treatment must of necessity he useless to prevent the evolution of the disease. The question of excision will be again mentioned under the head of the treatment of chancre. Sources of Syphilitic Contagion.—Up to within a comparatively recent period, it was believed that the chancre was the only contagious lesion of syphilis, and the only means whereby the disease could be spread from one individual to another. This theory was strongly supported by Ricord for many years, but this truly scientific sypliilographer at last saw his error, and, recanting, uttered in a new edition of liis “Letters” the expres- sion of his change of belief.1 We now know that the generalized lesions of syphilis are among the commonest sources of contagion, and it is no longer the custom, as it was at one time, to charge any individual presenting syphilis, no matter what his or her personal character and antecedents, with having indulged in illicit sexual intercourse. Among the generalized manifestations of syphilis those which are suppurative in character are most apt to convey the contagion. Mucous papules and patches are most commonly the source of infection, and after these in point of contagiousness are the pustular sypliilo- dermata—eethymatiform, acneiform, and rupial. The late lesions are not con- sidered contagious, although no direct inoculation-experiments have been practised with these. The blood of persons in the full course of syphilis is certainly infective,2 but at a later period its contagious quality gradually declines, and is finally entirely lost. The contagiousness of the normal secretions of the body—saliva, sweat, tears, milk, semen—hhs been examined into by various experimenters, with negative results, and I think we may say positively, that, as far as our present knowl- edge goes, none of these secretions act as the carriers of the syphilitic con- tagion. Modes of Contagion.—(1) Immediate.—The most frequent mode of syph- ilitic contagion is from the genital organs in sexual congress. Some abrasion of the skin is almost always if not invariably required in order to procure the entry of the virus into the system ; this, however, as is known, is not uneom- 1 “ L’homme absurde est celui qui ne change jamais,” said Ricord. * The contagious character of syphilitic blood has been ascertained by direct inoculation upon persons free from syphilitic disease. The fact is now universally admitted, so that it is not necessary to make any direct reference to the original investigations. Important as is the knowledge of this contagiousness of syphilitic blood, the manner in which it was gained, that is, by inoculating in some cases innocent and unsuspecting individuals, was unjustifiable and infamous. 345 GENERAL PATHOLOGY. mon in sexual intercourse. Now and then individuals are met with who appear to be quite refractory to the absorption of the syphilitic virus: such persons escape with impunity from an impure connection. Those who suffer from hereditary syphilis are believed to be exempt, and also most if not all persons who have already had the acquired disease. One attack of syphilis usually protects against a second, hut this is not invariably the case; Diday1 and others have reported cases of reinfection, where the disease ran its usual and regular course a second time. This goes to prove that syphilis is a curable disease, a fact which has been denied by some authorities. Now and then cases of contagion by the anus are observed, when this has followed as the result of unnatural intercourse. Contagion by the mouth is next in frequency to that by way of the genital organs. It is, indeed, not very uncommon. The source of contagion in this case, however, is usually the mucous patch. The most innocent persons may in this way contract the affection by kissing or fondling children suffering from hereditary syphilis, and children may in the same manner contract the disease from nurses, or may give it to them in the act of nursing.2 A few years ago the following case came under my observation, which illustrates the way in which syphilis may obtain entrance to a family quite unawares. A young girl, returning from a ball, kissed on parting the young man who had accompanied her home. She had been suffering from a cracked lower lip, and was consequently not alarmed when a “ fever-blister ” appeared in the locality a few weeks later. As this did not heal she sought relief after a time at a dispensary, where burnt alum or borax was applied for several weeks longer, the sore growing larger and harder all the time, and “kernels” appearing under the chin. When I saw her, at this time, the girl had a well-marked chancre of the lower lip, with hazel-nut sized induration, and accompanied 'by enlarged submaxillary glands. On inquiring as to the health of the family I learned that an infant sister, of whom my patient was very fond, had for some little time past ■showed “ fever-blisters ” on the commissure of the lips, and on visiting the house I found the child suffering with a small chancre of the commissure, together with a general maculo-papular eruption. I at once quarantined the victims of the disease, but too late, as the mother and two more children subsequently showed generalized syphilitic erup- tions, and the family remained under my care and observation for several years, showing various early and late lesions from time to time. Syphilis is also said, with some indirect evidence of truth, to have been conveyed in the act of ritual circumcision as practised among the Jews, the operator sometimes placing the infant’s penis in his mouth, previously tilled with an astringent fluid, after the operation, with the view of stopping the hemorrhage.3 Other modes of immediate contagion are the suction of the breast, or a wound, with a therapeutic purpose, the examinations or handlings of a mid- wife or accoucheur,4 or even the pressure of the body, as in cases where nurses have had chancres, the result of carrying infants upon the arm, who were suf- fering with mucous patches of the anus. Also, one case is recorded where a young man contracted a chancre of the thigh, of which he could give no his- tory, save that he had permitted a ballet girl affected with contagious syphil- itic lesions, and probably in very scanty attire, to sit for some time upon his knee. Syphilis is sometimes conveyed by the immediate contagion of bites. 1 Archives Generales de Medecine, Juillet et Aout, 1862. 2 See R. W. Taylor, The Dangers of the Transmission of Syphilis between Nursing Children and Nurses, in Infant Asylums and in Private Practice. Am. Jour. Obst., vol. viii. No. 3, Nov. 1875 ; also, Fournier, Nourrices et Nourrissons Syphilitiques. Paris, 1878. 3 See a paper on the question of the Transmission of Syphilitic Contagion in the Rite of Cir- ■cumcision, by R. W. Taylor, in the New York Medical Journal, Dec. 1873. 4 Bardinet (Mem. de i’Acad. de Med., Avril 14, 1874) gives the case of a midwife affected with a syphilitic lesion of the finger, through whom more than one hundred persons had been infected. 346 syphilis. A case has been reported where a man was bitten in a scuffle by bis antag- onist, who bad mucous patches of the mouth, and where a chancre followed in the wounded locality, and general syphilitic symptoms subsequently devel- oped. I have observed two cases of chancre following bites: in one of these a woman was bitten upon the nipple by her lover, during endearments which were never carried to the extent of sexual connection, and in the other a man was bitten upon the scrotum by a prostitute. In both of these cases I saw the initial lesion at an early date, and followed up the history of the indi- viduals. Similar cases are on record. The operation of skin-grafting may be the means of conveying syphilis.1 (2) Mediate contagion may occur from the passage of a cigar2 or pipe from mouth to mouth, from the use of various common utensils,® from sleeping in the same bed, or from workmen using such tools as are passed from mouth to mouth, as the blowpipes employed in glass works.4 Surgical instruments may convey contagion.5 Tattooing has sometimes been the means of convey- ing the poison of syphilis, as in the interesting series of cases, fifteen in all, reported by Maury and Dulles.6 Accoucheurs and midwives may become the sources of mediate as well as of immediate contagion. A case has been recorded in which the secretions of the female genitalia were the means of contagion. A woman had connection with a man having an infecting lesion upon the penis, and a few hours after with another man who had never previously had syphilitic disease. The second lover contracted a chancre- from this intercourse, while the woman whose vaginal secretions had carried the contagion remained healthy. In the early history of syphilis, it was imagined that the contagion could be carried by the air as smallpox could, and cases are on record where per- sons have been accused of conveying syphilis by whispering in the ear. We now know this to be a notion without foundation, and that actual contact is necessary. Another idea which was prevalent to within recent years was,, that an infant could contract syphilis from the mother in birth, as it passed through the parturient canal. Why this peculiar theory should have gained currency is hard to say. I believe it is entirely unsupported by any recorded cases. Many other means of contagion have been recorded by various writers which it is not necessary to enumerate, but the fact should be borne in mind in investigating obscure cases, and the physician should not be too hasty in imputing immorality when outward circumstances are against this view, and when even a possibility of mediate contagion- exists. One case may be mentioned. Clerc, a man not likely to take a credulous view of infection, showed to his pupils an old man of seventy, who had not indulged in sexual intercourse for many years. This man presented a chancre of the glans penis, derived from the rubbing of the organ against the front of a pair of suspected panta- loons which he had worn about two months.7 Vaccino-Syphilis.—The question of the conveyance of syphilis in vaccina- tion is one of great practical importance. The possibility of such an occur- 1 See Deubel’s case. Gaz. Med. de Paris, Nov. 5, 1881, p. 628. 2 Two Cases of Chancre of the Lip, probably acquired through Cigars. Transactions of the- American Dermatological Association. Archives of Dermatology, Oct. 1879. 8 See a Case of Syphilitic Inoculation by a Tooth-brush, by E. B. Baxter. Lancet, May 31, 1879.. 4 Rollet, Arch. G6n. de Med., 1859 ; Gaz. Med. de Lyon, Nov. 16 et Dec. 1, 1862. Also Decliaux, Epidemie syphilitique a la verrerie de Montluqon. Gaz. Med. de Lyon, Nos. 15 et 16, 1867. 5 As the Eustachian catheter. See Laillier and others, in Bull, et Mem. de la Soc. Med. des- Ilopit. de Paris, annee 1864, pp. 299, 213, et 1865, pp. 134, 136. 6 Am. Jour. Med. Sci., Jan. 1878. 7 See also Hyde, On Some Sources of Syphilitic Infection (American Journal of the Medical Sciences, January, 1874), and R0I16, Two Cases of Syphilis in which the Infection took place in- rather Unusual Situations (Chicago Medical Journal and Examiner, July, 1878). GENERAL PATHOLOGY. 347 rence was suggested as far back as the beginning of the present century, but general attention was drawn to the subject only as recently as 1852, when a veterinary surgeon of Berlin was condemned to tine and imprisonment for having conveyed syphilis to nineteen individuals by vaccination. The virus was conveyed by an infant, whose health appeared perfectly good up to the day of vaccination, but who, seven days afterwards, broke out with a general erythematous syphiloderm. In 1861 occurred the famous epidemic of Rivalta, a small Italian village of 2000 inhabitants. Two series of vaccinations were performed, with an interval of ten days. Some time after the first, thirty-eight children showed manifest symptoms of syphilis; in the second, one of these thirty-eight transmitted the disease to seven persons. These facts, as well as others subsequently reported, attracted much attention, and the subject lias of late years been studied with the result of making the symptoms and course of this form of disease much better known than formerly. A remarkable fact is, that in many of the reported endemics, the syphilitic- manifestations appeared at different times and in different forms in the various infected individuals. Some showed an early occurrence of characteristic cuta- neous and mucous eruptions, while in others the disease appeared at a later date, in the form of a lesion limited to the point of inoculation, generalized manifestations not appearing for four or five weeks more. Another confusing- circumstance was, that, many cases being inoculated with a liquid from the same source, the operation conveyed to some vaccinia, or syphilis, only, while others showed both affections simultaneously. In certain rare cases the vac- cinifer was found to be healthy. Viennois explained these apparently contra- dictory phenomena by showing that, when syphilis is transmitted by means of vaccination, the first lesion is a chancre at the point of inoculation, appearing after the usual period of incubation, and followed after the customary interval by general symptoms. When, however, the symptoms appear suddenly some days after inoculation, they cannot be regarded as the direct consequence of this procedure. Clinical observation has shown that the modification induced in the organism by vaccination may precipitate the appearance of eruptive- symptoms, in cases of individuals under the influence of syphilis. It remains to determine the agent of the contagion. The liquid of the vaccinal vesico-pustule cannot be held accountable, since, in many of the infants vac- cinated in the course of the various “ epidemics,” no syphilis followed. As we know that the blood of syphilitics is poisonous and infective, it appears likely that this was inoculated in the cases of transmission reported. The history of the cases makes this more sure, since it points to certain series of cases, where those vaccinated first from the arm of a syphilitic vaccinifer re- mained intact, while those near the end of the list, when the vesico-pustule was scraped by the lancet in order to obtain the last drops of vaccinal fluid,, suffered infection. It should be said, however, that all writers are not in accord regarding the theory that the blood alone is the infective agent in these cases. Epidermic scales, leucocytes, and lymph, according to some observers, may also be the vehicles of contagion. It has been asked whether the blood of an individual who has received the double inoculation of vac- cinia and syphilis is virulent already at the moment when the vaccinal pus- tules are developed—that is, about the seventh day—and consequently before the appearance of the chancre. The fact is as yet doubtful, although the fol- lowing case seems to favor the affirmative: During the epidemic of Rivalta, a certain patient, who had served to vaccinate, on the 12th of June, seventeen infants, of whom seven were subsequently affected with syphilis, observed her vaccine pustules changing to indurated ulcers. On the 2d of August, the patient’s skin became covered with an erythematous syphiloderm. To sum up: Vaccino-sypliilis may be derived from two sources, the vac- 348 cinifer and tlie vaccinated. The contagion is carried by means of the blood, and possibly by the epithelial scales and the white globules, and may infect either the vaecinifer or the vaccinated.1 Fournier says that to distinguish between vaccinal syphilis (that when in- fection and vaccination arc simultaneous) and the syphilis which is post- vaccinal (that declared in a congenitally diseased infant after vaccinia), it should be remembered:— (1) That in vaccinal syphilis there is a chancre at the point of inoculation with characteristic adenopathy of vicinity, while in infantile syphilis there is no chancre, but cutaneous, glandular, visceral, osseous, and other lesions. (2) The evolution of vaccinal syphilis is accomplished in the four periods of (a) twenty-day incubation, (b) explosive chancre, (c) forty-five-day incubation, (d) explosion of generalized symptoms.2 General Syphilis always Follows a Chancre.—Experience and also the results of accurate statistical inquiry show that in the vast majority of cases •of secondary syphilis, the existence of a previous chancre can be proved. Bumstead and Taylor give collated statistics of 1291 cases, in all of which, with the exception of 22, general syphilis was preceded by a chancre. These statistics, together with the fact that chancres are capable of spontaneous cicatrization, and may entirely disappear without leaving a trace, and also that in some situations, as the interior of the urethra, vagina, cervix uteri, and the buccal and rectal cavities, they may escape notice or be almost im- possible to detect, render it extremely probable (indeed, it may be said cer- tain) that general syphilis invariably originates in a chancre. It should be added that very many persons have had chancre without being aware of the fact, and that chancres are sometimes detected upon the persons of patients who are quite ignorant of their character and even of their presence. The chancre is often the most insignificant of all lesions. The initial lesion of syphilis is always a chancre, whether the infection has been derived from a chancre in the giver or from a secondary lesion. Syphilis has a certain definite period of incubation between the appearance of the chancre and the outbreak of the generalized lesions, which varies ac- cording to Diday’s statistics3 between 25 and 105 days, the average (of 52 cases) being 45 days.4 Bumstead and Taylor (op. cit.) sum up the matter in the following pro- positions :— A venereal ulcer which is not subjected to specific treatment (so called) will usually, if at all, be followed by secondary symptoms within fifty days, and always within six months. Conversely: The earliest symptoms of general syphilis (except in cases of hereditary origin) have been preceded by a chancre, probably within fifty days and certainly with- in six months. SYPHILIS. ’ Jullien, Trait6 pratique des Maladies VenSriennes. Paris, 1879. 2 A series of excellent papers by Dr. Frank P. Foster, of New York (Am. Jour. Syph. and Derm. vol. i., 1870, pp. 189, 293 ; vol. ii., 1871, p. 38 ; vol. iii., 1872, pp. 152, 318 ; vol. iv., 1873, p. 201), gives a complete review of the subject of vaccinal syphilis. See also a review by Dr. M. H. Murray, in the same Journal, vol. iv., 1873, p. 112, and see also Hutchinson, Illustrations of Clinical Surgery, Fasc. vi. 3 Diday, Nouvelles Doctrines sur la Syphilis, p. 265. 4 Excluding one case in Diday’s statistics where the inoculation was 105 days, the next highest figure is 70 days, and the average would then be much less. Bumstead and Taylor in giving these statistics remark that in 38 of the 52 cases, or in about four-fifths, this period was from 35 to 50 days. GENERAL PATHOLOGY. 349 Fournier1 gives the following striking analysis of the “ drama” of the ap- parition and development of syphilis. First Act : Contamination. The virus penetrates the organism by one mode or another. First Interval : Apparent repose of the organism—incubation. Nothing appre- ciable betrays the disease as yet. Second Act : Production at the point where the virus lias penetrated, and only here,, of a lesion called initial, which for the time constitutes the only expression of the disease. Second Interval : Another period of repose of the organism. The initial lesion continues to be the only symptom by which the disease is expressed. Third Act : Explosion of multiple and disseminated lesions, beyond and outside of the seat of contamination. This is the period of visible generalization of the disease. Syphilization.—Between tlie years 1844 and 1850, Dr. Auzias Turenne,. of Paris, brought forward and urged a theory of the prevention and cure of syphilis by means of “syphilization,” asserting that repeated and successive inoculations of the syphilitic virus would produce in animals and men a syphilitic saturation, and, as a result of this, certain immunity from a second infection of the same virus. Following him, Sperino, of Turin, as a result of numerous experiments, maintained that repeated and successive inocula- tions of the syphilitic virus, carried to saturation, would procure not only immunity against the infection of this same virus, but would also serve to cure the various syphilitic manifestations, initial as well as generalized.. At the time this theory was brought forward, no clear distinction was made between the virus of chancroid and that of syphilis. We now know that, while the chancroid is auto-inoculable, the unirritated chancre is not at all, or rather only very rarely, inoculable on the individual bearing it. Auzias Turenne, and those who shared his belief, usually inoculated the chancroid, and, finding that after repeated inoculations the sore could no longer be repro- duced, concluded that the individual was saturated with syphilis and incapa- ble of infection. He proposed syphilization as a prophylactic measure to be employed upon the community at large, and his earnest, impassioned, and persistent advocacy of his peculiar views gained for them an amount of atten- tion which, in the present state of our knowledge, it is difficult to understand. At present we know that the inoculation with venereal virus can have but two results, either (1) the individual experimented upon is already syphilitic, in which case the inoculation, if made with syphilitic virus, will be without effect—inoculations made with chancroidal virus, however, being capable of indefinite repetition ; or (2) the individual is free from syphilis, when the first inoculation of syphilitic virus will give him the disease; he will be in the same category as the former individual; and further inoculations will be without effect, while, as before, chancroidal virus may be reinoculated indefinitely. Boeck, of Christiania, was the most illustrious disciple of Auzias Turenne, and worked for years at the subject, finally compassing sea and land to make converts to his views, which were everywhere received with attention, fully investigated, and—rejected. Put to the test of careful observation by disin- terested investigators, the theory of syphilization was found to have absolutely no foundation in fact, and with the death of its enthusiastic advocates, Auzias Turenne and Boeck, the theory also died out completely.2 1 Lemons sur la Syphilis. Paris, 1873. 2 For a fuller exposition of the theory of syphilization, the curious reader may refer to Bum- stead’s work (3d edition), and to Report of Cases treated at Charity Hospital (Am. Jour. Med. Sci., July, 1870). Also to the original papers and works of Auzias Tureune (De la Syphilisation ou Vaccination Syphilitique. Arch. Gen. de Med., 1851, 4e s6r. t. xxvi.); Sperino (La Syphilisa- 350 SYPHILIS. Syphilis in Animals.—Although the chancroidal virus has been success- fully inoculated upon animals, yet syphilis has never yet been produced in any of the brute creation, though very numerous efforts have been made to attain success in -such inoculations, and though a variety of animals have been made the subjects of experiment. Thus, inoculations have been practised upon the monkey, dog, cat, horse, mule, sheep, rabbit, rat, Gruinea-pig, and heifer, but invariably without result.1 There is, however, room for further investigation in this direction. Reinfection in Syphilis.—Syphilis commonly occurs but once in the same person. The immunity conferred by one attack is just as great as in the case of the various other contagious and constitutional diseases—smallpox, scarlet fever, etc. Most of the numerous cases of syphilitic reinfection reported have been cases where lesions have relapsed after a certain interval, or where the observations were so imperfect as to throw much doubt upon their accu- racy. In most instances a recent attack of syphilis may be recognized— (1) By the induration of the preceding chancre and neighboring lymphatic ganglia. (2) By the time elapsing between the appearance of the suspicious ulcer and that of the general symptoms, the interval, when the latter are dependent upon the same infection as the former, and in the absence of treat- ment, being very uniformly about six weeks, and rarely exceeding three months. (3) By the character of the lesions, whether belonging to an early or late stage of syphilis. In the absence of these signs we may ascribe the lesions to an old infection. Before we can admit a second attack of syphilis, we must have an undisputed history of the iirst infection; we must have proof beyond doubt of a second chancre, which is followed by well-marked enlargement of the inguinal ganglia, and at a later period by secondary mani- festations of an undoubtedly syphilitic nature. Without this succession of lesions similar to those of the first attack, we cannot admit the claims of any case of syphilitic reinfection.2 A very considerable proportion of the reported cases of so-called syphilitic reinfection are nothing more than relapsing lesions of the original attack.3 The Evolution of Syphilis.—Writers upon syphilis usually classify the manifestations of the disease under the heads “ Primary,” “Secondary,” and “ Tertiary.” This is,however,as regards the last two divisions, an arbitrary dis- tribution, and one not always according to nature. For the “tertiary” lesions do not invariably appear in their due time, but may show themselves in the “secondary” period, without regard to preconceived ideas of their proper sequence, and without following the precedence commonly assigned to them. For this reason I prefer to classify the various stages in the evolution of syphilis as follows: (1) Period of the initial lesion or chancre; (2) Period of generalized lesions. These latter I shall consider according to their anatomical seat, and not generally according to their received chronological development. Hereditary syphilis, as sui generis, must be considered separately. The evolution of the various lesions commonly occupies about the same lion etudiee comme methode curative et comme moyen propliylactique des Maladies Veneriennes. Paris, 1853) ; and Boeck (Syphilisationen Studeret ved Sygesengen. Christiania, 1854 ; and On Syphilization, Am. Jour. Syph. and Derm., vol. i., 1870, p. 1). 1 See Traite thgorique et pratique de la Syphilis et des Maladies Veneriennes, p. 85. Par MM. les Docteurs L. Belhomme et Aim6 Martin. 2me ed. Paris, 1876 ; and Jullien, op. cit., p. 547. 2 Bumstead and Taylor, op. cit., p. 421. 3 See Kobner, Reinfection in Constitutional Syphilis. (Berlin, klin. Wochens., Nov. 1872. Translated in Am. Jour. Syph. and Derm., vol. iv., 1873, p. 128.) CHANCRE. 351 chronological period, hut this may be modified by the constitution and age of the patient, and still more by treatment. The following Table gives approximately the date of development of the various lesions following the appearance of the chancre. It may be of service in giving a general idea of the duration of the disease in any given case, but cannot be depended upon invariably, because, as has been remarked, treatment and other circumstances may modify the evolution of syphilis to a considerable degree. It has been compiled from various sources by Martin,1 and is here quoted from Bumstead and Taylor:— Symptoms. Date of usual development. Date of earliest development. Date of latest development. The erythematous syphiloderm . 45th day 25th day 12 th month Papular syphiloderm .... 65th “ 28th “ 12th “ Mucous patches ...... 70th “ 30th “ 18th “ Secondary affections of the fauces 70th “ 50th “ 18 th “ Vesicular syphiloderm .... 90th “ 55th “ 6 th “ Pustular “ .... 80 th “ 45 th “ 4 years Pustulo-bullous syphiloderm (“Rupia”) . 2 years 7th month 4 “ Iritis ... .... 6th month 60th day 13th month Syphilitic sarcocele ..... 12th “ 6th month 34 th “ Periostitis 6th “ 4th « 2 years Tubercular syphiloderm .... 3-5 years 3 years 20 Gummy tumors 4-6 “ 4 “ 15 “ Onychia . . * 4-6 “ 3 “ 22 “ True exostosis ...... 4-6 “ [2 “ . 20 “ •Osteitis, changes in the bones and cartilages 3-4 “ 2 “ 41 “ Perforation and destruction of the velum palati 3-4 “ 2 “ 20 “ Chancre. The chancre is the first local manifestation of syphilis. It appears at the point where the syphilitic virus has been inoculated, showing itself after an average incubation of from about twenty to thirty days. Although twenty-one days is given as the average period of incubation of the chancre, it must be remembered that in practice quite a considerable variation from this figure in both directions is encountered. Perhaps it would be safe to allow from fifteen to thirty- five days as the ordinary limit of variation. The following table* gives the result of a large number of observations by different syphilographers :— ' De 1’Accident primitif de la Syphilis constitutionelle, p. 87. Paris, 1863. * Jullien, op. cit., p. 552. 352 SYPHILIS. Duration of incubation. Diday. Le Fort. Mauriac. 1 day . . 1 case o case 3 days . 4 “ . 0 “ 3 cases 0 “ 2 CC 5 “ . 6 “ . 1 “ 0 “ 2 6 Cl Cl ■ 1 to 10 days 0 cases. 7 “ . 0 “ 3 Cl 8 “ . 2 cases 49 cc 9 “ . 1 case 11 li J 10 “ . 2 cases 35 u 1 11 “ . 2 “ 2 li 12 “ . 5 “ 17 Cl 13 “ . 0 case 5 Cl 14 “ . 0 “ 5 Cl 15 “ . 4 cases 114 Cl 10 to 20 days 3 cases. 16 “ . 1 case 5 Cl 17 “ . 0 “ 4 Cl 18 “ . 2 cases 5 Cl 19 “ . 0 case 2 a 20 “ . 1 “ 13 Cl j 21 “ . 2 cases 20 Cl 22 “ . 1 case 8 n 23 “ . 24 “ . 1 “ 1 “ 7 10 cc Cl 20 to 30 days 5 cases. 25 “ . 0 “ 9 it 26 to 30 days 1 “ 56 Cl . « 5 weeks 0 “ 10 Cl 30 to 40 days 14 cases. 6 “ . 0 “ 20 cc 40 to 50 days 15 “ 7 “ . 0 “ 3 cc 50 to 60 days 5 “ 2 months 0 “ 10 <( 60 and above 8 “ 3 “ . 0 “ 2 cc 28 cases 438 cases 50 cases. The typical chancre, as seen on the genitals, begins as a faint erythematous point, which rapidly develops into a pin-head sized papule, slightly eroded on its surface, and usually looking like a mere abrasion. As a lesion it is trifling. As Fournier remarks, it is “the smallest, the most superficial, the most benign, the most insignificant of all possible erosions.” This abrasion or erosion is roundish, oval, or sometimes linear, and covered, excepting at its- border, with a grayish pellicle (Plate XVIII. Fig. 1). It suppurates very slightly; is, indeed, scarcely more than slightly moist on the surface. In some cases1 it grows no larger; in other instances it increases in size progres- sively until it may attain the diameter of a centimetre or more, its base meanwhile becoming firmer and larger—indurating, in fact, until it has reached maturity (Plate XVIII. Fig. 2). In some cases the chancre first shows itself as a large papule, but after a time the surface of the lesion becomes excoriated or slightly ulcerated, and follows the same course as the typical lesion just mentioned. The floor of the chancre is very slightly eroded, the edges sloping gradually, not clear cut and excavated as in the case of chancroid. Xow and then, however, venereal sores are met with where considerable inflammation and suppuration have occurred, and where the edges of the sore are more or less excavated. In these cases it is impossible to distinguish the nature of the lesion at first, and the diagnosis for the time must be held in suspense. If the sore is a chancre, the characteristic induration of its base supervenes. Induration of Chancre.—This induration is an important element in the characteristic picture of chancre. It usually shows itself in the first week of the sore. Sometimes, however, it is delayed for two or three weeks. It is PLATE XVIII tliHt.S C ')'c’ ( 111 «> J Cl t auccc. M. BENCKE. LITH.CO. N.r. slight at first, but gradually increases in amount up to the time when the chancre heals over, when it begins to decrease again and gradually disappears, usually within a few weeks, but sometimes not for months. The induration underlies and surrounds the sore, which lies in it as if in a cup. When the sore is large and ulcerated the induration may be comparatively slight—so slight-as to be called “ parchment induration.” In other cases the induration is very considerable, raising the sore decidedly above the level of the sur- rounding skin. This is the ulcus elevutum1 of certain writers (Plate XVIII. Fig. 3). Induration is more marked in some localities than in others; thus, in chancres of the preputial mucous membrane, the corona glandis, and the balano-preputial groove, induration is apt to be more decided than in chan- cres of the skin. In women induration rarely occurs to a marked degree. It is, however, rarely absent in any case, and forms one of the most distinctive characteristics of the chancre. Now and then a small abscess forms in the induration just as it begins to be absorbed. Occasionally the induration ulcerates, so that it sometimes looks as if a new chancre were forming on the seat of the old one. Various Forms of Chancre.—Fournier2 gives an excellent description of the various clinical aspects presented by chancre as ordinarily met with. He gives the four following types: 1. The erosive, desquamative chancre; 2. The exulcerative chancre; 3. The ulcerative chancre; 4. The papular chancre. The erosive chancre consists simply of an epidermic or epithelial desquamation, which merely denudes the derma without excavating it. The exulcerative chancre attacks the derma superficially, laying it bare but not actually exca- vating it. The ulcerative chancre, on the other hand, is hollow, excavated, jagged—an ulcer in fact, but an ulcer at the expense of its own tissues. Finally, the papular or elevated chancre is situated on a sort of raised plateau, and forms a disk rising above and sharply defined from the surrounding tissues; it sometimes assumes the appearance of the ulcus elevatum mentioned above. A further variety of chancre is worthy of mention; it is that known as the “ multiple herpetiform” chancre, where half a dozen or a dozen lesions appear simultaneously. Care must be taken not to confound these lesions with those of simple herpes progenitalis, which they sometimes closely resemble. “ Mixed chancre” is the name given to the sore resulting from the inocula- tion of the syphilitic and the chancroidal virus at the same point. A person having a chancre may have connection with another individual free from syphilis, but having a chancroid, and may contract a chancroid on the very syphilitic sore, the two diseases running their course side by side. Or a per- son having a chancroid may have the sore inoculated with syphilis. The “ mixed chancre” is not an entity; it cannot be transmitted from generation to generation as such. CHANCRE. 353 Chancre usually Solitary.—The chancre is usually solitary,3 the reason being that the virus is not auto-inoculable. To have more than one chancre [> This term is also applied by some writers to the chancroid. Vide supra, p. 318.] 2 Op. cit., and also in Annales de Dermatologie et de Syphiligraphie, n. s., t. i. p. 750, from Jour, de Med. et Chir. Pratiques, 1880. 3 Fournier (op. cit., p. 75) gives the following statistics, relating, however, to women only: Of 203 patients observed, 134 had a single chancre ; 52 had two ; 9 had three ; 4 had four ; 3 had five ; and 1 had six chancres. He also gives, as extraordinary, one case where nineteen and another where twenty-three chancres occurred simultaneously. 354 SYPHILIS. we must have simultaneous inoculations at various points.1 The solitary character of chancre is important from a diagnostic point of view. Chancre Involves the Neighboring Lymphatic Glands.—The chancre almost invariably2 gives rise to involvement of the neighboring lymphatic glands, the glands affected being multiple, separate, so that they can be rolled under the finger, hard, indolent, without change of color, and, unlike the lymphatic engorgement of chancroid, only very rarely suppurating. The lymphatic engorgement of chancre is gradually absorbed, and disappears in a variable length of time. It often happens, when the duration of the chancre is prolonged beyond the ordinary limit, perhaps to three or four weeks, that the “constitutional” or generalized symptoms manifest themselves concomitantly. Chancre rarely Complicated by Inflammation or Phagedjena.—The chancre is very rarely complicated by phagedtena or gangrene, and seldom even shows inflammatory symptoms. After remaining for some days sta- tionary at its period of full development, it tends to heal over, and is gene- rally completely cicatrized at the end of a month. Chancre may be Transformed into a Mucous Patch.—When the chancre takes on the form called ulcus elevatum, it often closely resembles the mucous papule, and may easily be mistaken for this lesion; indeed, when the general eruption takes place before the chancre is completely cicatrized, the latter is occasionally transformed into a mucous patch.3 Relative Frequency of Chancre of Different Localities.—Chancre has no exclusive place of election: it occurs wherever the syphilitic virus has been deposited on an absorbing surface. Of course the genitalia are by far the most frequent seat of the lesion, being affected in about the proportion of 95 of every 100 instances. The relative frequency of chancre in the various genital regions is shown in the fol- lowing tables. Seat of Genital Chancres in the Male. (Clerc’s figures.) Total number . 394 Internal surface of tlie prepuce 63 Balano-preputial fold 171 Orifice of the prepuce 35 Frsenum...... 14 Gians 12 Meatus urinarius .... 33 Cutaneous surface of penis or prepuce 58 Scrotum ...... 3 Peno-scrotal angle .... 5 (Fournier’s figures.) Total number . 445 Gians and prepuce .... 314 Preputial furrow .... 60 Multiple, that is showing chancres of the furrow and prepuce, or of the furrow and glans . 11 Meatus urinarius .... 32 Intra-urethral .... 17 Scrotum ...... 7 Peno-scrotal angle .... 4 1 Fournier inoculated the discharge of ninety-nine chancres upon the patients themselves and succeeded in but one instance, in which the experiment was performed within a very short period after infection. Puche states as the result of his experience that auto-inoculation of the chancre is successful in only two per cent, of cases. Poisson obtained like results in fifty- two cases, and Laroyenne was unsuccessful in every one of nineteen. (Bumstead and Taylor, Pathology and Treatment of Venereal Diseases, 4th ed., p. 436.) 2 So invariably that the glandular involvement is a better sign of chancre than even induration. 3 See Fournier, Des Indurations secondaires et des Transformations du Chancre. Ann ales de Dermatologie et de Syphiligraphie, t. iii. p. 255. genital chancres. 355 Seat of Genital Chancres in the Female. (Fournier.) Total number ...... . 249 Labia majora .... 114 Labia minora .... 55 Fourchette ..... 38 Neck of the uterus 13 Clitoridian region 10 Vulvo-vaginal orifice . 9 Meatus urinarius, or urethra 7 Superior commissure of vulva 2 Vagina, properly so called . 1 Genital Chancres. Among genital chancres, those of the urethra in the male and of the cervix uteri and vagina in the female deserve especial notice. Chancres of the Urethra.—Chancres of the meatus are not by any means as rare as those of the deeper portion of the urethra. Jullien,1 in a total of 1773 chancres collected by himself, reports 89 chancres of the meatus and but 17 of the deep urethra. Bumstead and Taylor2 have seen several examples, ■one, two, and even three inches from the orifice. Keyes3 has observed two, one of which was one and a quarter inches from the meatus. Hyde4 has also observed two cases. When the meatus is involved, the chancre, incessantly irritated by the urinary current, sometimes presents the irregular appearance of chancroid; it is irritable, and is said to possess a tendency to phagedsena. The deformity frequently occasioned is characteristic, the induration (late sometimes in its appearance) causing the glans to look as if carved out of wood. A peculiar, square, somewhat enlarged urethral orifice is the occa- sional result of chancre in this situation. To perceive the induration of chancre of the meatus or deep urethra, the penis should he grasped between the thumb and forefinger in an antero-posterior direction. The attention is usually first attracted by a slight impediment to urination, and a purulent discharge, due to a surrounding urethritis set up by irritation in the mucous membrane of the neighborhood, the case resembling one of anomalous gonor- rhoea.5 With the endoscope, chancre of the deep urethra can be seen as an •erosion of the urethral walls, which have a grayish-red color. Chancre of the urethra is not usually painful. A characteristic sign, which is mentioned by Bumstead and Taylor, consists in inflammatory thickening of the prepuce on either side of the fraenum. The symptom is so constant as to be of considerable diagnostic value. Other aids to the diagnosis between chancre of the urethra and gonorrhoea are the slight, gluey, perhaps bloody, discharge, the localized impediment to urination, the subacute course of the lesion, and the involvement of the inguinal glands. Chancre of the urethra, especially when deeply situated, sometimes results in stricture to a greater or less degree, which must be divided with a knife. 1 Op. cit., p. 582. 2 Op. cit., p. 571. 3 The Venereal Diseases. New York, 1880, p. 89. 4 Chancre of the Meatus and Urethra in the Male. Chicago Med. Jour, and Exam., Aug. 1880. 5 The occurrence of chancre of the urethra has been thought the cause of Hunter’s mistake in taking gonorrhoea to be a syphilitic manifestation. John Hunter inoculated himself with the matter from a gonorrhoea, the result of which was the development of primary sores followed by general infection of the system. Ricord believed that Hunter had accidentally inoculated him- self from a urethral chancre, but Lane (op. cit., p. 6) suggests the greater probability of con- veyance of the syphilitic poison by the blood or morbid secretions of the person from whom the gonorrhoeal matter had been taken. 356 SYPHILIS. At times local medication must be used in addition to general treatment. Bumstead and Taylor recommend the use of bougies made of mercurial oint- ment two parts, and white wax six parts. Occasionally iodoform, one drachm to each ounce of the other ingredients, may be employed. Chancre of Cervix Uteri.—Chancre of the cervix uteri was formerly regarded as an extremely rare lesion. Fournier, however, met with 13 cases in a total of 249 chancres of the female genitalia, and quite a number of cases have been reported by other observers. It is undoubtedly more common than statistics would seem to indicate, and must often pass unnoticed. In the majority of cases, this form of chancre occupies the central portion of the cervix, seeming to lose itself in the orifice. It is commonly single, but may be multiple, and varies in size from that of a bean to that of a small coin, sometimes even reaching a diameter of three centimetres. When it occurs of small size it probably often escapes observation. As chancre of the cervix uteri is continually bathed by the various secretions of the locality, its color is less bright than that of the lesion as found on the skin, the sur- face often being whitish, gray, grayish-yellow, or greenish. Sometimes it is cup-shaped and excavated, particularly when eccentric, with smooth and var- nished bottom and borders sharply defined by a purplish or grayish, rose- colored collarette. (See Plate XVIII. Fig. 5.) At other times it is less sharply circumscribed, and its surface is prominent, mammillated, and vegetating, or at times pultaceous. The secretion from chancre of the cervix uteri is com- monly scanty or absent. Induration, although undoubtedly present in these cases, is usually difficult to make out by palpation. In the case of a woman suffering from prolapse of the uterus, on whose cervix a chancre was found, Ricord was able to per- ceive, on palpation, a sub-chancrous mass of almost wooden hardness, easily defined from the tissues of the surrounding organ. Chancre of the cervix uteri is indolent and pamless. It does not indicate its presence by any subjective symptom whatever, and is, therefore, as a gen- eral thing, only discovered by accident. Ganglionic involvement is in some cases difficult to recognize, while in others it is due, when present, to the coexistence of other sores than those on the cervix, a circumstance peculiarly liable to occur. In thirty-four cases of chancre of the cervix uteri observed by Fournier,1 only fifteen were single. In the nineteen remaining cases other ulcers could be seen, thirteen times on the labia, three times on the fourchette, once on the meatus, and twice on the integument about the anus. This circumstance of the multiplicity of lesions may perhaps be explained by the common observation that herpes of the genitals is an almost constant accompaniment of chancre of the cervix uteri. The diagnosis of chancre of the cervix uteri can often be made only after careful examination. It is most likely to be mistaken for chancroid of the same locality, but the latter lesion usually shows more excavation and more decided loss of substance, with undermined and eroded edges surrounded by a reactive inflammatory area. The surface of the chancre, on the other hand, is usually flat and sometimes elevated, without a very sharply defined border. The floor of the chancroid is rough, uneven, eroded, and covered with a yellowish secretion, while that of the chancre is smooth, as if varnished, grayish, or flesh-colored, and exuding a scanty sero-purulent or sanguinolent discharge. The floor of the chancroid is soft, that of the chancre hard. • Verbal communication to M. Jullien of later date than the statistics given before. See Jul- lien, op. cit., p. 588. 357 GENITAL CHANCRES. Differential Diagnosis between Chancre and Chancroid of the Cervix Uteri. (Fournier, op. cit., p. 300.) Chancre of the Cervix. Chancroid of the Cervix. of’ a prob- ISquivocal able character. signs. I. Habitually single on the cervix. Rarely multiple. II. Commonly of limited extent. III. Always erosive, or papulo- erosive. IV. Of an opaline tint, grayish and pseudomembranous. I. Single or multiple (often single from the fusion of several neighboring sores). II. Often extensive. III. Sometimes ulcerative with irregular jagged edges; sometimes also papu- lar, but with irregularities of surface depressions and elevations. IV. Yellow or yellowish in color, and of a brighter tint than the grayish dusky shade of the chancre. Y. Coincidently, at the vulva, chancroids of unmistakable character, and more or less numerous. In some cases chancroids in the vaginal ampulla in the neighborhood of the cervix. YI. Auto-inoculation producing a chan- croid. Coincidently, at the vulva, either ab- sence of any lesion, or chancres.1 YI. Auto-inoculation negative. Chancres of the cervix must sometimes be differentiated from follicular ulcers. These are small, cup-shaped, situated in the follicles, and usually no larger than the follicle from which they are derived. Catarrh of the cervix, hypertrophy of the cervix, fluor albus, etc., are also accompaniments of follicular ulceration of this. region. Simple erosions sometimes resemble chancre, but only in the earliest stage of the latter. Papillary erosion, a meta- morphosis of simple erosion characterized by the dark red points of papillae denuded of their epithelium, which are scattered over the surface and ac- companied by cervical and vaginal catarrh, must also be differentiated. The so-called herpetic ulcer may sometimes resemble chancre, but it is apt to be multiple, and the lesions run together forming an irregularly outlined sore. In addition, little herpetic ulcers tend to rapid cure. Carcinoma is distin- guished from chancre of the cervix uteri by its crater-like excavation, the depth of the sore, with irregular, thick, hard, bosselated edges; the uneven floor, covered with a dirty, purulent, and ill-smelling secretion; the frequently ■accompanying hypertrophy of the cervix, with immobility of the uterus itself as the growth progresses; the occasional stubborn bleeding; the pain; and finally the age of the patient. Tuberculous ulcers of the cervix are almost unknown as primary appearances, and are accompanied by signs of tubercu- losis in other organs.2 Chancres of the Yagina.—Chancre of the vagina (excepting in that por- tion immediately within the vulvar ring), is excessively rare. Among 249 chancres of the female genital organs, Fournier saw only one in the vagina, and that doubtful. Binet,3 in 128 chancres of the female genitalia, only observed two cases. The vaginal mucous membrane with its thick layers of epithelium is seldom eroded in sexual intercourse, and this will account for 1 A reservation must be made in the possible but exceptional circumstance of double contagion. * See an excellent article on the diagnosis of chancres of the cervix, by Rasmussen (Viertel- jahrsschr. fiir Dermatologie und Syphilis, Bd. viii. S. 517), of which an abstract may be found in (the Philadelphia Medical Times, March 26, 1881. 3 La France MSdicale, t. i. p. 38 ; abstract in Archives of Dermatology, July, 1881, p. 334. 358 SYPHILIS. the rarity of the vaginal chancre. Binet describes the lesion in one case as situated on the right vaginal wall, near the inferior extremity of the os uteri; a centimetre in diameter; the floor red, smooth, shining, and non-purulent; the edges slightly elevated and passing without a ridge into the bottom of the erosion. Induration was difficult to make out from the peculiar situa- tion of the chancre, but by passing the finger lightly over the tissues in the neighborhood, a slight resistance could be perceived as of a more resilient sur- face. The lymphatics running along the walls of the vagina were enlarged, and appeared to leave the erosion and run toward the indurated post-pubic ganglia. Small ganglia could also be perceived in the neighborhood of the obturator foramen. In Binet’s other case, the chancre was situated on the posterior wall of the vagina just within the carunculse myrtiformes. It was about twro centimetres in diameter, and presented the same features as the lesion in the first case. Extra-Genital Chancres. Extra-genital chancres occur in men in the proportion of 6 per cent, of chancres of all kinds. In women, the proportion of extra-genital chancres is much greater, amounting to 16 percent., an important clinical fact. The usual seat of extra-genital chancre is about the mouth in both sexes, and, in women, about the anus and on the breasts. The chancres of other extra- genital localities are much less frequent. The following statistics,1 compiled from various sources, show the comparative fre- quency of the different extra-genital chancres in men and in women. Men. Anus 12 Lips .... 36 Gums . . . 1 Tongue 8 Nose and cheek 3 Eyelids • 2 Abdomen . 9 Buttock 1 Lower limbs 3 Fingers 2 77 Women. Anus and perineal region . 21 Lips ..... 20 Tongue .... 2 Uvula .... 2 Mouth (in general) . 4 Breasts .... 11 Groin and thigh 8 Buttocks .... 4 Ala nasi .... 6 Forehead .... 3 Neck .... 1 82 Buccal Chancres.—Among chancres of the buccal region those of the lips are the most common. Chancre of the lip may be a very minute and insignificant lesion. It may also be a more extensive ulcer, raised, crusted, and involving the skin beyond the muco-cutaneous surface of the lip, being accompanied by very considerable oedematous swelling and firm infiltration of a characteristic sort, usually insensitive, but sometimes giving pain from tension, and not infrequently causing so much eversion of the lip as to prevent the mouth from being closed (Plate XVIII. Fig. 4). Chancre of the lip may also be a fissured ulceration, springing from a cracked lip, and unfortunately too apt to be mis- taken for this trifling lesion. When chancre occurs on the inner surface of the lip, the ulcer is less elevated than in chancre of the outer aspect, and is occasionally accompanied by perceptible loss of substance. The submaxillary glands become SAVollen in about ten days after the appearance of the chancre,, and often give rise to much pain and discomfort. In infants, buccal chancres, are usually derived from mucous patches on the nurse’s nipple. 1 Jullien, op. cit., p. 533. extra-genital chancres. 359 Chancres are also met with on the gums, the gingivo-labial surface of the tongue, the velum palati, the tonsils, and thq pharynx, the sore in each locality presenting certain characteristic features. Chancre of the tongue is usually situated on the top of this organ, and presents a peculiar opaline surface, which may cause it to be mistaken for a mucous patch. Chancre of the tongue may become phagedenic and be transformed into a large ulcer. One such case has been cited by Jullien. Chancre of the to?isil is very rare, and its exist- ence even has been disputed. The lesions, as described, are never sharply defined. They are dark-red, superficially ulcerated nodules, which secrete a scanty fluid. The history of the case, the subacute course of the nodules, the absence of inflammatory symptoms, and the enlargement of the cervical and submaxillary ganglia, would be the points upon which to rely in arriving at a diagnosis. Phagedsena is a rare complication of the buccal chancre wher- ever found. Anal and Rectal Chancre.—Chancre of the anus is much commoner among women than among men. In the former, it is probably, as a general thing, communicated by accidental contact in normal sexual intercourse, while in men the existence of chancre of the anus gives just cause for sus- picion of unnatural abuse, though it is possible that it may be contracted by contact with the finger, etc. French statistics show that in men 1 chancre in 119 is anal, while in women 1 in 12 is seated in this locality. Statistics are wanting for this country, but my impression is that anal chancre among men is of the rarest. The usual seat of anal chancre is in the folds of the anal mucous membrane. These being put upon the stretch, the lesion may be dis- covered in the form of an elongated reddish ulcer. Occasionally, however, the chancre is minimal in size, a small, excoriated papule. Xow and then it is large, cup-shaped, and excavated, with a well-marked, indurated base. Intra- anal chancre is generally of the fissured form. Rectal chancre is very rare, and can scarcely occur except as the result of unnatural intercourse. Anal chancre is usually indolent, very rarely exciting reflex spasm. This is a very important diagnostic sign, since simple fissures are usually accompanied by severe pain. In the lowest classes of women the anal chancre is sometimes “ mixed.” A not very infrequent complication is that of vegetations, which sometimes occur to a quite considerable size. Stricture of the rectum is rarely, if ever, the result of chancre. So-called chancral strictures are usually due to gummatous or other late syphilitic lesions. Indurated engorgement of the external inguinal glands is a usual accompaniment of anal chancre; it appears early, and is usually bi-lateral. Chancre op the Mammary Region.—Chancre of the breast is one of the most important among extra-genital chancres. Although it may be contracted by contact with the mouth or even the genitals of another adult, it is by far the most frequently met with as the result of contagion from mucous patches on the lips of nursing infants.1 This fact is of importance from a medico-legal point of view, and the characteristics of this lesion should therefore be borne in mind. When seated outside of the nipple, mammary chancre can be diagnosticated without difficulty. It shows itself as an erosion, or an eroded papule of some size, with or without a crust, roundish or ovalish, and resting upon an indu- rated base (Plate XVIII. Fig. 6). When, however, mammary chancre affects 1 According to “ Colies’s law,” which will he explained on a subsequent page in treating of the hereditary transmission of syphilis, the mother of an infant the subject of hereditary syphilis cannot contract the disease from her offspring. 360 SYPHILIS. the nipple, and especially when it is confined to the base of the nipple, it is sometimes difficult of diagnosis. Irregular in form, often very small, even like a slight fissure at times, and masked by a crust, it is very apt to be mis- taken for some simple lesion, such as a chapped breast, a furuncle, or a simple erosion, a circumscribed eczema, or a bite or some other injury contracted in nursing. It should be remembered that mammary chancre is at times one of the slightest and apparently most inoffensive of lesions. Two symptoms, however, may usually be relied upon to decide the diagnosis, or at least to aid it materially. The first of these is the induration of the lesion, characteristic of chancre, and wanting in the other lesions liable to be mistaken for it. The second is the enlargement of the axillary glands, which is never wanting, and which presents the peculiarities of syphilitic adenopathy—the cold, hard, indolent condition. The indolent and comparatively painless character of the lesion is also of importance from a diagnostic point of view. When the patient suffering from supposed mammary chancre is a nursing woman, she should of course be confronted with the nursling, and a careful examination should be made of the latter, with the view of ascertaining the presence or absence of signs of syphilis. Digital Chancres.—A few words may be said with reference to chancre of the finger, which, though rare, yet does occur from time to time, and may go unrecognized to the injury of the patient, and to the danger of those with whom he may be brought into contact. The type of chancre of the finger eommonly met with is the “ulcus elevatum.” Its evolution seems to be somewhat slower than that of chancre of the genitalia, the induration in par- ticular lasting a long time. The commonest seat of chancre of the finger is at the side or base of the nail, or at its free margin. It begins as a papule, pustule, slight excoriation, or fissure. On examination, a deep-red, hard, elevated mass of moderate size is perceived, which when ulcerated yields a scanty, serous secretion. The borders of the nail may be thickened or super- ficially ulcerated, but the sore is confined to the soft parts—a point of distinc- tion between chancre and syphilitic onychia. The entire distal phalanx is sometimes indurated, giving the finger a bulbous shape. The epitrochlear and axillary ganglia are usually enlarged, and moderate lymphangeitis is sometimes present. Physicians and mid wives are more apt than others to be affected with this form of chancre, and, especially in the case of midwives, the affection may be conveyed to others and very widely spread.1 Relative Frequency of Chancre and Chancroid. The relative frequency of chancre and chancroid is a matter demanding some notice. According to Belhomme and Martin,2 the French statistics on this subject are so diverse that it is impossible to draw an average, one observer reporting four chancroids to one chancre, while another meets with them in nearly equal numbers, and while others, especially of late years, tind the proportion nearly reversed. (See Tables, pages 333, 334.) One thing is certain, namely, that among the upper classes chancre followed by syphilis is the commoner affection, while in the lower classes chancroid is more frequently met with. In all probability chancroid is destined to greater rarity as time goes on, and it is not rash to hope for its almost entire extinction in the not very remote future.3 1 See Bardinet, Syphilis communiquee par le doigt d’une sage femme. Bulletin de l’Aca- demie de Medecine, Avril, 1874. 2 Op. cit., p. 12. 3 See Bumstead and Taylor, op. cit., p. 346. LESIONS OCCURRING CONCOMITANTLY WITH CHANCRE. 361 Lesions occurring Concomitantly with Chancre. Lymph angeitis.—In one case out of five, according to Bassereau, the chancre is followed by inflammation of one or more lymphatic vessels in its neigh- borhood. These appear in the form of cordy indurations under the skin, more or less straight, or occasionally wavy and moniliform. Sometimes several parallel lymphatics are involved, giving the sensation of a ribband under the skin. It is only rarely, and when the inflammation is more severe, that the enlarged lymphatics can be traced by their color, which shows of a light red under the skin. This engorgement of the lymphatics is unaccom- panied by fever, and patients sometimes fail to notice the change. At other times there is a slight sensation of weight and tension. After three or four weeks, the lymphangeitis commonly disappears by reso- lution. Occasionally, however, like the induration of the chancre itself, this induration may last for six or eight months. In rare cases an abscess, fol- lowed by a lymphatic fistula, exuding a clear fluid, occurs in the course of the vessels. This often is healed only with difficulty. The richness of the genital region in lymphatics makes the occurrence of angeioleucitis much more common in chancres of these parts than it is in connection with extra- genital chancres. In men, the lymphatics of the dorsum penis are those most usually affected, and their long cord-like course can easily be followed to the pubes and to the groin. In women, the inflamed lymphatics are hidden in the tissues of the labia minora and majora, and run up toward the ganglia parallel to the genito-crural fold. They are also met with about the mons veneris in the form of knotty masses buried in the fatty tissues of the region. When they cannot be perceived by the touch, the presence of inflamed lym- phatics in this region is often manifested by oedema of the mucous or muco- cutaneous surface of the vulva. Adenitis.—Adenitis is in reality not a complication of chancre, but a necessary accompaniment. It occurs almost invariably; as Ricord used to •say, “The bubo follows the chancre as the shadow follows the person.”1 Ade- nitis is, if not the most, at least one of the most important aids to the diagnosis -of chancre, and its peculiar characteristics should be carefully noted. The bubo symptomatic of chancre is found in the ganglia with which the lymphatics of the affected region are connected. If the chancre is seated ■on the genitalia, the glands of the groin are affected, but those of other re- gions, the sub maxillary, for instance, remain unaffected. If the chancre is in the mouth, the submaxillary glands are enlarged, but those of the groin remain intact. The following table, from Fournier, shows the seat of the bubo correspond- ing to chancres of various localities. Seat of Chancre. Corresponding Bubo. Genital chancres, that is, chancres of the penis, scrotum, labia majora and minora, f'ourehette, meatus urinarius, urethra, opening of the vagina, etc. Perigenital chancres : chancres of the peri- neum, genito-crural region, mons vene- ris, buttocks, thighs, etc. Inguinal ganglia. Inguinal ganglia. 1 Fournier, in 265 cases of chancre occurring in men, found, adenitis in 263 ; in 223 cases of chancre observed in women, 220 showed concomitant adenitis. 362 SYPHILIS. Seat of Chancre. Chancres of the anus and margin of the anus. Chancres of the lip and chin. Chancres of the tongue. Chancres of the eyelid. Chancres of the finger. Chancres of the arm. Chancres of the breast. Chancres of the cervix uteri. Corresponding Bubo. Inguinal ganglia. Submaxillary ganglia. Subhyoid ganglia. Pre-auricular ganglion. Epitrochlear ganglion ; axillary ganglia. Axillary ganglia. Axillary and sometimes subpectoral ganglia. Theoretically the pelvic ganglia ; in gene- ral, no engorgement in the groins ; ex- ceptionally, inguinal bubo. The induration of the ganglia begins about the same time as the indura- tion of the base of the chancre. In rare cases the induration may be de- layed, but, according to Ricord, never longer than a fortnight. Fournier, however, mentions one case where the ganglionic induration did not appear until twenty-seven days after the appearance of the chancre. In adenitis accompanying chancre of the genitalia, the induration may affect the glands of either or both groins. It usually occurs on the same side as that upon which the chancre is situated. One or more glands may be affected. The “ pleiad” of olive-shaped or globular tumors is felt, carti- laginous in hardness, freely movable on each other and the surrounding tissues, and without attachment to the overlying integument. One gland is usually more developed than the rest, and may be of almond size, while the- others as large as a bean or a cherry surround it like satellites. A marked peculiarity of the syphilitic adenitis accompanying chancre is its indolent character. Tlie glandular enlargement takes place insidiously, often without the patient’s knowledge. The skin remains unaltered, there is no pain, and only slight tenderness on pressure. The whole picture of “ syphi- litic bubo” is as widely different from that of chancroidal bubo as it is possible to imagine. (See article on Chancroid, page 329.) Less frequently a single tumor is felt in the groin, and this may be somewhat larger than those above described. The various characteristics, however, remain the same. Ganglionic induration is usually at its height within a week or two weeks. If mercury be given, it may diminish in degree, only to return when secon- dary or general symptoms show themselves. It may last from several weeks to five or six months, or longer. The adenitis of syphilis very rarely results- in suppuration. Bassereau found only 16 cases of suppurating bubo in 383 cases of syphilis, while Fournier found but 2 in 265. The importance of the non-suppurative character of syphilitic bubo, is seen in the investigation of cases where doubtful lesions, late in character, if syphilitic, show themselves. If the patient gives a history of venereal sores accompanied by non-suppurating buboes, syphilis may with great probability be inferred. If, on the other hand, the venereal sores were followed by sup- purating buboes, the probability, though much less strong, is in favor of the- occurrence of chancroid. It is a common but not invariable rule that syphilis does not follow an open bubo. Syphilitic adenitis is most apt to be confounded with strumous engorge- ment. The history of the case and the accompanying symptoms must decide the diagnosis. From simple inflammatory and virulent bubo, the indolent and non-inflammatory character of the lesion under consideration will dis- tinguish it.1 1 See Auspitz, Buboes of the Inguinal Region. Archiv fur Dermatologie und Syphilis, 1873. Translated in the American Journal of Syphilography and Dermatology, vol. v, 1874, pp* 131, 270. DIAGNOSIS OF CHANCRE. 363 Diagnosis of Chancre. The diagnosis of chancre is sometimes easy, and at other times very diffi- cult, but it is always a matter of great importance, both on account of the prognosis, and also on account of the treatment which is to be followed. One of the first questions that suggests itself here is at what date can a positive diagnosis be reached. Patients not infrequently apply to the physi- cian with an abrasion of recent date, perhaps not twenty-four hours old, de- manding a categorical answer to the inquiry what may be the nature of the lesion. The answer to this can be of but one kind. It is impossible to say, at so early a date, what such a lesion may turn out to be. The most virulent chancre, leading to the most malignant form of general syphilis, is, in the earlier days of its appearance, one of the most benign of all lesions. A pin- scratch looks more threatening. In fact, where a mistake in diagnosis has been made, it has been, nine times ©ut of ten, that the chancre has been mistaken for an abrasion. This fact should be kept in mind as giving a good notion of the ordinary appearance of a chancre when it first makes its appearance. It is not an ulcer; not a sore; it is an abrasion, or a scratch, to all appearance. A little later, when the chancre has begun to differentiate itself from lesions of similar appearance, two diagnostic points of much value present themselves. These are induration and glandular engorgement. All other diagnostic signs are delusive. The contour of the lesion, its form, its color,, the aspect of its surface, etc., are variable, inconstant, and not to be trusted. But palpation of the base of the suspected lesion will almost invariably reveal a peculiar resistance, a hardening of the tissues, which, when present,, is an almost certain sign of chancre. Ao other lesion likely to be mistaken for chancre presents tliis firmness of base, though when caustics or irritants have been used, there is often developed an inflammatory induration which is with difficulty distinguished from the induration of chancre.1 Again, if the suspected lesion is of some standing, at least one to two weeks, the pre- sence of glanglionic engorgement, that is, of a group of small, bullet-like, indolently swollen glands in the groin, will indicate almost with certainty that it is a chancre. Hext to a simple abrasion or scratch, the lesion which is most likely to be mistaken for chancre, and vice versa, is herpes progenitalis. It is indeed often very difficult to distinguish between the two lesions. One of the first diag- nostic signs is that herpes is almost always accompanied at its first appear- ance by heat or burning of a local character, while chancre is completely indolent and without sensation. This sign, though of value, depends upon the subjective sensations of the patient, and cannot, therefore, be entirely depended upon in many cases. More certain diagnostic signs are the con- dition of the ganglia, the presence or absence of induration, and the outline of the lesion. As to the ganglionic engorgement, this is not present where there are only one or two scattered lesions of herpes, but where the herpetic lesions are confluent and of some size, there is a ganglionic engorgement, differing from that of chancre, however, in being merely a slight sub-inflam- matory tenseness of the ganglia. The induration of chancre is marked; that of herpes, in the unusual circumstance of its being present, is nothing more than a very slight inflammatory firmness of the underlying tissues. The outline- of the lesion is strongly insisted upon by Fournier as one of the most satis- 1 In investigating a suspected sore, the question should always be asked : “ Has any applica- tion been made ?” 364 SYPHILIS. factory and certain diagnostic differences between herpes and chancre. The contour of a chancre is represented either by a circle of a certain diameter, more or less ; by an oval figure ; or by an irregular geometrical outline. The contour of a large patch of herpes on the other hand is of a curiously figurate character, made up of a series of incomplete circles (Fig. 333). This Fig. 333. Outlines of chancre and herpes, showing polycyclic contour of herpetic lesions ; a, chancre ; b, herpes. u polycyclic” form, as Fournier calls it, is not accidental; it results from the fusion of a number of independent circular lesions, and is pathognomonic of herpes. Of course chancre does not possess this peculiarity because it is not made up in the same manner. To these diagnostic signs between herpes and chancre, which are to be •depended upon when a conclusion is to be reached if possible at the first view, may be added another which requires time, I mean the ulterior evolu- tion of the lesion, which is of course the criterion par excellence. If the lesion is herpes, repair quickly takes place, and rapid cicatrization, with no after symptoms. If, on the other hand, it is a chancre, the process of repair is in most cases a slower one. The lesion extends a little, or more frequently remains stationary as regards size, meanwhile assuming a more and more characteristic appearance, and the accompanying ganglionic enlargement shows itself unequivocally. Of course, all uncertainty is at an end when, after a few weeks, generalized symptoms make their appearance. One cause of possible error must be alluded to at this point: it is the for- tuitous coexistence of herpes and chancre in an identical locality. This is not as rare as might be supposed; in fact, Fournier says it is not uncommon in women. It may occur through the inoculation of the syphilitic virus upon an herpetic ulcer, or, on the other hand, an outbreak of herpes is some- times induced as a result of the irritation of a chancre, and in its immediate neighborhood. In the female, chancre may occasionally be confounded with erosive vul- vitis, especially as this occurs in infants and young children.1 Ordinarily the diffuse and superficial character of the vulvitis is sufficient to distinguish it from that circumscribed form which sometimes shows itself around a chancre. How and then, however, instead of showing itself in the form of confluent and desquamative erosions, this form of vulvitis displays discrete and somewhat excavated lesions, of a bright red color or of a pultaceous gray aspect, and in these cases the affection resembles chancre so closely that it is almost impossible to distinguish the two affections at first sight. The im- portance of this, in a medico-legal point of view, in the case of infants and young children said to have been the subjects of criminal assault, is of course very great. Fournier says that in medico-legal cases he makes it an invari- 1 See Grougenheim, Des Folliculites Vulvaires Externes. Ann. de Derm, et de Syph., 2me ser., t. iii., Avril, 1880. diagnosis of chancre. 365 able rule, “ never to diagnosticate chancre by the chancre,” that is, never to found his diagnosis upon the appearance of the lesion itself. Fournier1 gives the following illustrative case :—A little girl, six years of age, was brought to the hospital as being the subject of chancres said to have been communicated in an attempt at criminal assault. Examination showed intense vul- vitis, the labia majora being swollen to the size of a quarter of an orange, oedematous, red, and painful, with abundant suppuration. In addition, there was erosive intertrigo of the genito-crural folds, and of the upper and inner portions of the thighs and inguinal regions, and three ulcers also could be seen upon the labia majora. One of these was the size of an apricot pit, the other two were circular and the size of lentils. These lesions were of a grayish color and covered with a diphtheritic looking membrane ; they were shallow, with a flat surface, even a little raised in one lesion. They were indolent and had a somewhat indurated base. Finally, in both groins there were enlarged, ganglia, indolent, multiple, and easily rolled under the finger. With these lesions before him, Fournier unhesitatingly diagnosticated chancre with vulvitis, but, in accordance with his rule in medico-legal cases, declined to express his opinion formally to the court of justice until after a delay of a few days. Fortunately for the accused, this delay changed entirely the aspect of affairs. Within a few days, under a simple dressing, the vulvitis and ulcers disappeared like magic, the ganglia lost their induration, and- the patient recovered without showing any subsequent signs of infection, though remaining under careful daily observation at the hospital for several months. I have given the account of this case because it shows in the most striking manner possible how the most distinguished living syphilologist could be completely mistaken in a diagnosis at first sight. In making this ‘ confession” public, with characteristic candor, Fournier adds the following moral: (1.) The case demonstrates first, that certain simple, purely inflammatory lesions may take on the aspect—the mask and stamp, so to speak—of chancre, with such fidelity to the genuine lesion as to impose themselves upon the most attentive and experienced observer as the initial lesion of syphilis. (2.) It demonstrates, moreover, that the medico-legal diagnosis of chancre should not be made on a single examination of the lesion supposed to be such, but rather by the collation of confirmatory signs, of which the symptom first presented (chancre) should constitute the first term, and the secondary, generalized, constitutional symptoms following at a date named, should constitute the final term. In considering the diagnosis of chancre thus far, the erosive and desqua- mative forms of the lesion have been kept in mind in connection with the other lesions with which these may be confounded. AVIien, however, the chancre becomes more or less ulcerated (see Plate XVIII. Figs. 2 and 3), it is- the chancroid with which it is most likely to be confused. The diagnosis between chancre and chancroid has been dealt with by Dr. Sturgis in the preceding Article (page 333.) and I shall therefore not dwell upon this subject at length, but shall content myself with giving the following table, based upon those furnished by Belhomme and Martin and by Fournier, which shows in brief the various points to be considered in the differentiation of the two- lesions, a task usually not very difficult. Differential Diagnosis between Chancre and Chancroid. Chancre. (1) Incubation on an average from fif- teen to thirty-five days. (2) Derived from the contagion of a chancre, of a secreting secondary syphi- litic lesion, or, in some cases, of the blood of a person suffering with secondary sy- philis. Chancroid. (1) No incubation. (2) Derived from the contagion of a chancroid or of a suppurating chancroidal bubo. 1 Op. cit., 2e ed., p. 203. 366 SYPHILIS. Chancre. (3) Usually single, rarely multiple, never confluent. (4) Non-inoculable on the patient. (5) Begins by a simple erosion, or in some cases by a papule. (6) When fully developed, the chancre is a superficial ulceration with sloping edges melting insensibly into the sur- rounding tissues, the centre covered in part with false membrane, the border bright red, usually of regular outline. Very little suppuration. (7) Chancre is rarely painful. (8) In ninety-eight cases out of one hundred, induration of the base is present; an elastic induration, gristly, having none of the characters of an inflammatory in- duration. (9) The lymphatic ganglia in the neighborhood enlarge, harden, and be- come gristly, without suppuration. The lymphatic vessels also become indurated at times. (10) Chancre is a lesion which gives rise to very little local reaction ; it tends to spontaneous cure; it ulcerates only slightly ; it rarely takes on phagedoena or gangrene; it follows a regular course. Chancroid. (3) Almost always multiple, often con- fluent. (4) May be inoculated any number of times on the patient. The pus of the suppurating bubo is also inoculable. (5) Begins by a vesico-pustule. (6) When fully developed, the chan- croid is a somewhat deep ulcer, of which the base is covered with a sort of organic detritus mixed with pus. The edges are almost perpendicular, and sharply defined. (7) Chancroid is almost always painful. (8) Chancroid is often accompanied by inflammatory hardness, but never by syphi- litic induration. (9) Chancroid is often accompanied by adenitis or lymphangeitis of phlegmonous character, suppurating sometimes, and furnishing occasionally an inoculable pus. (10) Chancroid is a rather serious local lesion ; it has a strong tendency to ulce- ration ; it follows a very irregular course, and does not tend to cure as chancre does. Phagedama and gangrene are relatively frequent complications of chancroid. Before leaving the subject of the diagnosis of chancre, attention must be •called to a circumstance which may render this difficult or impossible at times, at least for a certain period, namely, the simultaneous occurrence of chancre and chancroid upon the same individual. Though uncommon, yet this does happen from time to time, much more frequently with women, however, than with men. A prostitute having connection with a number of men within a short space of time can easily contract a chancre from one and a chancroid from another, each running its course independently. Time and repeated observation will serve to differentiate the lesions in such cases. With regard to the peculiar diagnostic points characteristic of the chancre in certain localities, as the urethra, breast, vagina, and cervix uteri, reference may be made to the account given of these lesions under the general descrip- tion of chancre.1 Prognosis op Chancre.—Regarded as a local manifestation, chancre is ordinarily not a serious lesion. In some cases, however, either owing to its location, or because of some complication, a very unusual circumstance, this lesion may affect the anatomical structure, or may interfere with the func- tions, of some organ, and may thus influence indirectly the general health. Thus phagedtena may give rise to mutilation of the glans, or to urethral fis- tula, in men ; to loss of the clitoris, or to destruction of more or less of the labia, in women; and to rectal stricture in either sex. Somewhat commoner 1 See also Ch. Mauriac, Diagnostic du Chancre Syphilitique. Ann. de Derm, et de Syph., n. s., t. i., p. 738. PROGNOSIS OF CHANCRE. 367 than these complications, however, and quite serious, are the interference with nutrition which may result from buccal chancres, and the hemorrhage which may occur in phageclsena. The difficulty in mastication and the pain caused by the passage of food, occurring particularly when the chancre is situated on the dorsum of the tongue, together, possibly, with the ingestion of septic discharges from the ulcerated surface, sometimes induce voluntary abstinence on the part of patients. As a result of this, gastric and anaemic disturbances may eventuate, dangerous not merely in themselves, but as diminishing the resistance of the organism to the assaults of the constitutional infection. As to hemorrhage, Ory1 cites the case of a young girl who had a chancre of the upper lip, which became phagedsenic and destroyed a considerable por- tion of the lip. Hemorrhage occurred repeatedly from the affected part, so that the patient became exsanguinous, and fell fainting on the least exertion. Iler life was preserved only by the most assiduous care, and convalescence was extremely slow. The question whether the benignity or malignity of an attack of syphilis depends upon the quality of the infective material in any given case, or upon the nature of the soil in which the seed has been sown, has often been dis- cussed. The first view, that of varying malignity in different virus, has one apparent fact in its favor—that is, the gradual diminution in the severity of syphilis since its first malignant epidemic occurrence in the fifteenth and six- teenth centuries. Syphilis at the present day is, in its earlier periods at least, a much milder disease than in former times. It has been asserted that this is due to the gradual attenuation of the poison in its transmission from gen- eration to generation; but I think it is quite as likely that improved hygiene and therapeutics have played the most important part in ameliorating the severity of the disease. Even at the present day, moreover, there are certain parts of the world, as Mexico and China, where malignant syphilis still shows itself. The other view, namely, that the severity of the disease in any given case depends upon the soil in which it is planted—that is, the constitution of the patient as influenced by hereditary or acquired infirmities of one kind or another, and by hygienic surroundings—has more clinical testimony in its favor. Jullien cites the case of a young woman who was contaminated by her husband just after confinement. The latter was suffering from a very slight attack of syphilis. The unfortunate wife, however, fared far otherwise. After an unusually short incubation, fifteen days, a chancre appeared which destroyed a large part of the vulva ; and towards the third month, in spite of energetic treatment, gummatous tumors appeared in various places. In less than a year the face had been destroyed by supervening phagedaenic ulcerations. Other cases might be cited, going to show that the severity of the disease depends upon the elaboration which the virus undergoes under the influence of the organism in which it has been implanted. The period of incubation is to some extent an index of the probable gravity of the affection in any given case. The less resistance the organism offers, the quicker the entrance of the virus—the briefer, in consequence, the period of incubation, and usually, also, the more malignant the subsequent symptoms. The character of the initial lesion, the chancre itself, is by many authorities regarded as indicative of the probable future course of the disease. Benign chancres, it is said, are followed by benign eruptions, and by non-suppurative lesions of the various tissues; phagedsenic chancres by severe pustular syphilo- dermata and ulcerations, and, at a later period, by exostoses, necrosis, and caries. 1 In his Thesis, L’Etiologie des Syphilides Malignes Precoees. Paris, 1876. 368 SYPHILIS. I do not think that this can be rightly formulated as a law; there are too' many exceptions. I have again and again observed severe syphilitic mani- festations to follow the most benign and insignificantdooking chancres. Among the various circumstances which may be mentioned as influencing the evolution of syphilis, the scrofulous or lymphatic temperament is perhaps one of the most important. “ Bread syphilis occurring in blondes,” says Diday. Old age, abuse of alcohol, debility from constitutional infirmity or from irregularity of life, pregnancy,1 and mal-hygiene, are all elements of value in the prognosis of chancre.2 Treatment of Chancre.—The abortive treatment of chancre—that is, its destruction with the view of preventing the subsequent development of general symptoms—has been discussed by syphilographers for many years without an unanimous opinion having been reached as to the desirability or the success of this procedure. At a time when the distinction between chancre and chancroid had not been clearly made out, such observers as Hun- ter and Ricord asserted that if the chancre were thoroughly cauterized before the fourth day after contagion, no constitutional symptoms would follow. But chancre does not make its appearance before the third week as a general thing, and almost never before the tenth day. Consequently, those chancres- which were aborted on or before the fourth day after contagion, were not chancres at all, but something else—chancroids, herpes, etc. More recently several observers, among them Auspitz3 and Kolliker,4 have extirpated chancres by the knife; but when carefully analyzed, and the doubtful cases rejected, their statistics do not offer satisfactory evidence in favor of this form of the abortive treatment. They have failed to bring forward conclusive evidence, in connection with their successful cases, that constitutional syphilis would have appeared if extirpation had not been practised.5 With regard to the cauterization or extirpation of a chancre considered as a local lesion, I think that this should not be performed, unless when pliagedsena is present. The lesion ordinarily tends to get well spontaneously, arid irritative or too stimulating applications are apt only to arouse irritation, and to give trouble in the future. The simplest dressing is therefore the best. Continence should always be urged upon the bearer of a chancre, whether male or female; not only to avoid the irritation resultant from coitus, but also, and still more, to prevent conveyance of contagion. Many men, when they have contracted a chancre, care but little whether they transmit it to- others or not. Women also, with whom chancre is usually such a minimal lesion, often think that they are unlikely to convey disease by means of such a trifling sore, and thus the affection is spread. In advising such persons, it is as well, in view of the selfishness of human nature, to lay stress upon the possible injury which patients may inflict upon themselves, by indulging in sexual intercourse while bearing a chancre upon their genitals, rather than upon the harm which they may inflict upon others. A strict regimen, including abstinence from wine or liquors, and in some instances from tobacco, should be followed out during the course of treatment. 1 See Cernatesco, De la Marche et de la Duree du Chancre Syphilitique et des Sypliilides Vul- vaires pendent le cours de la Gestation. Paris, 1878. 2 See Ch. Mauriac, Prognostic et Traitement de la Syphilis Primitive. Abstract in Ann. de Derm, et de Syph., n. s., t. i., p. 295 ; from La France Medicale. 3 Vierteljahrsschr. f. Derm. u. Syph., iv. 1877, 1 und 2, S. 101. 4 Centraiblatt f. Chirurgie, Nov. 30, 1878, S. 801. 5 Among recent writers on this subject are Chadzynski, “ Sur la valour prophylactique de PExcision de la Sclerose Syphilitique Initiate.” Ann. de Derm, et de Syph., n. s., t. i., p. 461 ; also, Primo Ferrari and Francesco Folinea, of whose papers Jullien has furnished abstracts in. the same journal, p. 362. PERIOD OF THE GENERALIZED LESIONS OF SYPHILIS. 369 Locally, the most scrupulous cleanliness must be observed, especially if the chancre is so situated as to be soiled by the excretions, as in the anus or vulva. Frequent warm baths are beneficial, especially if there is any ten- dency to irritation. The affected part should be protected from contact or rubbing with the neighboring parts, or with the clothing. In reality this is, in the majority of cases, all that is required. When the patient demands more active treatment, dilute solution of chlorinated soda, black wash, or some mild astringent powder, such as that of the oxide of zinc, may be pre- scribed. The fact is that in the majority of cases the chancre tends to a spontaneous cure, and only requires to be let alone in order to get well of itself. When the chancre is slightly painful, rest is to be prescribed, with frequent warm baths and sedative lotions, such as lead-water and laudanum; or the following ointment may be used, remembering that an ointment can- not conveniently be applied to a mucous surface, or in the balano-preputial fold:— R—Ung. hydrarg. 5V- Ung. aquae rosae, 5y> Tinct. opii, npvj. M. It would seem scarcely necessary to advise against the employment of stimulating or irritating remedies, did not experience show that these are daily employed by practitioners in the treatment of chancre. Touching with the nitrate-of-silver stick, or cauterizations with sulphate of copper, etc., are of no use, and are frequently harmful. Cauterization is only justifiable under two conditions: either to stimulate the surface of the chancre when this is sluggish, or tends to remain covered with a pseudo-membranous coating—when the nitrate-of-silver stick may be applied lightly at intervals of several days; or to repress exuberant granulations appearing during the process of repair. Sometimes, after the chancre has healed, there remains behind an indurated lump, which is slow to disappear. The expectant treatment alone is proper in such a condition. Patients are frequently anxious for something to be done to hasten the removal of what is sometimes a deformity, and will urge the employment of stimulant applications, caustics, or even the knife. Inter- ference, however, is not proper, as the result will probably prove very un- satisfactory. Fournier relates the case of a young man who had a chancre on the frsenum of the prepuce, followed by a walnut-sized induration. Not- withstanding the assurance of Ricord and Fournier that it would disappear spontaneously in time, the patient induced some ignorant or unscrupulous practitioner to excise the lump. Violent hemorrhage followed, only checked by the actual cautery. Afterwards, a larger lump than the preceding one gradually took its place, and the patient only recovered after some months with the loss of a good part of his glans penis, all on account of a lesion which, let alone, would have disappeared without leaving a trace ! Period of the Generalized Lesions of Syphilis. The various stages in the evolution of syphilis were formerly, and are still frequently, classified under three heads, primary, secondary, and tertiary. But, while the first two of these are distinctly separate, and divided the one from the other, it is not thus with the so-called secondary and tertiary periods, which possess no distinct line of demarcation in practice. I prefer therefore to consider all the lesions of syphilis following the chancre and its concomitants, under the comprehensive category of generalized lesions. Bor 370 SYPHILIS. the poison which has heretofore been confined, as to its outward manifesta- tions, to a single locality and its immediate neighborhood, now diffuses and spreads itself about throughout the economy, and shows itself in the form of constitutional symptoms of various nature. The term “ constitutional syphilis” has sometimes been employed to desig- nate the period under consideration, but I consider this term faulty, as implying a local character for the chancre, which indeed is as much a “ con- stitutional” symptom as any that follow. A further division of the generalized lesions into early and late may be made for convenience’s sake, it being understood that this subdivision is not and cannot be accurate, the chronology of the various symptoms not being the same in every case, although their sequence is never inverted. For example, the erythematous, pustular, and gummatous syphilodermata occur in this order, and usually with certain intervals of time between the appear- ance of each. But, while in certain cases where the syphilitic attack tends to assume a malignant type, these eruptions follow one another in such rapid succession as to appear almost synchronously, yet they never appear in in- verted order, and we never see a gummatous tumor followed by an erythe- matous syphiloderm. General Condition before and during the Outbreak of the Early Generalized Symptoms.—The chancre, as lias been said, is, for a time, the only manifestation which betrays the existence of syphilis. For a certain period, no other lesions show themselves to indicate that a virus is lurking in the system. This period of the “second incubation,” as it is called by some authors, the second interlude in the drama of the evolution of syphilis, as Fournier graphically terms it, is followed by the explosion of generalized symptoms. Its duration is on an average forty-five to fifty days, although it may vary, in exceptional cases, as much as a week or ten days on either side of these figures.1 Following this period of apparent repose, the generalized symptoms make their appearance in due chronological sequence, never appearing before the chancre, never appearing without the chancre having first appeared. There is no such thing as syphilis d’emblee, the sudden outbreak of generalized symp- toms ; a chancre, whether detected by the patient and physician, or whether eluding the closest scrutiny, has certainly, and of necessity, preceded any general outbreak. Condition of the Blood in Syphilis.—That the blood' must undergo some change during the evolution of the syphilitic poison in the economy, has long been admitted, but the first scientific observations upon the subject were made by Grassi, under the direction of Bicord.2 Grassi undertook a number of chemical analyses of the blood in persons suffering from venereal sores, and found that when these sores were not followed by subsequent syphilitic mani- festations (chancroid), the blood remained normal; while in cases where sub- sequent generalized symptoms resulted (chancre), the blood showed diminution of the globular mass with proportional increase of the albuminous constitu- ents. Grassi’s results were confirmed by Wilbouchewitch, of Moscow,3 who, desiring to study the influence of mercury on the composition of the blood, 1 Of course this refers to untreated cases. Mercury given during the early stages of the disease retards the evolution of symptoms. In rare cases the second incubation may he longer ; Keyes says as long as four or five months. (Op. cit., p. 101.) 2 Lemons sur le Chancre, 2e ed., p. 184. 3 De l’influence des preparations mercurielles sur la richesse du sang en globules rouges et en globules blancs. Archives de Physiologie, pp. 509, 537, 1874. SYPHILITIC FEVER. 371 commenced by inquiring into its condition before the administration of the drug, and during the existence of chancre. In ten cases studied by Wilbouchewitch, the average diminution of red corpuscles was 638,870 (the normal figures being taken as from 4,200,000 to 6,477,000), while the increase in the white corpuscles was 550, the propor- tion being 1 white corpuscle to 448 red corpuscles, instead of 1 white to 530 red, the average normal proportion. Of course this impoverished condition of the blood would be likely to lead to various characteristic symptoms, and thus we find in some cases disorders of circulation, irregularity in the action of the heart, murmurs in the larger vessels, pallor, epistaxis, and occasionally oedema of the lower extremities. In addition, general malaise, loss of energy, and a constant sense of fatigue; nervous symptoms, such as vertigo, insomnia, and headache, particularly of a temporo-frontal character; also vague and cliff use pains of various sorts—some- times in the muscles, giving rise to simulated torticollis, pleurodynia, or lum- bago—at other times concentrated in the joints or in the shafts of the long bones; in a word, any or all of the symptoms of an anaemic condition. While these symptoms of anaemia are not well marked in every case of early syphilis, yet one or another is almost always present in cases of average severity. Syphilitic Fever.—There are few cases of syphilis which, if closely watched, will not show some febrile movement, and occasionally the fever plays a prominent part in the history of the case. It is sometimes the chief symptom which the patient recalls subsequently, when examined as to the ■early history of the disease. The fever of syphilis commonly makes its ap- pearance from the fiftieth to the sixty-fifth day after contagion, perhaps on an average in from the third to the fifth week after the appearance of the chancre. Its outbreak is usually preceded by one or two days of headache and prostra- tion, followed by a more or less violent chill. The temperature commonly varies from 100.4° to 102.2° F., but in some rare cases it may reach 104°, 104.9°, and even 105.4°. (Fournier indeed reports a case where the tempera- ture reached 107°.) Courteaux1 describes three distinct varieties of syphilitic fever, as follows:— (1) The intermittent form, comprising a series of isolated attacks with intervals of complete apyrexia, is the most common. These attacks resemble very closely those of malarial intermittent fever. They usually begin in the evening, and last about twelve hours, occasionally assuming a quotidian type, but more frequently following an irregular course. Although following the usual routine of chill, fever, and sweating, they do this in a less complete and less regular manner than is the case in malarial intermittent, the stages of chill and sweating being scarcely perceptible, and, in fact, rarely being noticed by patients, who complain of the fever only. What is commonly observed is continuous fever, broken transitorily by intermittent chills, the sweats also occurring from time to time during the attacks of fever. The spleen is not enlarged. This form of syphilitic fever yields readily to the in- fluence of mercury, but is entirely uninfluenced by quinine. 1 These de Paris, 1871, written under the inspiration of Fournier. (Annales de Dermatologie et de Syphiligraphie, t. iii., p. 213.) In addition, reference may be made to the writings of Guntz (Das syphilitische Fieber. Leipsic, 1873) ; Bremer (Nordiskt med. Ark., 1874, and Gaz. Hebdomadaire, Mars, 1875) ; Vajda, Ueber das syphilitische Fieber und den Stoffwechsel syphili- tischer (Vierteljahrsschr. f. Derm. u. Syph. 2te Jahrg., 1875, S. 147), and with annotations by R. W. Taylor (Archives of Dermatology, vol. iii., 1877, p. 162) ; and, finally, Fournier, op. ■cit., 2e ed., p. 643. 372 SYPHILIS. As the likelihood of mistaking malarial and syphilitic intermittent fever, one for the other, is very great, and as it is important to make the diagnosis when this is possible, I add the following table of comparative symptoms from Fournier :—1 Syphilitic Intermittent Fever. (1) Almost always quotidian, not as- suming the tertian or other forms. (2) Almost always nocturnal. (3) Attack generally incomplete, not comprising the three classical stages, the stages of chill and sweating being usually absent, and the feverish stage most pro- minent. (4) Attacks almost always irregular, the stages being confused or inverted, and the symptoms of the various stages asso- ciated. (5) Attacks very variable as to form and general character, differing in one case from another, or in the same case at different times. (6) Attacks usually briefer in duration than those of malarial intermittent, and frequently very short. (7) Never enlargement of the spleen. (8) Attacks rebellious to the influence of quinine, but yield readily to mercury. Malarial Intermittent Fever. (1) Sometimes quotidian, but more fre- quently tertian, especially in well-marked forms and at the beginning. (2) Usually diurnal. (3) Attack generally complete, that is to say, composed of three successive stages, each one presenting characteristic symp- toms. (4) Attack methodical as to evolution, each stage being clearly defined, and the stages succeeding one another with per- fect regularity. (5) Attacks generally uniform, and similar in one case to another, or in the same case at different times. (6) Attacks generally somewhat pro- tracted. (7) Almost invariably appreciable in- crease in the size of the spleen. (8) Attacks yield to quinine, but un- influenced by mercury. (2) The continued form of syphilitic fever, with exacerbations, is usually accompanied by general asthenia, sometimes giving it very much the aspect of typhoid fever. In other cases the temperature (104° F. and over), fre- quency of the pulse, extreme flushing of the face, headache, rachialgia, and general prostration, cause the attack to resemble the prodromic fever of variola so closely that even when a chancre has been detected, the diagnosis must be suspended until the fourth day. When, as occasionally happens,the outbreak of the small pustular syphiloderm occurs in the midst of the fever, the diagnosis becomes extremely difficult; and I have in several cases seen experienced and able practitioners entirely at fault for a time. The records of our smallpox hospitals tell a similar story, supposed cases of variola being admitted now and then during a smallpox epidemic, only to show undoubted syphilitic symptoms a few days later. An important diagnostic point may be mentioned in this connection, namely, the normal performance of the more important functions of the economy in spite of the intensity of the morbid process. Frequently, for example, the appetite is preserved, the tongue retains its normal color, and the stools are regular in patients whose pulse beats at a high febrile rate. Gamherini has noted the absence of thirst, and Yajda has observed that the urinary deposits do not at all indicate the degree of mal-assimilation which would naturally he looked for with an elevated temperature. In addition there are no pectoral rales, such as often occur in typhoid; no laclirymation, no conjunctivitis, no coryza, as in rubeola; no angina, as in scarlet fever; no pro- fuse sweats, as in rheumatic fever. (3) The ambiguous form of syphilitic fever is much less frequent than the 1 Op. cit., 2e ed., p. 656. SYPHILITIC FEVER. 373 two former varieties. It is scarcely describable, passing and repassing from one form to another, from continuousness to intermittence, an intermittence capricious and indeterminate in character, and greatly prolonged. Diagnosis of Syphilitic Fever.—The diagnosis between the intermittent type of syphilitic fever and malarial intermittent has already been dwelt upon. The continued forms of syphilitic fever may be mistaken for variola, as has been already said, and also for typhoid fever and rheumatism. The diagnosis from variola will be touched upon further in dealing with the papular and pustular syphilodermata, for it is only when these eruptions are present that the mistake is likely to be made. From typhoid fever, the absence of initial epistaxis, stupor of the countenance, intestinal disturbances (diarrhoea, gurgling in the iliac fossa, meteorism, etc.), buccal coating, bronchial rales, swelling of the spleen, rose-colored lenticular rash, etc., will distinguish syphilitic fever. In a certain number of cases, where the syphilitic fever is accompanied by what Fournier calls “ secondary pseudo-rheumatism,” it simulates subacute rheumatic fever most closely, and the diagnosis can only be made after the most minute examination, bearing chiefly on the points of the correlative or independent occurrence of the febrile and articular symptoms; if these latter are or are not developed in a rheumatic subject and under the influence of an existent rheumatism ; if they atfect the characters of syphilitic joint-troubles1 rather than those of common rheumatism ; if they coincide with some symp- toms of the same order but more distinctly syphilitic (as, for example, peri- ostitis, periostosis, tenosynovitis, etc.). With these various points in mind, the diagnosis can in many cases be arrived at with some degree of certainty. FTevertheless, cases will arise in which it is simply impossible to distinguish between syphilitic fever accompanied by rheumatismal manifestations and ordinary rheumatism, at least until some symptom arises which is beyond doubt distinctive. Prognosis of Syphilitic Fever.—The intermittent form of syphilitic fever is a comparatively unimportant manifestation of the disease, but the continuous variety, particularly when it extends over a considerable period of time, may lead to more or less serious nutritive disturbance. Patients sometimes fall into a state of anaemia, languor, and general atony, from which it is difficult to arouse them. In women, who are much more prone than men to suffer with the severer forms of syphilitic fever, this condition sometimes exists to a marked degree. It may be added that the severe forms of continuous syphilitic fever are apt to be followed at a later period by grave visceral syphilitic lesions. Treatment of Syphilitic Fever.—Mercury, alone or combined with iodide of potassium, is the only satisfactory medicine which can be administered in syphilitic fever. Quinine, arsenic, etc., are entirely without specific value. The influence of mercury is, however, not uniform in all the varieties; while it is rapidly and certainly effective in the intermittent form, it is much less energetic and is slower in its action when given in the continuous variety. For this reason the dose should be double or triple that given in the inter- 1 Fournier points out the following peculiarities of syphilitic joint-troubles : There is less acute and less inflammatory articular effusion—often, indeed, this is minimal and insignificant (many oases of articular syphilis are nothing more than simple arthralgia, without tumefaction, red- ness, effusion, or appreciable lesion); the articular attacks are more invariable, not as shifting nor as multiple as in rheumatism ; there are very frequently nocturnal exacerbations ; there are less marked general reaction, fewer sympathetic symptoms, absence of sweating and cardiac compli- cations, etc. 374 SYPHILIS. mittent form of the disease. Mercury is usually well borne in syphilitic fever, and in the rare cases in which it is found to disagree when given by the stomach, it may be administered in the form of inunction. Affections of the Lymphatic Glands.—Lymphangeitis may first be men- tioned. In certain cases of syphilitic disease, delicate knotted cords, indi- cating the course of inflamed lymphatic vessels, can be perceived in the upper portions of the arms and thighs; they rarely extend towards the extremities. Jullien1 reports the case of a woman who, three months subsequent to syphil- itic infection, suffered with a general engorgement of all the lymphatic vessels and ganglia, coincident with the outbreak of a tubercular eruption. Ordinarily, lymphangeitis tends to resolution, and, moreover, it is not a striking lesion ; evidence of its presence must be sought for, as otherwise it is apt to escape attention. Adenitis, on the other hand, is more apparent and obvious. Few persons affected with syphilis fail to show symptoms of adenitis in the secondary period. In twenty cases observed by Campana (quoted by Jullien), the glands of the groin were affected in every instance, those of the sides of the neck in thirteen cases, those of the nucha in eight, those of the sub- maxillary region in five, those of the crural region in three, those of the axillary, the parotid, the epitrochlear, and the submammary regions each in two instances. These little glandular nodules are in every respect similar to those attendant upon chancre; they may occur independently of any tegumentary disturbance, and simply as the expression of the presence of the virus in the ganglia. The generalized involvement of the lymphatie glands always lasts a long time, and only disappears very slowly by resolu- tion. Occasionally, in strumous subjects, a secondary scrofulous inflamma- tion may occur, resulting in the formation of the usual scrofulous glandular abscess. The glands of the submaxillary, subhyoid, and cervical regions,, those situated anteriorly and posteriorly to the sterno-mastoid muscle, and possibly also those of the retro-pharyngeal region, are most apt to be thus affected. As regards the influence of the appearance of these lymphatic disturbances on the general prognosis of the disease, it is unfavorable if the glandular enlargement is marked and intense. Condition of the Spleen.—The spleen may be affected in the stage of syphilis of which we are treating, being sometimes enlarged to the extent of passing four or five inches above the floating ribs. 'This enlargement is observed in from 7 to 8 per cent, of all cases,2 and is usually accompanied by gastric disturbances and enteritis, boulimia, and polydipsia; occasionally vomiting and diarrhoea supervene. Enlargement of the Tonsils is not an infrequent accompaniment of this stage of syphilis, these glands sometimes attaining considerable size, and giving rise to one form of deafness occurring at this period.3 Supra-renal Capsules.—Jullien4 lias drawn attention to the “pigmentary syphiloderm ” (vide infra) as in all probability caused by syphilitic disease of the supra-renal capsules, of which the cortical portion at least is composed of lymphatic follicles. 1 Op. cit., p. 643. 2 Attention was first called to this subject by Weil, of Heidelberg. (Ueber das Vorkotnmen des. Milztumors bei frischer Syphilis. Deutsches Archiv fur klin. Med., Mai, 1874, and Centralbl. f. die med. Wissensch., 1874, No. 12.) 3 See Tanturri, Syphilitic lymphadenomata in the isthmus faucium. Rivista di Med., etc. Milano, Aprile, 1873. 4 Op. cit., p. 647. AFFECTIONS OF THE LIVER. 375 Affections of the Osseous System.—The close connection between the medulla of bone and the lymphatic elements of other portions of the system, has induced Jullien to offer disease of this tissue as an explanation of the osteocopic pains (6 t| |j 11ih> de* nU H. BENCKE LITH.CO. N.Y. PLATE XXII cfivl'e ( o ili-> - H. BENCKt LITH.CO. N.Y. THE BULLOUS SYPHILODERM. 397 not altered in color, nor is the outline of the growth discernible. The deposit increases slowly in volume, until through a period of weeks or months it gradually assumes definite shape and consistence. It is now seen to be a more or less rounded tumor, imbedded in the subcutaneous tissues, the skin over which becomes pinkish or reddish. In size it may vary from that of a hazelnut to that of a walnut, or even larger, with a slightly elevated semi- globular shape, and with a soft, doughy, somewhat elastic feel. Gummata are usually solitary, rarely occurring more than one or two at a time. They may occur in any part of the body, but are most commonly met with in the looser and softer tissues, as upon the fiexor surface of the ex- tremities, the abdomen, the sides of the thorax, the penis, etc. (Plate XXII. Fig. 3.) The gumma tends strongly to break down and ulcerate, with destruction of the tissues in which it has its seat. The ulcer is a circumscribed, deep excavation, usually rounded in form, with abrupt, perpendicular edges. It may vary from the size of a finger-nail to that of the hand. Its bottom is uneven, and covered with a grayish-red gummy deposit. The loss of tissue is usually great, but the process of repair leaves often a much less marked cicatrix than would have been predicted. Gummata are occasionally ab- sorbed without ulceration. The diagnosis of the gumma is usually not difficult. It is to be distin- guished from furuncle and from abscess, from enlarged lymphatic glands, from carcinoma, and from fibrous and fatty growths. I think the gumma is more apt to be confounded with abscess than with any other affection. I have often seen gummata which have been mistakenly poulticed until they have broken down into ulcers. This is an unfortunate mistake, as the early administration of iodide of potassium will often put back and cause absorp- tion of the syphiloma, thus shortening the duration of the affection, and in many cases preventing the subsequent formation of a scar. The history of the case, the freedom from pain and febrile reaction in a lesion which to the eye presents the appearance of marked and decided inflammation, as well as the history of its slow and usually painless evolution, will serve to stamp the suspected furuncle or abscess as in reality a gumma. The gummatous ulcer will be diagnosed from the non-syphilitic ulcer by its history, depth, sharply defined edges, and punched-out appearance ;x by the character of the secretion; the absence, as a rule, of pain, excepting in gummatous ulcers of the leg, when pain is often present; and the presence, in many cases, of other symptoms of syphilis. The Bullous Syphiloderm. The bullous syphiloderm2 is characterized by blebs containing a clear, watery fluid, which tends soon to become cloudy and thick. At times, indeed, the lesions are more like pustules than blebs. In size they vary from that of a pea to that of a walnut. They are discrete, disseminated, circular or ovalish in form, and surrounded with a slight areola. They may be fully or only partially distended, but after lasting a variable time they break, the contents drying into yellowish, brownish, or dark greenish crusts. These sometimes assume a lieaped-up, oyster shell-like appearance which gives rise to the name rupia, applied to this eruption as well as the large flat pustular syphiloderm above described. Beneath the crusts are seen erosions or shallow ulcers, which in 1 This characteristic is shown in PL XXII., Fig. 3. 2 Formerly, to the confusion of the student, called “ syphilitic pemphigus.” 398 SYPHILIS. healing leave more or less pigmented cicatrices. The course of the eruption is variable, depending upon the condition of the patient’s general health. The bullous syphiloderm is a late eruption, and usually occurs in connection with other syphilitic manifestations. It is rare, and is met with in cachectic, broken-down subjects. It often occurs as the result of hereditary syphilis in the new-born, when it closely resembles pemphigus vulgaris.1 The charac- ter of the blebs, and of the subsequent crusts, will, however, easily serve to distinguish this syphiloderm from pemphigus. The Pigmentary Syphiloderm. This eruption, the existence of which has been denied by some observers, is very rare. It has been described (with a chromo-lithographic illustration) in the second edition of Fournier’s “Lemons sur la Syphilis,” and in this country by G. II. Fox2 and by J. E. Atkinson.3 It consists in a more or less circumscribed pigmentation of the skin, in the form of roundish, ovalish, or irregularly shaped, split-pea or finger-nail sized, discrete or confluent macules, on a level with the skin. They are not preceded by hypersemia, nor do they follow upon the site of other syphilitic lesions. Their color is a pale, yellow- ish-brown, often so faint as to cause them to present rather the appearance of dirt marks than of lesions in the skin. They are apt to coalesce and form a sort of net-work. There are no subjective symptoms. The affection occurs in the latter half of the first and in the. second year of syphilis. Its course is slow, and it is uninfluenced by specific treatment. Local Treatment of the Syphilodermata. The general and internal treatment of the syphilodermata is that of syphilis in general, and for this reference may he made to the section on treatment. The local management of these lesions demands, however, some special notice here. The erythematous syphiloderm does not require local treatment, nor will this, unless in the form of the mercurial vapor-bath, be apt to do much ser- vice. The papular syphiloderm likewise does not often require the aid of local applications, excepting when the surface of the lesions is denuded, as in the moist papule, or where they occupy a conspicuous position, as on the face. For the moist papules occurring about the anus or genitalia, especially when accompanied by vegetations, extreme cleanliness, separation of the adjoining parts with dry lint or cloths, and thorough washing with dilute solution of chlorinated soda, may be employed. In connection with these measures, the rhoist surface of the lesions may be dressed with finely powdered calomel, or anointed with the following ointment:— R Pulv. liydrarg. chlor. mit. 3SS- Ung. aquae rosae, M. The same ointment, well rubbed in, hastens the disappearance of papular lesions on the face. Great relief may be obtained in the case of pustular eruptions by the early 1 See under hereditary infantile syphilis. 2 Am. Jour. Med. Sci., April, 1876. 3 The Pigmentary Syphiloderm, a paper read before the American Dermatological Association, at its second annual meeting, 1879, and published in the Chicago Med. Jour, and Exam., Oct. 1879. 399 LESIONS OF THE APPENDAGES OF THE SKIN. removal of the crusts when these begin to form, and by dressing the eroded or ulcerated surfaces with some mildly stimulating ointment, such as that just given, or with the following:— R.—Hydrarg. ammoniat. 3j. Ung. aquae rosae, 3j< M. Of course, when the lesions are numerous, local applications are made with difficulty to every part, and must then be confined to such lesions as, from their situation, give rise to much discomfort. In case of the more discrete and widely scattered pustular eruptions, a warm bath, taken when the crusts are ready to become detached, will loosen them entirely, and then the eroded surface of the lesions may be lightly anointed with some very mild stimu- lating ointment, such as this:— R—Zinci oxidi, 3ss. Adipis, 3iiss* Sevi, 3v. 01. rosae, nffij. M. The mercurial ointments should not be employed over large surfaces, or on numerous lesions, for fear of absorption. In the ulcerating tubercular or serpiginous tubercular syphiloderm, I know of no application as useful as iodoform in one shape or another. Dusted lightly on the surface of the ulcer and covered with a piece of raw cotton, its good effect is often really surprising. Lesions will often heal up under iodoform with marvellous rapidity. A good iodoform ointment is this:— R Pulv. iodoformi, Bals. Peruv. aa 3ss. Adipis, $\x. M. But the penetrating and disgusting odor of iodoform is a serious bar to its employment, and more commonly we must make use of other remedies. Among these, the most generally useful is the black wash of the U. S. Phar- macopoeia, and, in some cases, the yellow wash. These two washes are also useful, particularly the yellow wash, in the treatment of gummatous ulcers. Occasionally these ulcers, as they occur upon the lower extremities, are irri- tated, inflamed, and painful; under which circumstances rest and soothing applications, such as lead-water cloths or poultices, must be applied first, before the more stimulating applications are brought into play. Lesions of the Appendages of the Skin. Onyxis.1—Syphilitic affections of the nails may assume several different forms, some of a comparatively trifling character, others much more trouble- some. Occasionally a comparatively ephemeral affection occurs on the nails, chiefly of the fingers and most commonly met with in women, where the nail becomes dry, friable, and fissured, the free portion showing transverse ridges, and the nail breaking and splitting with the least- pressure or violence. This is an early manifestation, and it may persist through a considerable period {onyxis craquelee, friable onychia). Another form occasionally met with is hypertrophic onyxis. The nail may assume three or four times its normal thickness, its color changes to a dull 1 See Emanuel Kohn, Remarks upon the Pathology and Therapeutics of Syphilitic Diseases of the Nails. (Wien.med. Presse, Nos. 24, 27, und 28,1870.) Translated in Am. Journ. Syph. and Derm., vol. ii., 1871, p. 78. 400 SYPHILIS. grayish or yellowish tint, it is covered with rough transverse or longitudinal ridges, and its free border may be bent and horn-like, or it may be thickened and squared off with a rough laminated edge. One or more nails may be affected. Commonly this affection runs a course pari-passu with the other early, generalized symptoms,the diseased nail tissue being gradually replaced by healthier structure as the general system recovers its tone under the in- fluence of constitutional treatment. Now and then it runs a slower course,, and, being stubborn to both general and local treatment, persists for months after other symptoms have disappeared. A third form of onyxis is that in which, the matrix being involved, a part or the whole of the nail is detached from its bed, and is gradually separated and shed. Not infrequently the nail is first separated at its root,, and is then carried gradually forward, leaving the rough and hardened mat- rix imperfectly covered with a corneous growth behind. Regeneration gra- dually takes place, and in time, with the improvement of the general health, under treatment, a healthy nail takes the place of the diseased one. None of the affections of the nails above described are painful, and they are important chiefly on account of the deformity to which they give rise,, and as indicative of the general state of the system. Perionyxis.—When a syphilitic papule is developed in the cutaneous fold bordering the nail, the hypertrophied epidermis becomes fissured and more or less horny, and exfoliates, forming a sort of dry, squamous perionyxis which is painless, and which, although extremely persistent, gives no trouble unless picked and irritated by the patient, when it may develop ulceration. Another form of perionyxis begins by a peri-ungual swelling like an ordinary “ run- around the extremity of the member becomes more or less enlarged, and of a dull currant or coppery color. The process, which is a sub-inflammatory one, goes on slowly and without pain, in this respect differing from the acuter painful course of the “ run-around.” It never terminates in an abscess,, usually ending in resolution, but sometimes ulcerates superficially, forming ulcerative perionyxis. Ulcerative 'perionyxis is characterized by a loss of substance of variable extent and degree, affecting the border, sides, or free extremity of the nail, or pulp of the member. The ulcer has an unhealthy aspect, being covered with sanious sanguinolent pus, and the swollen tissues in the neighborhood are dusky and more or less livid. This form of perionyxis when occurring in the toes is easily confounded with ingrowing toe-nail, but the extent of the swelling, its indolent character, and the extension of the ulceration serve to mark the syphilitic character of the lesion. The perionyxis may be com- plicated by onyxis, the nail separating entirely or in part, and the member becoming greatly enlarged, and covered with ulcerating and fungous granula- tions. After a considerable period, reparation takes place, with the entire or partial restitution of the nail, which is rarely normal in appearance; or, when the matrix has been nearly destroyed, a rough, hard, knobby surface remains in place of the normal nail. The treatment of the dry form of onyxis and of perionyxis is the general treatment of the early stage of syphilis. The inflammatory form is best treated by occlusion with the Emplastrum de Vigo,1 and by use of the ordinary 1 The Emplastrmn de Vigo, formerly extensively employed, is composed of lead plaster, 2 lbs. 8 oz.; yellow wax and resin, each 2 oz.; ammoniac, bdellium, olibanum, and myrrh, each 5 dr.; saffron, 3 dr.; mercury, 12 oz.; turpentine, 2 oz.; liquid storax, 6 oz.; oil of lavender, 2 dr. The gum, resin, and saffron to be powdered, the mercury to be rubbed with the storax and turpen- tine in an iron mortar until completely extinguished. The plaster then to be melted with the wax and resin, and the powders and volatile oil added to the mixture. When the plaster has 401 LESIONS OF THE APPENDAGES OF THE SKIN. antiphlogistics. When the ulceration is once established it is exceedingly diflicult to obtain a cure. Jullien says it is “ one of the most embar- rassing problems of therapeutics,” and my own experience entirely con- firms this opinion. Among the remedies most likely to give a satisfactory result may be mentioned the twenty per cent, solution of nitrate of silver (argenti nitrat. gr. c, aquse fsj). Small pledgets of lint soaked in this solution are inserted into the ulcerated cavities (Diday). Fournier recom- mends powdered iodoform, and Vanzetti of Padua powdered nitrate of lead. Camphor and alum is another topical application which has been suggested. Bumstead and Taylor advise the use of strong solutions of caustic potassa (3j-iv to to repress the profuse granulations of the matrix. They also suggest prolonged immersion of the member in very warm water con- taining powdered borax (3\j-Oj), to diminish the swelling and remove the secretions. Gradual pressure, carefully applied, may sometimes be advan- tageously used, and soothing ointments, such as that of belladonna, or Goulard’s cerate, may be required in inflammatory cases. The most assiduous clean- liness is required, and the various applications named, as well as others which may suggest themselves, should be essayed in turn when the case is rebellious.1 Alopecia.—Falling of the hair may occur, without any special lesion of the integument, as a result of perverted nutrition caused by the syphilitic poison. The hair becomes dull, tarnished, and dry-looking, and the patient, as Diday says, looks as if he wore a wig. The least effort brings out the hair “ by the handful.” A very common seat of alopecia of this variety is the eyebrow, a segment of which is often denuded completely of hair. This alopecia of the eyebrow is regarded by Fournier as pathognomonic of syphi- lis, even when met with alone. Sometimes general alopecia occurs, involving not only the scalp, but the eyebrows, eyelashes, beard, pubes, etc. But even when the scalp has become almost bald under the influence of the syphilitic disease,2 complete restitution of its normal covering may be hoped for if the general condition improves under the influence of specific treatment, and the same is the case with this form of alopecia occurring elsewhere. In spite of the current notion, more prevalent, however, in Europe, where the popular know- ledge of syphilis is more general if not more accurate, than in America, that premature baldness is due to syphilis, this is not at all the case. Syphilitic alopecia, of the form just described, is the most curable variety of the affection. Another form of syphilitic alopecia is that caused by syphilitic eruptions of the scalp. Acneiform or pustular lesions of this region are not uncommon, even in the earlier periods of the disease, so that one of the commonest ques- cooled, but while still liquid, the mercurial mixture to be thoroughly incorporated. This is now superseded for general use by the emplastrum ammoniaci cum hydrargyro of the U. S. Pharmacopoeia. The mixture of diachylon with mercurial ointment is, in Bumstead and Taylor’s opinion, smoother and more efficient than either the ordinary mercurial plaster or the Emplastrum de Vigo. 1 See Victor de Meric, Syphilitic Affections of the Nails (Brit. Med. Journ., 1865, p. 45); Betz, Treatment of Syphilitic Perionyxis by Occlusion (Giorn. Ital. delle Mai. Ven., 1868, t. ii. p. 180) ; Delattre, Treatment of Onyxis (Giorn. Ital. delle Mai. Ven., 1868, t. ii. p. 370) ; Em. Kohn, Zur Pathologie und Therapie der syphilitischer Nagelerkrankungen (Wien, med. Presse, 1870, xi., 24, 27, 28) ; Diday, Traitement du Perionyxis Ulcereux (Annales de Dermatologie et de Sypli., 1871, t. iii. p. 182) ; Fournier, De l’Alopecie, de l’Onyxis et du Perionyxis comme accidents de la Periode SGcondaire de la Syphilis (Annales de Dermatologie et de Syph., 1871, t. iii. p. 12) ; Bergh, Syphilitic Affections of the Nails (Hosp. Tidend., 1880, vii., Nos. 46, 47. Abstract in Archives of Dermatology, vol. vii., 1881, p. 336) ; Hutchin- son, Diseases of the Nails (Med. Times and Gaz., April 20, 1878). 2 Fournier tells of a patient who, at one period of his alopecia, could boast of but seventeen hairs upon liis entire head. 402 SYPHILIS. tions asked of a patient from whom it is desired to elicit a history of syphilis is, “ have you ever had crusts or scabs on the scalp, or falling of the hair ?” Papular and pustular eruptions may indeed give rise to alopecia, but this variety, like the first mentioned, is only temporary, the hairs being renewed when the lesions are cured, excepting in those cases of pustular eruptions where the hair follicles may have been destroyed. A third variety of# alopecia occurring in the course of syphilis is that met with late in the disease, when ulceration of the sealj) has occurred with de- struction of the follicles. This variety is, of course, irremediable. Syphilitic alopecia requires nothing more than the usual constitutional reme- dies in order to cure it completely; nevertheless, for the purpose of quieting the patient’s mind, and also, perhaps, to hasten a return to the normal condi- tion, certain topical applications may be employed with advantage.1 The following is a good tonic hair wash:— R Tinct. cantharidis, f3v. Tinct. capsici, f3ij« 01. ricini, f$v. Aq. cologniensis, ad f^iv—M. In some cases this pomade may be more conveniently employed. R Medullae bo vis, Tinct. cantharidis, rr^xx. Hydrarg. chlor. corros. gr. ss. 01. rosse, rr^ij—M. Syphilis of the Mucous Membranes.2 The term mucous patch is sometimes used indiscriminately to designate both syphilitic lesions, other than ulcers, occurring on mucous membranes, and also moist papules of the cutaneous or muco-cutaneous surface. Although there is a strong similarity in many respects between certain syphilitic lesions of the external integument and those of the mucous membranes, yet for con- venience’s sake I have chosen to consider them under distinct heads, giving the name moist papule to the lesion of the general integument (see description of the Large Papular Syphiloderm), and reserving the name mucous patch for the lesion as found upon the mucous membranes. The Seat of Moist Papules and Mucous Patches. The statistics of Davasse and Deville3 show that in 186 women these lesions were seated:— Upon the vulva in . . . . . 174 cases. About the anus ...... 59 “ On the perineum . . . . . 40 “ On the buttocks and the inner and upper as- pect of the thighs ..... 38 “ On the tonsils ...... 19 “ On the nose ...... 8 “ On the tongue ...... 6 “ About the toes . . . . . . 5 “ 1 For further information, see : Dulaurier, Alopgcie; par les Preparations Mercurielles (Gaz. des Hop., 1864, p. 310) ; Donet, Syphilis Constitutionelle ; Alop<5cie (Gaz. des Hop., 1864, p. 259) ; Fournier, De l’Alopecie, de l’Onyxis et du Perionyxis comme accidents de la S6condaire de la Syphilis (Annales de Dermatologie et de Syph., t. iii., 1871, p. 12). See, also, Fournier, Lemons, etc., 2e ed., p. 347. 2 For further description of the various lesions of the mucous membranes, especially the later ones, see Syphilis of the Digestive Tube, etc. 3 Des Plaques Muqueuses. Archives Gen. de Med., 1845. SYPHILIS OF THE MUCOUS MEMBRANES. 403 Bassereau’s statistics show that in 130 men these lesions were observed:— About the anus in . . . . . 110 cases On the tonsils ...... 100 “ On the scrotum ...... 66 “ On the mouth and lips . . . . 55 “ On the glans and internal surface of the pre- puce ....... 28 “ On the velum palati ..... 27 “ On the tongue ...... 18 “ On the half arches . . . . . 17 “ On the internal aspect of the cheeks and lips 11 “ In the interdigital spaces of the feet . . 11 “ The mucous patch, like its counterpart, the moist papule, is one of the most important lesions in the entire series of syphilitic manifestations, not only because of its extremely contagious character, but also because of the frequency of its occurrence. Many persons who contract syphilis escape the severer skin •eruptions, and the grave, late manifestations, but scarcely any, if, indeed, any at all, escape mucous patches in some shape, or at some period of the early development of the disease. Indeed, as Jullien remarks, the history of an average case of syphilis may be summarized as follows: a chancre, a transi- tory erythematous rash, and, following this, mucous patches, relapses of mucous patches, more mucous patches ! Mucous patches occur and recur without regard to other manifestations, which may come and go, he present or absent, without influencing the course of the mucous lesions. The secretion of the mucous patch is, as has been said, in a high degree contagious. Xext to chancre, the mucous patch is the commonest source of infection.1 The most frequent seat of mucous patches in men is within the mouth, while in women these lesions are more commonly found upon the vulva. Their development within the mouth is favored by the use of tobacco, either by smoking or chewing, while in all regions uncleanliness is both an inciting •cause and a means of keeping the lesions in existence. Mucous patches within the genital organs of both sexes sometimes give rise to a discharge from the neighboring mucous membrane, resembling gonorrhoea, which is not infrequently observed about the time that early secondary symptoms appear, or when a relapse of general symptoms takes place.2 Mucous patches within the buccal cavity present the appearance of grayish- white, irregular patches, not elevated, or sometimes depressed below the sur- face, looking as though they had been pencilled over with nitrate of silver (whence the name “ opaline patches,” by which they are sometimes known). The most common seat of these lesions is upon the internal surface of the lips and cheeks (Plate XIX. Fig. 2), upon the tongue (Plate XIX. Fig. 3), upon the gums, tonsils, and soft palate. They sometimes extend beyond the pillars of the fauces, and are seen upon the walls of the pharynx and the posterior nares. They have also been seen upon the epiglottis and mucous membrane of the larynx.3 When mucous patches occur near the angle of the mouth, they often extend into the muco-cutaneous structures at the commissure of the lips, where they form cracks and fissures which possess the characteristic pearly-gray color of these lesions, and where they are often continuous with a patch of the small flat papular or pustular syphiloderm. On the dorsum of the tongue their base is sometimes hard, indurated, and fissured; or the pellicle which covers them 1 See above under Sources of Syphilitic Contagion. 2 Bumstead and Taylor. 2 Ibid. 404 SYPHILIS. may be rubbed off by the attrition of the food, when a slightly depressed,, smooth, red surface remains. Vegetations may occasionally form in this locality, as in the case of moist papules on the integument. These, in my experience, are much more rebellious to local treatment than the ordinary mucous patches occurring in this locality. Mucous patches upon the tonsils are peculiarly exposed to irritation, and are often very difficult to heal. Sometimes they develop into ulcers, attended by considerable inflammation and swelling of the surrounding parts, which may at times obscure the ori- ginal lesion and render it difficult of diagnosis. Deglutition may be con- siderably impeded, and the swelling may close the Eustachian tube and pro- duce more or less complete, temporary deafness. The neighboring lymphatic glands are sometimes sympathetically enlarged when the mucous patches are inflamed. The earliest appearance of mucous patches is on the twentieth day after contagion ; the usual period for the first appearance of the lesions is from one to two months after contagion, although they may not appear for five or six months after this period. The early administration of mercury delays the appearance of mucous patches sometimes to eighteen months. Their reappear- ance at a later period in the history of the disease is one of the most certain signs of the renewed activity of the virus. Treatment.—Mucous patches invariably demand local as well as general treatment. When they occur within the female genitalia, astringent and detergent injections, such as the decoction of oak-bark or Labarraque’s solu- tion, are useful. Pencilling with nitrate of silver may also be required. For mucous patches of the mouth, pencilling with nitrate of silver, in stick or solution, should be frequently practised, and the following mouth-wash may be employed:— Powdered chlorate of potassium, 3j. “ Eau de Botot,” f^iv. Use a teaspoonful in a wineglass of water, as a gargle, four or five times daily. It is hardly necessary to add that the most scrupulous attention to cleanli- ness is demanded, and, in case of mucous patches of the mouth, the use of tobacco must be strictly forbidden. The tobacco-chewer, in particular, is apt to keep his mucous patches indefinitely. I always insist upon the abandon- ment of this mode of using tobacco, and decline to treat the case without a pledge that my directions in this matter will be complied with. Syphilis of the Cellular Tissue ; Gummatous Tumors. Something has already been said about the gummata in dealing with the syphilitic affections of the skin, and some farther remarks on the nature of these tumors will be made further on when describing the various lesions of the viscera. It may be repeated now, however, that the chief seat of the gumma is in the connective tissue wherever found. The name gumma is given to those small tumors which contain at one period or another of their existence a thick gummy fluid. They are among the later lesions of syphilis. Their appearance differs somewhat, according to the region attacked. At the outset, gummata of the subcutaneous connec- tive tissue present themselves in the form of grouped or isolated tumors of small size, rolling under the finger, roundish, hard, arid completely indolent. After a time they lose their mobility, and become adherent to the superjacent skin, which in its turn gradually becomes involved. The tumor now softens in the centre, and the skin covering it begins to change, becomes red in color,. 405 SYPHILIS OF THE CELLULAR TISSUE; GUMMATOUS TUMORS. softens, and is finally perforated. The gumma may remain in a fluctuating condition for some time without opening. When it does open, if this is early, the escaping fluid is clear, viscid, and gummy. If the tumor does not open for a long time, the fluid discharged is more apt to be sanious and fetid, or purulent. The opening is smaller than the cavity of the abscess formed, and the bottom of the tumor retains its firmness and induration—at times an im- portant point in diagnosis.1 The ulcer succeeding the gummatous tumor is roundish, excavated, and surrounded by a dusky red areola. When a number of tumors have been grouped together or agglomerated, the resulting ulcers may unite, forming a large and very irregular sore, with numerous perforations, the openings of deeper gummata. The floor of the gummatous ulcer is generally covered with a peculiar, whitish, putrid layer of debris of characteristic appearance. When a gumma heals, it leaves behind a roundish, hollowed, white cica- trix, surrounded by an areola of pigment, which gradually disappears. In addition to these general characteristics of gummata, they possess special peculiarities dependent upon the locality in which they occur, and which will be noted in describing the lesions of the various organs. Occasionally the growth of gummata may cause pressure upon some important part, and thus arouse functional disturbance. Gummata are not infrequently accompanied by other syphilitic manifesta- tions, such as the severer syphilodermata; and not infrequently by lesions of the bones and viscera—exostoses, syphilitic sarcocele, etc. The commonest localities for the occurrence of gummata are the face and scalp, the external surface of the limbs, the posterior portion of the shoulder, the attachment of the sterno-mastoid to the sternum, various parts of the mouth, the isthmus of the fauces, and, among the viscera, the testicles .and the mamnue. Though sometimes single, gummata are more frequently found in groups. They may indeed be very numerous, more than 150 lesions having been •counted on a single patient. The gumma is, as has been said, a late lesion, never occurring previous to the sixth month, and sometimes not for years after the initial lesion. Cases have been reported where the first recognized symptom of hereditary syphilis has been the appearance of a gumma thirty years after the patient’s birth. The course of the gumma is naturally very slow; it may remain stationary for months, at any period of its development. Ho other syphilitic lesion is so rapidly influenced and modified by treatment. Diagnosis.—The diagnosis of gummata sometimes offers considerable diffi- culty, especially when the tumors are deeply seated ; treatment is in doubtful •cases often the only touchstone, and will decide the question with certainty. When the gumma is situated in the subcutaneous cellular tissue, or in the submucous cellular tissue of the buccal cavity or upper part of the pharynx, the objective signs usually suffice to establish the diagnosis. When concomi- tant syphilitic symptoms are present, it is easy to make out the character of the lesion. When these are absent, and above all when the gumma is soli- tary, some difficulty may be met with. The not yet softened gumma may be recognized by its rounded form, its firmness, its invariably moderate size, and its indolence. The seat of the tumor, its mobility, and the absence of ganglionic involvement, must also be taken into account. While these char- acteristics are met with in other than syphilitic tumors, they are rarely so well marked. 1 See illustration of gumma of the penis, PL XXII., Fig. 3. 406 SYPHILIS. G umma of the mamma may be mistaken for adenoid tumor. The symptoms and course of the two forms of tumor are much the same, and it is difficult to distinguish between them. The touchstone of treatment here comes into play, and will decide the question. Much as I dislike this resource of weak- ness in syphilitic cases,yet I know not how else, oftentimes, the diagnosis can be settled. It is far different in the syphilitic skin manifestations. To fly to mercury and iodine for the purpose of settling the nature of a doubtful skin disease, is to take the ready refuge of ignorance and incompetency. It is oftentimes difficult to distinguish between gummata of certain re- gions—as the tongue, isthmus of the fauces, and penis—and cancer of those parts. When suppuration has once begun, the gumma is unlikely to be mistaken for any other affection excepting chronic abscess, and particularly scrofulous abscess. The scrofulous abscess, however, has not as long a period of incubation as the gumma, and, when it breaks down, suppuration takes place at all points, the resulting ulcer having everted edges rather than the undermined edge of the gummatous ulcer. The age of the patient and the seat of the affection also bear upon the diagnosis. The gummatous ulcer is distinguished from the scrofulous ulcer, for which it is most likely to be mistaken, by the fact that the latter shows itself chiefly upon the face and neck in young subjects. Its edges are everted and viola- ceous ; the pus which bathes its surface is gummy and caseous, and the cicatrix which succeeds the ulcer is prominent and keloid-like. In addition, the concomitant enlargement of the lymphatic glands in the case of scrofula, and the general appearance, are to be borne in mind. Prognosis.—The prognosis of gumma is always grave, for its presence signi- fies the tenacity and persistency of the syphilitic virus in the system. It is often accompanied indeed with more or less marked debility. Treatment.—Iodide of potassium is the great remedy against gummata. It should he given in large doses, often even to the amount of a drachm ora drachm and a half daily. When the constitution is debilitated, tonics, such as cod-liver oil, iron, and quinine, should be given freely, as well as nourishing food, and, in properly-selected cases, stimulants. A gumma which has not opened should never be poulticed or cut into, even when fluctuation has set in. This is a golden rule, unfortunately too often broken by practitioners who fail to make a correct diagnosis, and who fancy that they have to deal with some sort of an abscess, or by surgeons who cannot resist the impulse to drive a bistoury into any fluc- tuating tumor which may present itself. Gummatous tumors can often bo resolved, even at the last moment and when fluctuation can be distinctly felt, under proper treatment. When a gummatous abscess has actually formed, various local applications may be employed. Tincture of iodine, pure or mixed with water, black wash or yellow wash, or one of the mercurial ointments, may be employed, Now and then the detergent influence of chlorinated soda may be brought into action. It may be said, finally, that now and then the iodide of potassium treat- ment, which is successful in the vast majority of cases, fails. In this case, mercury can be joined to it or used Sometimes an entire suspension, of antisyphilitic treatment for a time seems to do good. 407 SYPHILIS OF THE ALIMENTARY TRACT. Syphilis of the Alimentary Tract. Mouth.—The mouth is almost invariably the seat of some syphilitic lesion, at one time or another in the course of the disease, and various lesions may occur in this locality, from the most superficial to the most profound. Chancre, as has been stated, may occur about the mouth, being most com- monly met with upon the lower lip, and being also encountered upon the tongue or tonsils, and, more rarely, upon the internal surface of the cheek, the gums, or the uvula. Under the name of acute syphilitic angina, an erythematous efflorescence has been described, which occurs simultaneously with the earliest generalized manifestations of syphilis, appearing upon the palate, tonsils, and pharynx, as a diffuse redness with slight infiltration of the mucous membrane, and followed by the occasional formation of minute follicular abscesses. Associated with this condition there is often a general oedema, especially of the velum and uvula. The uvula is sometimes greatly swollen, but neither under such circumstances, nor even when it has become considerably eroded by later ulcerative lesions, should it be removed, since nature carries out a better system of repair spon- taneously. Acute syphilitic angina cannot be distinguished from simple sore throat, except by the aid of the history or concomitant symptoms of the disease.1 Mucous patches, and the slighter ulcerative lesions of the mucous membrane of the buccal cavity, have been described under the head of lesions of the mucous membranes.2 It may be noted in passing that mucous patches are not found upon the walls of the pharynx, a curious fact which is explained by the theory that as these lesions chiefly affect the papillary layer of the mucous membrane, the absence or ill-development of papilke in the pharynx accounts for their absence in that locality. The subjective symptoms to which mucous patches of the mouth give rise are almost nil, causing the patient oftentimes to be unaware of their presence. When, however, ulcera- tion takes place, particularly about the tonsils, this may be quite extensive even when only superficial in character; it may give rise to great discomfort, and, when situated about the tonsils, to considerable difficulty in deglutition. The deeper syphilitic ulcers which are met with in the bucco-pharyngeal cavity occur either spontaneously, or as following and resulting from gummata, submucous tubercles, or osseous lesions. These ulcers are indolent, with a sharply defined, punched-out appearance, and with a dull, dusky base covered with grayish deposit. They are commonly limited in extent and do not tend to spread, but occasionally they take on phagedenic action and effect the most frightful ravages. A case has been reported where one of these ulcers penetrated to the lingual artery, requiring ligation of the primitive carotid to save life. Hecrosis of the underlying bone occurs, at times, when the ulcer is situated in the pharynx or over the hard palate, communication sometimes being established between the nose and mouth, in the latter case, by this means. Treatment.—The local treatment of the more superficial syphilitic lesions of the buccal mucous membrane is essentially that described under the head of syphilis of the mucous membranes. Something more, however, may be here added. The two customary caustics employed are nitrate of silver, either in stick or in solution, and acid nitrate of mercury. The second is preferable, 1 See Martelliere, De l’Angine Syphilitique. These de Paris, 1854. 2 See, also, Kaposi, Die Syphilis der Haut und der angrenzenden Schleimhaute. Wien, 1881. Neue (unveranderte) Ausgabe. 408 SYPHILIS. not only because less superficial and more thorough than the nitrate of silver, but because it does not leave a black stain as the silver application does. The latter is a matter of some moment to patients who may have a visible lesion, as a mucous patch of the commissure of the lips. Nitrate of mercury has one fault, however—it gives rise to pain and swelling ; but these can be avoided by due caution in its application. Caustics should not be applied to the bucco-pharyngeal mucous membrane without due precautions. The affected surface should first be dried, as otherwise the caustic will flow in all directions. Solutions should never be applied by means of a glass rod. A case of death has been reported, occurring from spasm of the larynx induced by a drop of nitrate-of-silver solution let fall during cauterization of the pharynx. The solid stick is less dangerous. Though not to be recommended for use in the pharynx, yet if em- ployed, only a short piece should be used, as of course the quantity swallowed in case of accident would be less. For caustic solutions, a bit of soft pine wood, or a carefully moistened camel’s hair pencil, is the best applicator. The deeper lesions, when not phagedsenic, are best treated by cleanliness and dependence upon internal treatment, iodide of potassium having peculiar efficacy in these cases. When a disposition to phagedsenic action shows itself, caustics may be employed in addition, but the internal treatment must also be strongly pushed. Tongue.—The tongue is the seat of various syphilitic lesions which in this locality present certain peculiarities worthy of notice. In the earlier stages of the disease, an erythematous rash is sometimes though rarely encountered, showing itself in the form of a group of roundish red patches surrounded by a border of desquamating epithelium. A form of syphilitic papule is another rare lesion, which, however, is occasionally met with upon the tongue. It assumes the appearance of a slight elevation, covered with dull epithelium which gives it a whitish color. The mucous patch is a very common syphilitic lesion of the tongue. In one variety it usually occupies the median portion of the dorsal surface, in the form of an erosion, a smooth, red, rounded patch de- prived of its papillae, and of a polished aspect. In a more advanced stage of evolution this erosive patch is papular and mammillated, owing to hyper- trophy of the papillary layer of the derm. Its color is still bright red, and its surface smooth and polished; it may grow to the size of a cherry or almond pit, disfiguring the surface of the tongue. Syphilitic patches on the tongue may be distinguished from somewhat similar lesions, as follows:— Chancre—Solitary lesion; induration; edges of a frankly Inflammatory red color; deep ulceration, the bottom often covered with false membrane, and, at a later period, with exuberant granulations ; submaxillary adenitis. Aphthae Slight ulcers, with irregular borders, without induration, often covered with denuded epithelium on which a yellowish lactescent fluid can be observed; lesion rarely isolated ; usually painful when ulcerated. Ulcero-membranoas Stomatitis.—A rare affection, particularly upon the tongue ; co- incidence of ulceration on the gums, the internal surface of the cheeks, and the lips; fungous and pultaceous condition of the base of the ulcer, swelling of adjacent parts; frequent localization on one side of the mouth; frequent and considerable develop- ment of painful ganglia corresponding to the lesion. Another variety of lesion, not infrequently found upon the tongue, is that known by the barbarous name of “buccal psoriasis.”1 It is more apt to be found on the side of the tongue. In its earlier stages, this variety of the 1 This name is given to non-syphilitic lesions of the tongue as well. It is confusing, and should he abandoned. SYPHILIS OF THE ALIMENTARY TRACT. 409 mucous patch may give rise to considerable swelling and oedema, while at a later period it assumes a hard, gristly appearance, and becomes exceedingly intractable to treatment, sometimes lasting a very long time without change.1 The later syphilitic lesions of the tongue are of two distinct varieties, called by Fournier2 sclerous glossitis and gummatous glossitis. Both varieties are much commoner among men than among women. They generally make their appearance between the fifth and the twelfth year of the syphilitic disease, although now and then they may appear as early as the second, or as late as the fifteenth or even the twentieth year. They usually affect the dorsal surface of the tongue. Sclerous glossitis may be either superficial, characterized by induration in small or large patches, involving only the upper layer of the mucous mem- brane, and having a sombre red tint, with a smooth depapillated surface; or it may be deep (“ lingual sclerosis,” “ lobulated glossitis ”), characterized by cellular hyperplasia extending to the parenchyma of the tongue, and charac- terized by tumefaction, mammilation and lobulation of the dorsal surface of the organ, deep induration of the affected parts, with Assuring, together with various alterations of the mucous membrane covering them.3 Gummatous glossitis occurs in two varieties, according as the mucous mem- brane or the submucous and muscular tissues of the tongue are attacked. The former of these begins in the form of pin-head or pea-sized indurations, situ- ated superficially in the mucous membrane of the tongue, hardly perceptible to the sight, but firm to the touch. After a time these little nodules slowly break down and form ulcers, which are peculiarly deep and sharply cut, as if with a small punch. The deep or muscular gumma of the tongue is chiefiy distinguished from the former variety by its size (from pea to al- mond, or even date size), and by the fact that it clearly involves the muscu- lar tissues of the tongue. When it breaks down it leaves a large, deep, well-marked ulcer, usually on the dorsum of the tongue. The diagnosis of late syphilitic glossitis ot whatever kind does not usually offer any great difficulties. Chancre, “ psoriasis buccalis,” or “ lingualis,” smokers’ glossitis, dental glossitis, and tuberculous glossitis, can usually be distinguished without much difficulty. With cancer of the tongue, how- ever, some difficulty may arise. The history, if carefully obtained, will in this case be of considerable value. The following Table is given by Fournier to show the differential diagnosis between ulcerative cancer and ulcerative gumma of the tongue :— Ulcerative Cancer of the Tongue. 1. Affection of mature age, maximum frequency between 50 and 70 years. 2. Predisposing cause, hereditary ten- dency. No syphilitic antecedents except- ing by chance. 3. Frequent antecedents of “ lingual psoriasis.” Ulcerative Gumma of the Tongue. 1. May occur at any age after puberty. Generally observed at an earlier age than cancer. 2. Syphilitic antecedents. No antece- dent cancer excepting by chance. 3. No antecedents of “ lingual psoriasis.” 1 A representation of this lesion is given in Plate X. Fig 3. See also Debove, Psoriasis Buccal, Thhse de Paris, 1873 ; and Mauriac, Du Psoriasis de la Langue et de la Muqueuse Buccale, Paris, 1875, for a fuller description of these lesions, especially from a diagnostic point of view. 4Des Glossites Tertiaires. Avec trois planches en chromolithographie. Paris, 1877. An .excellent monograph. 3 The deep form of sclerous glossitis is represented in Plate XIII. Fig. 3. 410 SYPHILIS. Ulcerative Cancer of the Tongue. 4. Begins by the appearance of a hard superficial nodule, an external tumor ; then more or less rapid ulceration of the sur- face. No opening or evacuation as of an abscess at the beginning of the ulcer ; no excavation. 5. Lesion always single and unilateral, with rare exceptions. 6. May occupy the inferior aspect of the tongue. 7. Lesion made up of a tumor, the su- perficial portion of which is ulcerated. 8. Edges in relief, forming a raised bor- der, irregular, everted, notched, etc. 9. Surface bleeding easily at the slightest touch.' 10. Secretion abundant, becoming in the advanced stage fetid and ichorous. 11. The ulcer spontaneously painful, lancinating. Occasionally radiating pains towards the ear. 12. Functional troubles always marked and sometimes extreme; immobilization of the tongue ; difficulty of speech, of mas- tication, of deglutition ; salivation, etc. 13. Lesion leading gradually, after a given time, to general symptoms of ca- chexia. 14. Anatomical examination reveals the characters of epithelioma. 15. Ganglia affected after a certain period. 16. Anti-syphilitic treatment is without benefit, or even injurious. Ulcerative Gumma of the Tongue. 4. Begins by a hard internal nodule? then sudden opening as of an abscess; a cavern at first, then rapid ulceration, dis- playing the mammillated bottom of the tu- mor. 5. Lesion sometimes multiple and bi- lateral. 6. Is localized exclusively upon the superior surface and edge of the tongue; never affects the lower surface. 7. Lesion made up of an ulceration without a true tumor, in the proper ac- ceptation of the word. 8. Excavated, sharply-cut edges, smooth, and defined. 9. Bottom irregular and not bleeding. 10. Secretion relatively scanty and not ichorous. 11. Ulcer not spontaneously painfulr not lancinating. 12. Functional disturbances very much less marked than in cancer. Tongue not immobilized as in cancer—at least not to the same degree. 13. The lesion itself does not give rise to cachexia. 14. Anatomical examination reveals the characters of degenerated gummatous- hyperplasia. 15. Ganglia intact. 16. Anti-syphilitic treatment produces a beneficial effect. Treatment.—The treatment of the more superficial and early forms of syphilis of the tongue is that of early syphilis in general, mercury holding- the most important place. The later affections, and in particular deep sclerous glossitis and gummatous glossitis, require iodide of potassium for their successful management. Local treatment is important. It comprises cleanliness and various topical applications. In the case of the superficial lesions, astringent gargles containing chlorate of potassium (as mentioned under the head of mucous patches), together with stimulating applications,, as of the nitrate-of-silver stick lightly touched upon the part, will be found most satisfactory. But for the later lesions these must be laid aside: chlorate of potassium, alum, borax, etc., are here all useless, as are also mercurial gargles, which, indeed, are sometimes positively harmful. Mucilaginous washes are most soothing and grateful. Decoction of marsh-mallow—not gargled hastily, but allowed to remain in the mouth at least five minutes, and repeated twenty or thirty times a day—will be found to give much relief to the patient, and to hasten the cure. Emollient douches of marsh-mallow decoction serve to keep the surface clean and pure in the ulcerative forma of the disease, and the atomization of warm emollient decoctions, and, in SYPHILIS OF THE ALIMENTARY TRACT. 411 rebellious cases, of a solution of iodide of potassium, ten grains to the ounce, is attended with the happiest results. Cauterization must be employed in the sclerosed variety with precaution, and not, as is too frequently done, promiscuously. The fissures and raw sur- faces may be cauterized, but not the sclerosed surfaces. The nitrate-of-silver stick is the best application; acid nitrate of mercury and the stronger eaustics often aggravate instead of relieving the condition. Cauterization should not be repeated too frequently—once a week is often enough. In the gummatous form of glossitis, cauterization is only demanded to hasten the process of repair when this has once set in. A light application of tincture of iodine about the border of the ulcer, once or twice a day, or a slight pencilling with the crayon of nitrate of silver to stimulate forming granulations, is all that is required.1 Pharynx.—Lesions of the pharynx, though not among the commoner lesions of the mucous membranes, are not rare. Mucous patches, as has been observed, are not found in this locality, but ulcerating submucous tubercles,, gummata, and bone lesions, are not infrequently met with. The ordinary or serpiginous ulcers of the pharynx are commonly met with in the posterior wall, and resemble the same lesions as observed in the hard palate.3 Gum- mata of the pharynx are among the late lesions, and are usually situated on the posterior wall, the lesion showing itself first in the form of a small sub- cutaneous nodule, which increases in size very gradually, pushing forward the mucous membrane under which it lies, and which becomes discolored. After a greater or less period of time has elapsed, the tumor softens and ulcerates, or, if proper treatment has been employed in time, resolution may take place- without a scar. Gummata of the pharynx may be mistaken for cancer. Maisonneuve3 gives the case of a patient who underwent a serious operation for a supposed encephaloid cancer of the pharynx. After six months the tumor began to- grow again, and grew so rapidly that the patient was given up in despair and sent to the hospital to die. When examined, upon his entrance, an enormous tumor was found occupying the left lateral region of the neck and the entire parotid region. It pro- jected into the pharynx, obliterated the velum palatRand threatened the patient with death by asphyxia. The true nature of the tumor being suspected, the patient was at once placed upon iodide of potassium in sixteen-grain doses thrice daily. In less than, six weeks the tumor had disappeared without leaving a vestige ! Carcinoma, in fact, is the affection with which gumma of the pharynx is most apt to be confounded. It should he remembered, in making the diag- nosis, that the cancerous tumor (it is epithelioma which is here understood) is not as sharply circumscribed as the gumma, that, it is less movable in the- surrounding tissues, and, contrary to what is observed in gumma, is usually accompanied by some change in the neighboring lymphatic ganglia. Retro- pharyngeal abscess is distinguished from gumma, when acute, by the inflam- matory concomitant symptoms, and when subacute and cold, by the very early appearance of fluctuation. The prognosis of syphilitic affections of the pharynx is grave when any important function is involved, when a large gumma in suppurating gives rise to purulent infection, or when irregular contractile cicatrices are formed, 1 For further information see various monographs by Bouisson, Graz. Med. de Paris, 1846 ; Lagneau, Des Tumeurs Syphilitiques de la Langue, Gaz. Hebdom., 1859, Nos. 32, 33 et 35, and Arch. Gen de Med., t. i., 1860, p. 217; and Maisonneuve, Sur les Tumeurs de la Langue. These- de Concours. Paris, 1848. 2 See Wigglesworth, Buccal Ulcerations of Constitutional Origin. A paper read before the American Dermatological Association, at the fifth annual meeting, Newport, 1881. Archives of Dermatology, January, 1882. » Leqons Cliniques sur les Maladies Cancereuses. Paris, 1854. 412 SYPHILIS. which may, in some cases, interfere with phonation or audition. Late affec- tions of the pharynx are very apt to be present, or to have existed, in cases of cerebral syphilis. The treatment of syphilis of the pharynx is, in the first place, that of the •constitutional affection; then, the local applications described under the head- ing of lesions of the mouth, and, in addition to these, the use of medicated vapors by means of the atomizer, as described by Wiggleswortli. Bumstead and Taylor employ saturated solutions of nitrate of silver, applying the vapor by an arrangement of glass tubes which permit the spray to be directed to the very seat of the disease. (Esophagus.—The occurrence of stricture of the oesophagus as a result of •syphilis was, according to Bumstead and Taylor, first pointed out by James F. West, of Birmingham,1 who reported a case where, without direct evi- dence of syphilitic disease of the oesophagus, the collateral evidence of such disease, as giving rise to fatal stricture, was very strong. Other cases have since been reported, among them a very interesting one by the late Dr. F. F. Maury, of Philadelphia,3 where gastrostomy was performed. As yet, how- ever, direct evidence of syphilitic lesions in the oesophagus leading to stric- ture has not been presented, though gummata have been found in the walls ■of the tube. The treatment in suspected cases would, of course, be the usual anti-syphilitic treatment, strongly pushed in the earlier stages. In the cica- tricial stage, dilatation with bougies is a palliative measure; or the establish- ment of an oesophageal or gastric fistula might be resorted to in extremity. Stomach and Intestines.—Functional disturbance of the digestive organs, shown by loss of appetite or by inordinate desire for food, as well as by oc- casional vomiting, is not uncommon, especially during the earlier stages of syphilis. Whether the same organic changes may occur in these viscera as are observed in the external parts during the earlier stages of syphilis, is a question as yet undecided. Late lesions, as gummatous infiltration followed by ulceration of the stomach and intestines, may however occur, and cases of this kind have been reported where post-mortem examination proved the- existence of quite extensive disease. The symptoms during life were those •of dyspepsia or chronic diarrhoea, but little more.3 In many reported cases, iodide of potassium was employed in large doses by the stomach, or, where this was irritable, in the form of enemata (gr. xv-lxxv to water, siv-vj). Rectum and Anus.—Many cases of so-called syphilitic stricture of the rectum are, in reality, nothing more than the contraction due to chancroidal ulcers.4 In these, of course, specific anti-sypliilitic treatment is without -avail. The early syphilitic lesions may also, according to Barduzzi, produce stricture of the rectum.5 But it is in the later stages of the disease that this •condition is most likely to be produced. Syphilitic stricture of the rectum is much commoner among women than among men. Statistics collated by Jullien show that of 60 cases, 7 were in men and 53 in women. What the reason of this diversity may be, it is impossible to say. Many women date the beginning of their trouble to a previous preg- nancy. The affection is commonest in middle life. ' Dublin Quarterly Journal of Medical Science, February, 1860. 2 Am. Jour. Med. Sci., April, 1870. 3 See Cornil, op. cit., p. 406 ; Cullerier, De l’Enterite Syphilitique, Union Med., 1854, t. ir.; Xancereaux, op. cit., p. 248. 4 The occurrence of chancre of the rectum is more than doubtful. 8 Griorn. Ital. d. Mai. Yen., No. 1, 1875. SYPHILIS OF THE ALIMENTARY TRACT. 413 The manner in which stricture of the rectum is produced is, in all cases, by the contraction of a cicatrix following an ulcerative lesion or a submucous gumma. The ulcerative lesion is a comparatively early syphilitic develop- ment, and often coincides with cutaneous and mucous manifestations. The ulcers, as seen near the anus, are usually elongated in the direction of the swollen anal folds, between which they are often hidden, so as not to become visible until the mucous membrane is put upon the stretch. Further up in the rectum they are roundish, sharply cut, and almost always covered with pultaceous detritus and adherent mucus. To the touch they offer the sensa- tion of a granular, somewhat resistant substance. Their duration is naturally long, and they are subject to pliagedsena, owing to the various causes of irri- tation to which they are exposed. When the syphilitic ulcer of the rectum does heal, cicatrization is apt to cause a valvular stricture, if it has involved a portion, or an annular stricture, if it has extended around a greater part of the circumference of the tube. Submucous gummata of the ano-rectal region are extremely rare, but their existence is maintained by Jullien. Diffuse gumma, called by Fournier “ ano-syphiloma,” is a late lesion, and consists in an infiltration of the ano-rectal walls by a neoplasm of, as yet, unde- termined structure, originally, but susceptible of degenerating into a retractile fibrous tissue, and thus giving rise to narrowing of the intestinal calibre to a greater or less degree and extent. It is the most frequent cause of rectal stricture. Ano-rectal syphiloma is more frequently met with about the rectum than about the anus. In the former position, its chief symptom is a hard,firm thick- ening of the rectal walls. To the touch, the walls of the rectum are not only hard, but they are rough, mammillated, and divided into thick ridges. The mucous membrane is, both to touch and to ocular examination, perfectly healthy. It is the lowest portion of the rectum which is the customary seat of the form of syphilis under consideration; it rarely extends to more than two and a half inches beyond the anus. The lesion is indolent in its earlier stages, giving neither pain nor inconvenience. The anus is rarely affected alone by this lesion, but almost always in con- nection with the rectum. The lesion here takes a nodular or sometimes a vegetative form. Treated in good time, the ano-rectal syphiloma, and also the other syphi- litic anal and rectal manifestations, may be dissipated and caused to disappear. Heglected, as these affections too often are, they not only persist, but they tend to degenerate, and thus lead inevitably to stricture of the rectum. Treatment.—To be successful, the treatment of syphilitic disease of the- rectum and anus must be undertaken early in the history of the affection.. If postponed until cicatrization sets in, anti-syphilitic treatment has but little effect. When cicatrization has begun, it proceeds usually without regard to any treatment which can ordinarily be administered. The usual anti-syphilitic treatment is, of course, called for, and should be pushed vigorously as long as any chance of success by this means can be hoped for. When constriction of the rectal tube has once fairly begun, internal medication, as has just been said, is of no avail. Dilatation by means of bougies may serve to keep the passages open for an indefinite period, and should be practised assiduously. When this fails, and complete stenosis of the rectum is threatened, operative interference is called for, as will be set forth in other portions of the work.1 1 Fournier, in his complete monograph, Lesions Tertiaires de l’Anits et du Rectum, Paris, 1875, says that he has known half a dozen patients suffering with syphilitic stricture of the rectum, who, by using dilatation with bougies from time to time, have been able to go about comfortably for five, eight, and ten years. 414 syphilis. Syphilis of the Olfactory and Auditory Apparatus. Olfactory Apparatus.—The mucous membrane, cartilages, bones, and nerves connected with olfaction, may be affected by syphilis in one stage or another of its evolution. The pituitary membrane may, in the earlier stages of the disease, be the seat of erythema, mucous patches, or superficial ulcera- tion, just as the buccal mucous membrane is the seat of such lesions. Some- times an erosion or shallow ulcer may be seen within the nasal orifice, sur- rounded by swollen mucous membrane, and rendering the ala nasi tender upon pressure. Plugs of inspissated mucus, mixed with blood and pus, fre- quently obstruct the passages, and are from time to time discharged. The character of these lesions is often difficult to make out in the absence of other concomitant syphilitic manifestations, and sometimes only their disappearance under anti-syphilitic remedies serves to show their true nature. Rhinitis.—In the later stages of syphilis, ulcerative syphilitic rhinitis, or syphilitic ozeena, is met with, one of the gravest of the ulcerative affections of the mucous membranes, and one which is all the more dangerous because so often mistaken for simpler and milder affections, until it has made irreparable ravages. At the outset, stuffing up of the nostril, with sensitiveness over the affected point, and some catarrh, is observed. From time to time dark spongy crusts covered with blood are expelled, together with an almost odorless, serous fluid, and also mucus. When it has extended more deeply, the affection gives rise to an ill-smelling, sero-sanious discharge, which becomes more fetid as the disease penetrates more deeply. If the affection happens to be seated near the opening of the nares, a roundish, elevated, fungous ulcer, usually covered with a yellow crust, can be seen on the nasal septum or within the ala. The rhinoscope is necessary to examine lesions further within the nasal passages. Whether the lesion begins in the mucous membrane and penetrates to the bone, or whether the osseous lesion is first in point of time, and the super- jacent mucous membrane only becomes involved at a later period, fragments of cartilage and bone are very apt to be denuded, detached, and discharged. In this case the discharge becomes blackish and extremely fetid, the sense of smell is almost or entirely lost, the mucous membrane in the neighborhood of the ulcers becomes swollen and painful, and the nose changes its shape, and, if the septum is attacked, becomes flattened. The ulcerative process may perforate the floor of the nasal cavity, extend into the pharynx, find its way along the Eustachian tube, and even penetrate the cranial cavity, involving the meninges; more commonly, however, the membrana tympani becomes ruptured, and purulent discharge takes place through the external auditory canal. Deafness may ensue from obliteration of the Eustachian tube by a cicatrix. The disease has been known to pass up the lachrymal canal, involving the lachrymal bone and even the eye (Bumstead and Taylor). Respiration through the nose is usually hindered more or less by the lesions described, and sometimes it is permanently pre~ vented, breathing being entirely performed through the mouth, and the voice having a nasal twang. Treatment.—The constitutional treatment of syphilis of the nasal passages is that of the disease in general, and its nature must depend upon the stage of the affection and upon the character of the lesions. In addition to mercury and iodide of potassium, tonics and cod-liver oil are frequently called for. The most efficacious local treatment is by means of mercurial inhalations, a sufficient quantity of calomel or of the bisulphuret or binoxide of mercury being heated on a metallic plate over a spirit lamp, and the fumes being directed 415 SYPHILIS OF THE EYELIDS AND LACHRYMAL APPARATUS. into the nostrils by a cone of paper or other convenient method. Blood-warm injections of a strong solution of chlorate of potassium or of common salt {3j ad Oj), or of a diluted solution of chlorinated soda (1 part to from 12 to 20 parts of water), are also useful. The nostrils should first be thoroughly cleansed by means of the nasal douche. It is a matter of great importance to follow out a thorough and complete system of cleansing and local medication in these cases, in order to limit and check the progress of the disease as rapidly as possible, and it must be remembered that, as long as there is any necrosed bone to come away there will be a foul discharge, so that the prognosis must be made with this fact in view. Olfactory Neuritis.—That the olfactory nerves may be attacked by syphilis has been shown by Bayle and Kergaradec1 who cite a case where these nerves were destroyed. Virchow also gives a case where these nerves were lost, so to speak, in the general disorganization of surrounding tissues. Gros and Lancereaux2 likewise cite analogous cases. Anosmia is of course the promi- nent symptom under these circumstances. Auditory Apparatus.—Syphilis of the ear is comparatively rare. Buck, of Yew York, met with but 30 cases out of a total of 3976 cases of ear affec- tions, though, owing to the fact that many cases go unrecognized, the propor- tion is probably larger. Chancre of the external ear has been met with in one recorded instance, and the various syphilitic lesions of the skin are of course encountered here, papules being most apt to occur in the post-auricular angle and upon the lobule of the ear, while the macular syphiloderm is seen in the fossa navicularis and concha. Vegetating papules are found in the external auditory canal, solitary or few in number near the outer opening, but sufficiently numerous and luxuriant further inwards to occasionally fill up the canal and hide the drum. Sometimes vegetations form on the drum itself, when perforation may result. They are accompanied by the discharge of a sero-purulent fluid which causes the affection to look like otitis externa. Simple papules or papulo-squamous lesions are not found within the meatus. At a later period in the evolution of syphilis, ulcers of roundish form, covered with diphtheritic membrane, are liable to occur within the meatus, and gum- mata of the cellular tissue, cartilage, or bone, are also met with. Hyperosto- sis and exostosis may likewise occur in the external bony canal. The middle ear is that portion of the olfactory apparatus which is most apt to be the seat of syphilitic disease. Chancre of the Eustachian tube has been reported as the result of using unclean aural instruments, and mucous patches are not infrequently met with either in this tube or in the middle ear, sometimes disappearing under treatment, but sometimes ulcerating and ■destroying the tissues to a greater or less extent.3 Syphilis of the Eyelids and Lachrymal Apparatus.4 The various tissues which go to make up the eyelids may each be the seat of one or another of the lesions of syphilis. Chancres of the eyelids have 1 Nouv. Bibliotheque Med., quoted by Lancereaux. 2 Affections Nerveuses Syphilitiques. 3 For a description of the syphilitic lesions of the middle and inner ear, reference may be made to the article on affections of the ear in Vol. IV. of the present work ; to Bumstead and Taylor’s Treatise (p. 730 et seq.); and to the following monographs and papers: Gruber, Ueber Syphilis des Gehororgans (Wien. med. Presse, 1870, 1, 3, 6, 10); Roosa, Syphilitic Affections of the Ear (Am. Jour. Syph. and Derm., 1871, p. 97); Sexton, The Sudden Deafness of Syphilis (Am. Jour. Med. Sci., July, 1879, and Jan. 1880); and F. R. Sturgis, Affections of the Middle Ear during the Early Stages of Syphilis (Boston Med. and Surg. Jour., vol. cii. p. 533, 1880). 4 The syphilitic lesions of the eye proper are considered in another article. 416 SYPHILIS. been reported ; the syphilodermata may affect the skin of the lids; mucous- papules or mucous patches may occur upon their commissure; the glands may be involved, causing blepharitis; and gummata of the angle of the eye are not very rare. Most of these lesions are easily distinguished from the non-syphilitic affections which they resemble. A form of late ulceration occurring near the free border of the lids is liable to be mistaken for ophthalmia tarsi or epithelial cancer, but the history, and in a last resort the touchstone of treatment, will settle the question. Bumstead says that non- ulcerating gummatous nodules from small-pea to filbert size occur in the lids, the skin over them being unchanged in color or appearance. These may sometimes remain unaltered for a considerable period, and are liable to be mistaken for tarsal or meibomian tumors. They may usually be resolved by the free use of antisyphilitic remedies, especially the mercurials. Syphilitic inflammation of the tarsal cartilages is characterized by a thickening from inflammatory infiltration of the cartilage, which usually retains its shape, and from swelling of the lid, in which the skin may or may not be involved. The cartilage is apt to lose its normal elasticity. The affec- tion is obstinate, lasting weeks or months, and is apt to be followed by loss of the cilia. The affections of the lachrymal ducts have been carefully studied by various writers, among others by Lagneau,1 who says that they are generally due to some osseous lesion—periostosis, exostosis, caries, or necrosis; more rarely they are due to some lesion of the soft parts. The chief diagnostic marks are the presence of an indurated, resistant swelling, of a bony character at bottom, perceived by the touch at the lower and internal portion of the orbit, or by the sound in the nasal duct. The syphilitic character of the cutaneous orifice of the fistula, when one exists; the coincidence of late syphilitic lesions in the neighborhood, or elsewhere; and the history of the case, will also throw light on the nature of the disease. The course of the affection is slow, with occasional erysipelatoid attacks. Internal treatment,, employed at an early stage, must be relied upon. Syphilis of the Generative Apparatus. Penis and Urethra.—The urethra, both in the male and in the female, may be the seat of various syphilitic lesions analogous in most respects to those occurring in the respiratory and alimentary passages. The cavernous structure of the penis may be the seat of a gummatous deposit which may give rise to a sort of chordee; the affected section of the penis being flaccid during erection, the organ assumes a curved shape, and is pointed in one direction or another according to the seat of the gumma. Other deposits in the cavernous portion of the penis may give rise to the same symptom, which is not, therefore, peculiarly characteristic of syphilis. Bumstead and Taylor2 speak of a tubercular or gummy ulcer of the penis which closely resembles chancroid, with sharply-cut edges and grayish exca- vated floor, an abundant purulent secretion, and a soft base, seen most fre- quently in the furrow at the base of the glans, where it tends to undermine the integument of the penis.3 This sore, however, is solitary, while chancroid is usually multiple. Testicle.—Syphilitic Epididymitis.—First described by Dron4 in 3 863, 1 Maladies Syphilitiques des Voies Lachrymales. Arch. G6n. de. M6d., 1847. * Op. cit., p. 361. 3 See PL XXII., Fig. 3. 4 De l’Epididymite Syphilitique. Arch. Gen. de Med., 1863. SYPHILIS OF THE GENERATIVE APPARATUS. 417 this affection is characterized by the insidious occurrence of a small, smooth, round or oval tumor just above the testicle, the latter and the scrotum itself being unaffected. Its size varies from that of a pea to that of a Lima bean. It is indolent, and may exist for a long time unchanged. It readily disappears under the influence of mercury. This affection is a rather early manifestation of syphilis, occurring in most cases within the first six months. It may, how- ever, show itself as early as the second month, or as late even as the fifth year after infection. It may be confounded with tubercular epididymitis, and has sometimes been mistaken for the result of acute or chronic urethral inflammation. An important point in the diagnosis of the affection is that it attacks the globus major, whereas in gonorrhoeal epididymitis the globus minor is most commonly involved alone. Syphilitic orchitis may occur as soon as the fourth or fifth month after contagion, while early symptoms are still present; but in the majority of cases it does not appear until several years after the primary sore, and is accompanied by well-marked late manifestations in the fauces, periosteum, or bones; or in some instances it is the only evidence of syphilitic disease which the patient presents. Syphilitic orchitis commonly attacks both testicles, either at the same time or one after the other. The testicle becomes enlarged, without pain, even on pressure, or any sign of inflammation. There is a feeling of weight, espe- cially towards evening, as the testicle grows heavier, and sometimes a dull pain is felt about the loins; but there is no nocturnal exacerbation, as is usual with many syphilitic troubles. The testicle is somewhat increased in volume, but rarely above double its normal size. Some of the apparent swelling is due to hydrocele, as there is in nearly all cases a slight effusion into the tunica vaginalis. ‘When considerable effusion is present, it may be necessary to evacuate the fluid before the condition of the testicle can be ascertained, but commonly a little manipulation will enable the gland to be grasped and examined. At an early stage in the disease, small indurated nodules, of a gummatous character, can sometimes be felt upon the surface of the testicle, and at a later period these may coalesce and form an indurated tumor, but with- out giving rise to great irregularity of outline. Sometimes the tumor is smooth from beginning to end. The course of the affection is slow, frequently lasting for several years. Left to itself, it frequently terminates in obliteration of the seminiferous tubules and partial or complete atrophy ; at other times the parenchyma of the gland may degenerate into fibrous, cartilaginous, or even osseous tissue. It was formerly supposed that suppuration never took place in uncomplicated syphilitic orchitis, but it has been shown that this result is occasionally observed.1 There are two forms of syphilitic orchitis, pathologically considered. In the first or diffuse form, a sub-inflammatory condition is found, with diffuse cell-infiltration and effusion. In the circumscribed variety, there are gum- matous nodules scattered through the body of the testicle. The two varieties may occur together. Syphilitic orchitis may be confounded with gonorrhoeal epididymitis, with cancer, with tubercular disease of the testis, or with simple chronic orchitis. The gonorrhoeal affection is so clearly inflammatory in its character—being at- tended by severe pain, difficulty of motion, redness, heat, and tension of the scrotum—that these symptoms alone should suffice to distinguish between the two conditions. In cancer of the testicle (generally encephaloid), the pain,slight at first, increases with the progress of the disease, and becomes very severe and 1 Secondary softening of the interior sometimes takes place. See Lancereaux, op. cit., 2me 6d., p. 221, and for an illustration, Ibid., PI. I. Fig. 9. 418 SYPHILIS. lancinating; the tumor is irregular in shape, grows with great rapidity, and often attains an immense size; and the cord and neighboring ganglia are fre- quently involved. Tubercular disease of the testis comes on about puberty in strumous subjects; the deposit occurs in the epididymis or in the centre of the testis; adhesions with the scrotum and tunica vaginalis occur, and suppuration and ulceration may follow. Evidences of tubercular deposit may often be detected simultaneously in the vesiculte seminales, by examina- tion with the finger per anum, or in the cord or inguinal ganglia. Chronic orchitis is a very rare affection, and the diagnosis between it and the disease under consideration can usually be made by exclusion.1 In cases of doubtful diagnosis, it is always best to wait, and, if necessary, attempt a cure by spe- cific medication before operating. It is said, on good authority, that many patients suffering from curable syphilitic orchitis have been uselessly castrated hy rash operators. Iodide of potassium combined with mercury is the best remedy in syphil- itic orchitis, which will often yield to the “ mixed treatment” when the iodide alone, even in large doses, has failed. With broken-down patients, mercurial inunctions, with iodide of potassium and tonics internally, form the best treatment. The testicle may be supported by a suspensory, and, in case the effusion into the tunica vaginalis is excessive, it may be evacuated by means of a lancet or broad needle. The danger of wounding the swollen testis is too great to admit the use of a trocar, as employed in the ordinary method of tapping for hydrocele.2 Syphilis of the Female Generative Organs.—In addition to the early manifestations of syphilis—chancre, moist papules, mucous patches, etc.—which have been already described as they are found upon the external genitalia of the female and upon the cervix uteri, other later lesions, chiefly tubercular and ulcerative-tubercular in character, are found in these parts. They do not, however, present any peculiarities worthy of special note. Syphilis of the uterus and its annexes, however, requires some special men- tion. With regard to the uterus itself, some doubt exists as to whether syphilis in its latef forms has been known to attack this organ. It seems likely, however, that certain cases of so-called cancer of the uterus are nothing more than ulcerated tubercular or gummatous deposits, since, in one or two instances,3 specific treatment has brought about a cure when cancer had been diagnosticated and a fatal result looked for. Lecorche and Lancereaux4 have reported cases where the ovaries, in un- doubtedly syphilitic cases, appeared at the autopsy to have been the seat of diffuse or sclerous syphiloma. These cases showed no clinical sign of the disease found. Gummatous tumors of the ovaries, as in a case reported by Lancereaux, have shown their existence by objective symptoms during life, in the shape of egg-sized enlargements, elongated in the direction of the broad ligament, quite perceptible in the ovarian region, and disappearing under the use of iodide of potassium. Richet also reports a case where autopsy revealed an undoubted gummatous tumor in the substance of an ovary. 1 Bumstead and Taylor (op. cit., p. 637) give tlie more prominent symptoms of chronic orchitis. Curling (On the Testis, 2d ed., London) may also he referred to in this connection. 2 Bumstead and Taylor. 3 Cited by Jullien, op. cit., p. 934. 4 Jullien, op. cit., p. 935. SYPHILIS OF THE KIDNEY AND LIVER. 419 Syphilis of the Kidney. The earlier disturbances of the urinary function have been already men- tioned (page 376). The affections of the kidney about to be described are of later date, and of more serious significance. Syphilis of the kidneys is of two varieties, pathologically dissimilar, hut clinically not to be differentiated. One is characterized by gummatous 4eposits; the other is a diffuse nephritis, not unlike the diffuse syphilitic sclerosis of the lungs and testicles. In both forms of syphilitic kidney-trouble, the affection begins in an in- sidious manner. After a time the effect of the renal disease comes to show itself in the system at large ; the patient becomes pale and weak, suffers from general malaise, with gastric disturbance, nausea and vomiting, headache, lumbar pain—in a word, the usual symptoms of beginning renal disease. At a later period, oedema about the ankles, puffiness of the face, and extravasations into the serous cavities follow, as do also epistaxis and haemoptysis. At this stage the polyuria and albuminuria become somewhat lessened; the patient is like the subjects of ordinary Bright’s disease, and, unless the morbid process can be arrested, goes on through anasarca, ascites, “ indolent” pleurisy, lesions of the eye and brain, and finally complete cachexia, to death. It will be' observed that the symptoms just mentioned are manifested by syphilitic kidney affections in common with non-syphilitic renal troubles, but as regards prognosis the difference is very marked. Taken in time, and appropriately treated by means of mercury and iodide of potassium, together or alone, the morbid process is arrested, amelioration can be hoped for in many cases, and it is not rare even to obtain a complete cure.1 Of course, it is understood that timely measures are carried out; the treatment should he prompt, thorough, and persistent, from the moment when the nature of the affection is understood. Sypiiilts of the Liver. Early Hepatic Syphilis.—The earliest manifestations of syphilis in the liver have already been described (page 375), but those which occur at a later period in the history of the disease are of more importance and deserve a fuller discussion. In what may be called the middle stage of the early evo- lution of syphilis, the liver is now and then attacked in the same manner as in the earlier period already described, but to a rather more marked degree. This form is met with from two and a half to three months after the first out- break of generalized symptoms, and is accompanied by hypertrophy of the liver, pain, and sometimes icterus, together with certain concomitant symptoms to be mentioned. The liver begins to enlarge at an early period, and continues to increase in volume until treatment is instituted. It remains stationary for a time under treatment, and then begins slowly to decrease in size, but with interruptions caused by recurrent attacks of congestion, alter- nations of amelioration and aggravation occurring without ostensible cause. The volume of the liver is variable, but in some cases the organ may rise as much as two fingers’ breadth above the floating ribs in the line of the nipple, and may form a more or less prominent tumor in the line of the sternum. Pain is a constant symptom. Weight in the hypochondrium, difficulty of locomotion which aggravates the pain, and increased distress with lancinat- 1 See Fournier (op. cit.), for a striking case illustrating the curability of this affection. 420 SYPHILIS. ing pain on percussion or palpation, are characteristic symptoms. The pain leaves before the hypertrophy has been entirely reduced by treatment. Icterus is not a constant symptom. When present, it comes on after the hypertrophy and pain, and disappears with those manifestations. When observed, it is intense, with scanty, bile-colored urine, and clayey stools; but none of these symptoms persists more than a few days after treatment has been instituted. As was observed above, in treating of the earliest forms of syphilitic liver trouble, gastric and intestinal catarrh are absent. The digestive disturbances noted supervene after the appearance of the hepatic disorder, and are accounted for by the condition of the liver. Loss of appetite is observed, while the tongue is moist and normal in appearance. Digestion is slow and difficult, and accompanied by sensations of weight and discomfort in the epigastric region, and by a tendency to constipation. The other symptoms of syphilis, eruptions of various kinds, cephalalgia, etc., usually relapse or break out afresh coincidently with the appearance of the hepatic disorder, and it has been observed that in some cases the spleen and kidneys are involved at the same time. The diagnosis of this form of syphilis of the liver, which it may be men- tioned is a rather rare atfection—if we may judge from the scanty records published—must be made chiefly by exclusion. There is scarcely any affec- tion excepting syphilis which can give rise to this sub-clironic condition of the liver, and of course the coincidence of other syphilitic manifestations is an important aid. The prognosis is more serious than in the earlier form of hepatic trouble, and it is likely that the repeated congestive attacks and relapses which mark the course of the affection, point to a locus minoris resistentice which may be the seat of subsequent attacks of syphilitic disease of a more serious character. The coincidence of other visceral manifestations, and the fact that when eruptions of the skin occur in this connection they are often of the type called “precocious”and“ malignant,” also mark the affection under consider- ation as one of serious import. The treatment should be prompt and energetic, every effort being made to build up the patient at the same time that specific remedies are administered with a free hand. The “ mixed treatment” is that to which recourse should be bad, and in order to save the stomach as much as possible, mercurial inunc- tion may be combined with the internal administration of iodide of potas- sium, beginning with the dose of five grains thrice daily, given immediately after eating, and rapidly increasing this to ten grains or more at a dose, care being taken to avoid irritation of the stomach. (See remarks on treatment.) Tonics, such as iron and quinine, nourishing food, douche and other baths, and change of air and scene, may be required in one case or another. It must be remembered that it is not merely a patient with liver trouble that must be treated, but at the same time an individual poisoned by an unusually severe attack of syphilis, which may even threaten life in its later stages, if these, its earlier manifestations, are not deprived of their virulence and crushed out. Among local remedies various revulsives may be used. Dry cupping, and afterwards, flying blisters, are perhaps the most satisfactory in their effects. It must not be forgotten that even after the patient appears to be cured, relapses may take place, and that the antisyphilitic treatment should be kept up for a long time, or, if this is impossible, should be resorted to for short periods at intervals. Late Hepatic Syphilis.—The late syphilitic lesions of the liver manifest themselves under two forms—1. Interstitial hepatitis. 2. Gummatous hepa- SYPHILIS OF THE LIVER. 421 litis. Lac-ombe1 considers these two forms as anatomically the same, hut they are best described separately. Some authors consider amyloid degene- ration of the liver as a syphilitic lesion, hut it is rather the effect of a cachexia which may or may not he syphilitic in origin. Again, peri- hepatitis has been considered as an independent affection, hut recent writers regard this as merely the result of interstitial hepatitis. In perihepatitis, the lesions are situated in the fibrous envelope of the organ, which is thickened, and which shows marked adhesions attaching it to the neighboring organs, particularly the diaphragm. The membrane sometimes contains a greater or less number of small, hard, whitish nodules. In interstitial hepatitis, the volume of the organ varies according to the stage of the disease. In the earlier stage it is hypertrophied, in the later stage atrophied and shrunken. The color of the organ is changed to a more or less bright yellow on the surface, and in section, when also white strife formed by the prolongations of the hypertrophied fibrous membrane can be seen. In the gummatous form of hepatitis, a more or less considerable number of gummy tumors, similar to those observed in the cellular tissue, are found in various stages of evolution. Virchow has described a syphilitic lesion of the liver which assumes the form of cicatrices. The surface of the liver is also found to show loss of substance at circumscribed points, replaced by whitish stellate patches, the prolongations of which penetrate more or less deeply into the tissues beneath. The biliary canals and vessels are rarely intact; sometimes they are found to have entirely disappeared. The lesions may occupy the entire organ or only a single lobe. Syphilitic affections of the liver are most apt to occur in individuals who have not been properly treated during the early stages of their disease, either because of neglect, or because the earlier manifestations were so trifling as to escape notice. It is commonly met with between the ages of thirty and forty. Extraneous influences, such as traumatism or superactivity of the organ, predispose to the disease. Alcoholism is a recognized predisposing cause. Symptoms.—The symptomatology of syphilis of the liver is by no means as well understood as its pathology. The course of the disease may be divided into three stages, corresponding to the pathological changes which take place in the affected organ. (1) The first stage, corresponding to that of connective tissue hyperplasia—• hypertrophy of the liver—is characterized by enlargement of the organ to a degree perceptible to external examination. Percussion shows dulness, sometimes extending two or three finger-breadths above the floating ribs, while the tumor can be seen in the epigastric region. This hypertrophy is a late manifestation; it may occur from three to four years after the early syphilitic symptoms, or in some cases as late as twenty years. Its duration is very variable. It may increase by successive exacerbations. Pain is a characteristic symptom. Usually of a dull dragging character, and aggravated on walking, it may occasionally occur in acute paroxysms of much greater severity, especially at night. The pain radiates toward the epigastrium, the iliac fossa, and the kidneys. It gives rise to such sensitive- ness that the least pressure causes distress, and that patients cannot at times even so much as button the clothing. Icterus, usually succeeding the hypertrophy, is an occasional symptom of this period of hepatic syphilis. It is supposed to be due, under ordinary circum- stances, to extension of the inflammation to the bile-ducts, and to oblitera- tion of these by desquamation. Another explanation, suggested by the 1 Etude sur les Accidents Hepatiques de la Syph. chez l’Adulte. Thfese de Paris, 1874. 422 syphilis. observations of Virchow and others, is stoppage of the biliary passages by pressure from a gumma. Clinically, the icterus in the first of these cases is more marked, but not as persistent, as in the second case—that of compression by a gumma. Ascites is occasionally observed, though not to a marked degree. It is due to involvement of the hepatic vessels interfering with the circulation in the liver. The chief characteristic of these various symptoms of the first period of hepatic syphilis is that of being curable. They yield with tolerable promp- titude to antisyphilitic treatment. In addition, the spleen and kidneys may be involved simultaneously, ulce- ration of the pharynx is very apt to be present, and various other symptoms of syphilis may coexist to make the diagnosis easy. It should be remarked that digestive troubles are not usually present. (2) The second stage is unmarked by any physical or functional symptoms of a characteristic nature. (3) The third stage is marked by physical and functional symptoms. Atrophy is generally well marked, but as atrophy of one part of the liver is at times compensated by hypertrophy of another, percussion must be made very carefully, when it will show marked irregularity of outline—atrophy in one place, hypertrophy in another. Occasionally, irregularities and lobula- tions can be perceived by manipulation of the edge of the liver. Sometimes the abdominal walls will be observed to be immobile during respiration, instead of gliding over the surface of the liver, as in the normal condition. Among the functional signs, icterus, although sometimes observed, is rare. Ascites is well marked, beginning slowly and insidiously, through the period of a month or more, and then suddenly developing to a considerable degree within four or five days, so as to interfere with locomotion and to hinder respiration, requiring* puncture at times, and even then oftentimes returning with increased rapidity. Ascites is a grave symptom when it appears; little or no relief can be expected from treatment. Digestive disturbances constitute a marked feature of the affection under consideration. They arise in part from the condition of the liver, and in part from the general cachexia. Vomiting is an early symptom; it may precede all others. Diarrhoea, on the other hand, is more frequent in the later stages of the disease, when it is met with in six cases out of seven. The stools are pale and discolored if there is retention of bile. The intestinal functions are likewise imperfectly performed; there is meteorism; the abdomen is dis- tended ; and, as nutrition does not go on perfectly, the patient becomes thinner clay by day. The course of hepatic syphilis is slow, progressive, insidious, or even con- cealed. In some cases it runs its course without giving rise to any perceptible external symptoms. Its duration is long, unless when an extension of the ascites or some complication causes death, and it may exist months or years without causing any considerable disturbance of the system at large. The affection terminates most frequently by producing marasmus and cachexia. Diagnosis of Hepatic Syphilis.—Syphilis of the liver is to be distinguished from cancer, hydatid cyst, and drunkard’s liver. The diagnosis is at times very difficult, but attention to the following points may aid in distinguishing doubtful cases:— Cancer only shows itself at an advanced age, fifty or sixty years on an average. It invades both lobes at the same time. Pain is more severe; there is vomiting, rapid depression of the vital forces, and special cachexia. The affection does not last more than from six months to two years. Icterus is SYPHILIS OF THE RACEMOSE GLANDS. 423 very marked, or at least the characteristic discoloration of the cancerous cachexia. Hydatid Cyst.—A fluctuating, globe-like projection, larger than that of the syphilitic disease, advancing toward the epigastrium, and often simulating a lesion of the stomach. Pathognomonic vibratory trembling. Digestive troubles. Dyspnoea. Ascites rare. Drunkard’s liver is distinguished anatomically from syphilis of the liver by its localization at the periphery of the lobule. The neoplasm incloses the lobule, but does not penetrate it—does not interpose between the cellules. Clinically, the lesions are more extensive than those of syphilis; ascites is more frequent. The course of the disease is slow. There are various digestive symptoms coincident: dyspepsia and anorexia; also nervous disturbances, as formication, cramps, and trembling. The prognosis of hepatic syphilis is grave. If the affection can be taken in time it may be cured in many cases, but if atrophy has set in, the prognosis is very serious. Treatment.—The “mixed treatment” offers the best chance for a cure. It is better than the use of either mercury or iodine alone. The literature of hepatic syphilis, particularly that which relates to the pathological anatomy of the disease, is very abundant, much attention having been paid to the subject in the last few years.1 Syphilis of the Racemose Glands. Mammary Glands.—The mammary glands are rarely attacked by syphilis, but twenty cases, according to Jullien, are on record. The affection is of two kinds, diffuse sclerous infiltration, and localized gummy deposit. The first variety is apt to be met with among men. It is a comparatively early manifestation, and is characterized by diffuse tumefaction, by tenderness on pressure, without external inflammatory appearance, and by rapid disap- pearance under specific treatment. The gummatous affection of the mammary glands is a late syphilitic mani- festation, and is much commoner among women. When first noticed, the gumma is often buried deeply in the tissue of the mammary gland, and may easily be mistaken for an adenoid tumor. It grows in size, however; some- times attaining that of an egg or an apple, or even (in one case reported by Sauvage) that of a child’s head. The tumor is irregular and bosselated, and sometimes accompanied by ganglionic engorgement. As it approaches the surface of the skin, fluctuation, or at least the sensation of a softened infil- trated tissue, is perceived, a point of decided diagnostic importance. If not influenced by treatment, the skin softens, and an ulcer is formed. It is not always easy to distinguish this lesion from cancer, and, unless some concomitant and unmistakable syphilitic symptoms are present to guide to a conclusion, the only plan to follow is to use the “ touchstone of treat- ment.” But an unnecessary surgical operation may be avoided, perhaps, by giving in doubtful cases the iodide of potassium, or perhaps the “mixed treatment,” and watching its effects. Salivary Glands.—Lancereaux has reported a case where the submaxillary gland, in a patient dying in full tide of syphilis, was found affected by 1 The following writers may be particularly referred to, and in their works will be found numerous references to the contributions of others : Lancereaux, Traite de la Syphilis, 2e §d. Paris, 1878 ; Quinquaud, Affections du Foie, Premiere Fascicule ; Lacombe, These de Paris, 1878 ; Leudet, Recherches Cliniques sur l’Etiologie, la Curabilite et le Traitement de la Syphilis Hepatique (Arch. Gen. de M6d., Fev. I860) ; Cornil, Leqons sur la Syphilis. Paris, 1879. 424 SYPHILIS. diffuse syphilitic sclerosis. Fournier has reported a case of syphilitic disease of the sublingual gland ; the patient, while suffering from generalized syphil- itic symptoms, was attacked by a tumor the size of a date, which could be perceived in the right sublingual fossa, and was firm and hard to the touch. The administration of iodide of potassium reduced the tumor in a few days to its normal volume. Verneuil has reported a somewhat similar case, in which, however, the nature of the tumor was not made out at the time. Pancreas.—Lancereaux says that, in many autopsies of syphilitic subjects, the pancreas is found indurated by sclerosis. He also reports a case of gumma of the pancreas, this, with the addition of one reported by Rostan, being the only cases on record.1 Syphilis of the Spleen, Supra-Renal Capsules, and Thyroid Gland. Spleen.—The condition of the spleen in the early stages of syphilis has already been alluded to (page 374). Like the lymphatic ganglions, the spleen is almost always attacked hy early syphilis, but the later and severer stages of the disease leave it untouched in the vast majority of instances. In the few cases observed after death, gummy deposits were noted in some, but they were usually small and few in number. They were usually situated in the connective tissue of the capsule. Diffuse sypliiloma of the spleen is charac- terized by partial hypertrophy of the organ, the tissues of which are con- densed and of a dark-brown color. At a later period, grayish patches are observed, which terminate in depressed cicatrices. Clinically, the affection has rarely, if ever, been recognized. Supra-Renal Capsules.—The supra-renal capsules are often found enlarged in syphilis. Virchow has seen them surrounded by fatty degeneration. Chvostek2 has reported an interesting autopsy. ISTo clinical facts are known. Thyroid Gland.—Lancereaux3 has observed enlargement of the thyroid gland in numerous autopsies of syphilitic subjects. Microscopic examination shows increase of the glandular elements, with occasional fatty degeneration.4 Syphilis of the Respiratory Passages. Larynx.—It was formerly thought that all syphilitic diseases of the larynx were propagated from pre-existing lesions in the pharynx, and that they were closely assimilated to these as regarded the period of their develop- 1 The following references may be made by any one interested in the scanty literature of the subject of syphilis of the racemose glands : Vernenil, Tumeurs gommeuses du Sein (Bull, de la Societe Anatomique, 30e annSe, p. 96); Ambrosoli, D’une Maladie de la Glande Mammaire qui quelquefois s’associe avec differentes formes dela Syphilis (Gazz. Med. di Lombard, No. 36,1864); Icard, Note sur un Cas de Tumeur Syphilitique simulant un Cancer du Sein (Jour, de Med. de Lyon, t. vii. p. 21, 1867); Paul Horteloup, Des Tumeurs du Sein chez l’Homme (These d’Aggre- gation, p. 42, 1872); Lancereaux, Traite de la Syphilis ; Fournier, Dggen6rescence Syphilitique de la Glande Sublinguale (Annales de Dermatol, et de Syphiligr., t. vii. p. 81); Rostan, Altera- tion Syphilitique du Pancreas (Bull, de la Soc. Anatom., p. 86, 1855). 2 Wien. med. Wochens., Aug. 1877. 3 Op. cit., p. 287. 4 The following references may be made to recent articles on syphilis of the spleen and supra- renal capsules : Moxon, Syphilis of the Supra-Renal Capsules (Guy’s Hospital Reports, 3d s., vol. xiii. p. 339, 1868); Huner, Syphilis of the Spleen (Deutsches Arch. f. klin. Med., Bd. v., S. 270, 1869); Besnier, Syphilis de la Rate (Diet. Encyc. des Sci. Med., Art. Rate, 1874); Chvostek, Syphilis of the Supra-Renal Capsules (Wiener med. Wochenschr., Aug. 1877). SYPHILIS OF THE RESPIRATORY PASSAGES. 425 ment and their general character. It is now known, however, that the syphilitic lesions of the larynx may occur at any period of the general de- velopment of syphilis, without regard to the appearance of other lesions. The superficial syphilitic lesions of the larynx include erythema, mucous patches, superficial ulcerations, and vegetations. The deep lesions are deep ulcerations, gummatous tumors, perichondritis and chondritis, caries, and necrosis. The farther from the opening of the larynx is a lesion situated, the more serious is it. But the severity and threatening character of a lesion are by no means proportioned to its individual character. There is often more to be dreaded from a shallow mucous patch accompanied by oedema, than from a deep ulceration. The subjective symptoms connected with syphilis of the larynx are comparatively trilling. Quite a large and deep ulcer may exist without the patient being even aware of its presence. The invasion of the larynx is insidious, and the subsequent course of the lesions is chronic and devoid of pain. According to the views of some authorities, the parts of the vocal organism most often in contact during the performance of its function are most frequently attacked by syphilis. Hence the vocal cords and the arytenoids are the most susceptible regions (Bumstead and Taylor). The lesions of laryngeal syphilis are rarely painful, excepting when the cartilages are attacked. There is rarely any cough, and but slight expectora- tion, this, if present, being scanty, mucous, or muco-purulent. The sputa may he tinged with blood from an ulcer, or may contain fragments of cartilage or hone. In the latter case they are apt to he fetid. The voice is rarely altered, although in some cases there may be hoarseness or whispering. Dys- phagia may occur in rare cases where the disease is far advanced, or where the epiglottis is attacked. Dyspnoea is an important symptom. It may supervene on stenosis of the passage caused by oedema, vegetating growths, cicatricial contraction, and possibly spasm. Tracheotomy is sometimes called for, but it should only be employed at the last moment, since prompt and vigorous specific medication—if necessary, by the hypodermic method— will sometimes save an apparently desperate case. In considering the special lesions of the larynx, it is scarcely necessary to more than mention the early and slighter affections. Erythema is easily made out when concomitant symptoms are present, or when a trustworthy history can be obtained. When the epiglottis is involved, it may become cedematous and much tumefied, and may assume a bilobed shape. There has always been some question as to the relative frequency of mucous patches in the larynx, but recent writers, such as Krishaber, Mauriac, and Whistler, consider them tolerably frequent. They possess in general very much the same characters in the larynx as in the mucous membrane of the mouth; but the difficulty of examining them closely, and the more com- plicated arrangement of the parts, render them less easy of recognition in some cases. The superficial ulcerations in laryngeal syphilis involve only the mucous membrane. They are very sluggish, persisting with slight change for an indefinite period. They are apt to be confounded with the ulcers of phthisis, but these begin in the ventricular bands, and are paler than the syphilitic lesions. The ulcers of phthisis are bathed in a copious, muco-purulent secre- tion, and are apt to be accompanied with decided swelling and oedema of the arytenoids. Finally, the concomitant symptoms of phthisis are likely to he found elsewhere. The chronic inflammation of laryngeal syphilis may be an early or a late lesion; it is apt to be persistent, and to lead to thickening or hypertrophy of 426 the mucous membrane, quite a different symptom from the oedema some- times accompanying erythema. Operative interference is occasionally called for to relieve accompanying dyspnoea.1 Chronic ulcers and occasionally vege- tations are found in connection with this form of inflammation, the favorite seat of vegetations being at the insertion of the inferior vocal cords. The deep ulcerations of laryngeal syphilis may occur by extension from the pharynx, or by degeneration of gummatous deposit. They are insidious, and much destruction may occur in the epiglottis, the ligaments, and the vocal cords, without very marked symptoms. These ulcers, which present a similar appearance to those occurring on other mucous membranes, are sometimes mistaken for cancer; but in this disease the tonsils and submaxillary glands are apt to be affected at an early period with infiltration. Pain, sometimes extreme, is a symptom of cancer, but is absent in syphilis until the parts have been extensively destroyed. Gummy tumors of the larynx are often single, and may attain a large size; but they may also be small and multiple. They generally tend to ulceration. A fatal termination may ensue in the course of these lesions from impediment to respiration, due to the size of the tumor, or to an acute oedema of the larynx. Tiirck has recorded a case of death from hemorrhage. Perichondritis usually occurs from extension of an inflammatory or ulcera- tive process from the mucous and submucous tissues. The cartilage itself may be involved, in which case it is said that crepitation can be observed on palpation. Caries, or true necrosis, when ossification of the cartilage has taken place, is a common sequel of invasion of the perichondrium by inflammation or gum- matous ulceration. Fragments of sequestrum may be expectorated, or, lodging in the air passages, may cause alarming or even fatal dyspnoea. Mauriac gives an account of a peculiar phlegmonous inflammation of the parts sur- rounding the larynx, secondary to the invasion and death of the cartilage. Syphilitic aphonia has been observed from time to time. Its cause, when occurring in the earlier stages of syphilis, has, I believe, not yet been pointed out; but Simyan and Paget describe a paralysis of the vocal cords which has been observed in the later stages of syphilis. It is unilateral, and yields to specific medication.2 SYPHILIS. Trachea and Bronchi.—The syphilitic affections of the trachea and' bronchi are naturally closely analogous to those of the larynx. The lower portion of the trachea is the usual seat of the disease. The lesions are com- monly developed in the submucous tissue rather than in the mucous mem- brane itself; they consist either of diffuse infiltration into the submucous 1 See the account of a case in which tracheotomy was performed four times in five years. Trans. Clin. Soc., vol. x., 1877. 2 The following papers may be referred to for fuller details : Gerhardt und Roth, Ueber sypli. Krankheiten des Kehlkopfes (Arch. f. path. Anat., Heft. xxii. 1861) ; Krishaber, Contribution a l’etude des troubles resp. dans les Laryngopathies Syph. (Gaz. Hebd., 1878, Nos. 45—47) ; Elsberg, Syphilitic Memb. Occlusion of Rima Glottidis (Am. Jour. Syph. and Derm., 1874) ; P. Ferras, De la Laryngite Syphilitique (These de Paris, 1874) ; Krishaber et Mauriac, Des Laryngo- pathies Syph. pendant les premieres phases de la Syphilis, Paris, 1876 ; Whistler, The Early Manifestations of Syphilis in the Larynx (Med. Times and Gaz., 1878, Nos. 1473 to 1484) ; Simyan, Syphilis Laryngfie Tertiaire (These de Paris, 1877) ; Mauriac, Sur les Laryngopathies Syph. Graves compliques de Phlegmon peri-laryngien, Paris, 1876 ; Simyan et Paget, Des Paralysies du Larynx (These de Paris, 1877) ; Dance, Eruptions du Larynx survenant dans la secondaire de la Syphilis, Paris, 1864 ; Trelat, Sur la Trachgotomie dans les lesions sypliilitiques des Voies Respi- ratoires (Bull, de l’Acad. de M6d., Dgc. 8, 1868) ; Bryant, Trans. Clin. Soc. London, vol. i. 1868, p. 127 ; H. L. Williams, St. Bartliol. Hosp. Rep., 1869, p. 124; T. G. Wollaston, Liverpool Med. and Surg. Rep., vol. iii., 1869, p. 20 ; Erichsen, Med. Times and Gaz., April 8, 1871; W. Stokesr Brit. Med. Jour., April 1, 1871. SYPHILIS OF THE RESPIRATORY PASSAGES. 427 tissue or of circumscribed gummatous tumors. In the bronchial tubes the lesions are apt to be found near the bifurcations. The symptoms which mark the syphilitic affections of the trachea and bronchi vary somewhat according to the nature of the lesions. Their earlier appearance and progress are insidious, and patients are frequently ignorant of their existence. A slight difficulty of respiration, a little cough, and the feeling as of something in the air passages perceived about opposite the upper end of the sternum, comprise the ordinary symptoms. The respiration may also be a little harsh or hissing in some cases, there may be some oppression on going up stairs, or a sense of suffocation at night, with a dry cough. At a more advanced stage of the affection the cough is more frequent and trouble- some, and muco-purulent sputa, striated with blood, or nummular, yellowish- green sputa, are observed. Auscultation fails to reveal any abnormal respira- tory sound. The symptoms mentioned persist for some time and then begin to diminish, especially if appropriate medication is employed. The ameliora- tion is not permanent, however, for when cicatrization begins, the symptoms previously observed once more set in, only in a more marked degree, and with less hope of improvement through medication. One of the most important symptoms observed at this period occurs in the form of suffocative attacks coming on suddenly, and without any well-defined cause, and sometimes so severe and so frequently repeated as to endanger life. Lowering of the larynx and immobility of this organ during speech and deglutition, are likewise to be noted as important symptoms of tracheal syphilis at an advanced stage. In addition, a peculiar hardness of the trachea may be perceived by the touch, and a diminished degree of mobility on the part of this organ among the surrounding tissues. It is said that one may at times perceive the lesions in situ by the aid of a laryngeal mirror, but this view I fear will not often be granted excepting to the expert laryngoscopist. When the disease affects the bronchial tubes only, the symptoms are some- what different from those described above. It was formerly supposed that the bronchial tubes were only affected secondarily from the throat, or at least subsequently to it, but this is very frequently not the case. The first symp- toms are very similar to those of ordinary catarrh. The voice is altered, however; there is continual dryness and irritation in the larynx, which gradually extends to the bronchial tubes. Patients suffer from a sensation of painful constriction over the sternum, with a dry cough. At a later period the sputa appear of a purulent character, and indicate suppuration. Hectic fever is now observed, if it has not previously appeared; dyspnoea is common; and the patient may iinally die in an attack of suffocation. These affections are rare, and often fatal, especially when the trachea is involved, because of the difficulty of recognizing the disease in time to apply proper remedies. The diagnosis of syphilis of the trachea and bronchi is chiefly made by ob- serving the symptoms of dyspnoea, a peculiar wheezing sound in inspiration —the voice preserving almost its natural timbre—pain, or a sensation of a foreign body at some point in the air-passages, and, subsequently, attacks of suffocation without appreciable pulmonary lesion.1 As to the treatment appropriate to these affections, it may be said that mer- cury is perhaps the best remedy, since iodide of potassium has been known in some instances to provoke oedema, which is likely to complicate matters. 1 For further information, especially as to the differential diagnosis of syphilis of the trachea and bronchi, reference may be made to Lancereaux (op. cit., p. 321), and Biermer, Mem. sur les Re- treciss. de la Trachee et des Brunches (Gaz des Hopitaux, Sept. 9, 1869); two cases, one by Mois- senet, the other by Demarquay, where fatal dyspnoea resulted from cicatricial stenosis of the air- passages following the healing of a syphilitic lesion, are given in the Annuaire de la Syphilis,. 1858, p. 324, and are quoted by Bumstead and Taylor (op. cit., p. 624). 428 SYPHILIS. Astringent and sedative sprays may likewise be employed. Treatment, to be effectual, must be timely and thorough.1 Lungs.—Two syphilitic affections of the lungs are commonly described, diffuse or interstitial pneumonitis, and circumscribed or gummatous pneumonitis. Diffuse pneumonitis may be situated in either the superior, middle, or lower lobes, without, however, invading any considerable portion of tissue. The affected portion of the lung is firm, hard, elastic, friable, impermeable to air, and, consequently, non-crepitant. Circumscribed pneumonitis, which is rather less rare than the diffuse variety, is characterized by the formation of gummy deposits in the lung tissue at one or more points, without any particular locality of predilection. When, however, the gummy tumor is found in the upper lobe, it is at its base rather than at its apex, contrary to what occurs in the case of tubercular deposits. Gummy tumors of the lung are generally ffrm, smooth, and circumscribed by indurated fibrous tissue; they undergo necrosis at an early date, with fatty or cheesy degeneration beginning at the centre of the nodule. Subsequently absorption may occur, partially or entirely, but more commonly the softened gummatous matter is evacuated by the bronchial passages, leaving a cavity circumscribed by fibrous tissue. Cicatrization may then take place. The symptoms of syphilis of the lung are not characteristic in any way, .and the affection is therefore very difficult of recognition. The diagnosis must depend, to a very considerable degree, upon the history of the case .and upon the concomitant symptoms. At the same time, there are certain symptoms manifested which may indicate, in a doubtful case, the presence of a syphilitic lesion. For example, a certain degree of dulness on percussion, with a blowing sound and without febrile reaction, the symptom being limited to one of the lower lobes or to the middle lobe, in a cachectic indi- vidual the apices of whose lungs are intact while his liver is diseased, con- stitutes a strong presumption in favor of a syphilitic pulmonary affection. The sudden appearance of abundant sputa, and the seat of alteration being limited in extent, and particularly confined to one side of the thorax alone, are circumstances which likewise aid in the diagnosis. Tuberculous disease of the lung, which is most likely to be confounded with the affection under consideration, is marked not only by a more rapid evolution and more ex- tensive involvement of the organ, hut chiefly by making its onset in the apices of the lungs. When, however, the syphilitic lesion happens to occur in the same part, the diagnosis becomes extremely difficult, even to the skilled clin- ician. The prognosis of lung syphilis is serious, not as much because of the severity of the lesions themselves, as because they are ordinarily accompanied by other visceral lesions, and because they usually occur at an advanced stage of syphilis, when the system is more or less broken down by the dis- ease. The syphilitic phthisis and asthma of some writers are not, it should he here remarked, independent affections, but are in reality symptoms of the two forms of syphilitic lung disease described, and particularly of the ulcer- ation and stenosis which sometimes occur. The relationship between syphilis and tuberculosis of the lung has sometimes been the subject of discussion, but although the facts in our possession do not at present war- 1 See Cohen, Diseases of the Throat and Nasal Passages, New York, 1879 ; and the article on Injuries and Diseases of the Air-passages in Yol. Y. of the present work. Also De la Tracheotomie dans les Lesions Syphilitiques des Voies Respiratoires (Graz. Hebdom., 1869, Nos. 17, 18, et 19). SYPHILIS OF THE CIRCULATORY SYSTEM. 429 rant any very positive assertion, yet I think I may safely say that these two affections, are never connected together as direct cause and effect. It is true, however, that the cachexia produced by syphilis may favor the deposit of tubercle in the lungs of an indi- vidual thus predisposed, and also, on the other hand, it is very possible that the irri- tation of a diseased lung may predispose to the deposit of syphilitic material, on the principle of the locus minoris resistentice. There are no facts, however, as yet, to sup- port this latter hypothesis.1 Syphilis of the Circulatory System. Heart.—The syphilitic lesions of the heart are of two kinds, diffuse and circumscribed. The former, similar in all respects to diffuse syphilitic myositis, is rarely met with, excepting in connection with the latter (gum- matous) form. The symptoms of syphilitic disease of the heart have not as yet been very exactly made out, because of the small number of cases, and because of the brief period during which these have been under observation. They are of two kinds, functional and physical. Palpitation is almost always present, with irregularity of pulse, and a feeling of weakness. During the latter period of life, severe pain and constriction in the precordial region are observed. There is a certain amount of discoloration (cyanosis) of the face, the lips are slightly cyanosed, and there is a slight degree of oedema. The most marked physical sign is dulness on percussion over the precordial region, and a dull sound, with occasionally a slight murmur accompanying the first sound of the heart, most clearly perceived toward the apex. The veins of the neck and of the extremities are apt to be distended. The pro- gress of the affection is slow, tedious, and insidious. The symptoms of cardiac syphilis are not very strongly differentiated from those of other heart affections. For this reason, in order to make a positive diagnosis, the general affection must usually be recognized. It may be as- serted, however, that syphilitic heart affections form a class in themselves which may in very many instances be differentiated from those of a rheumatic character. They usually manifest themselves only by the symptoms of op- pression, dyspnoea, irregularity of cardiac action and irregularity of pulse, while the rheumatismal affections which are specially apt to attack the valves of the left heart, particularly the mitral, generally give rise to a well- marked murmur, and are sooner or later accompanied by oedema. Rheuma- tismal and alcoholic myocarditis, and secondary dilatations of the cardiac cavities, are like the syphilitic lesions in not giving rise to murmurs, and also in causing asystolic symptoms at a certain period. The antecedents of the patient and the presence or absence of cachexia will serve to aid the diagnosis in such cases.2 1 The following papers may be referred to for fuller details regarding syphilitic disease of the lungs: Gintrac, Phthisie Syphilitique (Graz. Hebd., 1877); Hertz, Ein Fall von Aneurysma und Pneumonia syphilitica (Archiv f. path. Anat., 1873, S. 421); Lancereaux, Des Affections Syph- ilitiques de l’Appareil Respiratoire (Arch. Gen. de Med., 1873); Id., Note sur un Cas de Syphilis Pulmonaire, suivie de reflexions sur la Syphilis des ViscSres et les erreurs dont elle est l’objet (Bull, de l’Acad. de Med., 2e Serie, t. vi. No. 43); Aufrecht, Zwei Falle von syphilitische miliar Tuberculose (Deutsche Zeitsclir. f. prakt. Med., 1874, No. 26); Fournier, De la Phthisie Syphil- itique (Gaz. Hebdom., 1875, pp. 758, 773, 802) ; Thoreson, Syphilis und Phthisis (Norsk Mag. f. Laegevid., 1875, and Schmidt’s Jahrbiiclier, 1875); Rollet, Lungensyphilis (Prager Viertel- jahrs., 1877, S. 13, from Wien. med. Presse, 1875, No. 47); Tiffany, Syphilis of the Lung (Am. Jour. Med. Sci., July, 1877, p. 90); also, leading article in reference to discussion in London Pathological Society (Lancet, vol. i., 1877, p. 354). 2 See Lancereaux, op. cit., p. 295 et seq. 430 syphilis. Bloodvessels.—Syphilitic lesions of the veins are so rare as to be practi- cally almost unknown. Gosselin1 has reported two cases where small gum- ma ta were found in the connective tissue of the external covering of the saphenous veins, forming painful cord-like tumors under the skin. The syphilitic lesions of the arteries are primary or secondary (that is, result- ing from lesions in the immediate vicinity). Verneuil, according to Jullien, gives a case of the latter variety, where perforation with excessive hemorrhage resulted from the extension of a phagedenic ulcer. The tissues surrounding the artery and its own coats were involved. Primary syphilitic disease of the arteries is commonest in the smaller vessels of the brain. Pathologically the affection consists in a thickening of the arterial walls by an infiltration of small cells, especially into the tunica intima. The process differs from -ordinary atheroma by its most common localization in the smaller arteries; by its more rapid extension, making as much progress in months as atheroma does in years ; by its tendency to narrow the calibre of the vessels, while atheroma tends to dilatation with thinning of the vascular walls. Syphilitic lesions of the bloodvessels betray their presence by the trophic visceral affections to which they give occasion. Obliteration of the carotid causes pain in the head, epileptic attacks, and enfeeblement of the cerebral functions, followed by coma and death. In cases where the cerebral arteries, strictly so-called, are involved, severe headache, almost always frontal, worst at night, and joined to various alterations in the psychical functions and those of the organs of sense, shows ischaemia of the brain, and serves as a prodrome of coming mis- chief. At a later stage an apoplectic attack, with or without loss of con- sciousness, and more or less loss of motion, or more frequently with aphasia, unilateral paralysis, etc.*, shows the indirect influence of syphilitic vascular disease. Delirium may also supervene. The diagnosis of syphilitic arteritis must be made with the aid of the pa- tient’s history. The prognosis is a matter of grave importance; the question whether syphilis may be a cause of aneurism has for some time engaged attention, and has been at length decided positively in the affirmative.2 Syphilis of the Lymphatic Vessels and Ganglia. Syphilis may affect the lymphatic vessels and ganglia both in its earlier and later stages. The adenitis accompanying chancre has already been men- tioned. It is limited to the vessels and ganglia in the immediate neighbor- hood of the initial lesion, and as it often lasts until after every trace of the chancre has disappeared, it may at times serve as an important aid to diag- nosis in difficult cases. The adenitis accompanying the early generalized outbreak of syphilitic symptoms appears at various points simultaneously, the glandular engorge- ment being most marked in the suh-occipital, mastoid, epitrochlear and sub- maxillary regions. Its appearance is contemporaneous with that of the earliest syphilitic eruptions, that is, from the sixth to the twelfth week of the disease. It has been asserted indeed that the glandular engorgement is due to the influence of the eruption, hut this is disproved by the fact that it may occur without the presence of any skin manifestation. The generalized glandular engorgement is very much the same in appear- ance and symptoms as the localized glandular involvement of chancre. The 1 According to Jullien, who gives no reference. 2 See Wilks and Moxon, Lectures on Pathological Anatomy ; Lancereaux, ArtSrite Syphi- litique (Gaz. des Hop., No. 21, 187(3). SYPHILIS OF MUSCLES AND TENDONS. 431 ganglion grows little by little, increasing slowly in size without inflamma- tory reaction until a pea or filbert-sized tumor is observed, movable, indolent, and disappearing slowly, only perhaps after months. Treatment often fails to quicken its disappearance. Lymphangeitis is sometimes observed in connection with this glandular engorgement. It is more apt to be met with on the inner side of the upper and lower limbs. The vessels appear as cords under the skin, with enlarge- ments at various points. The late syphilitic affections of the lymphatic glands affect those which are deeply situated. They have only been studied during the past few years. The glands most commonly affected are the abdominal, vertebral, lumbar, iliac, and femoral; then the bronchial and mesenteric glands; lastly those of the limbs. These lesions are not uncommon in the later periods of syphilis. They are -apt to occur in connection with visceral lesions, but they may occur inde- pendently. They show no sign during life, and are usually found only on post-mortem examination. Syphilis of Muscles and Tendons. Muscles.—I have already, in treating of the general condition of the sys- tem before and during the outbreak of generalized symptoms, spoken of the peculiar form of muscular contraction due to the influence of the syphilitic poison.1 It therefore remains here only to describe the muscular pains of syphilis, and the gummatous tumors of the muscles. In the early stages of the generalized period of syphilis, certain vague, shifting, rheumatoid pains are observed, seated chiefly about the articulations, or following the course of the muscles and tendons. At a later period, also, somewhat similar pains are noticed at times, involving the muscles, tendons, and fibrous tissues generally. These pains differ, however, from those of the early period of syphilis, in being fixed and persistent, instead of coming and going, now in one place and now in another, like the early lesions. Both the early and the late forms of syphilitic rheumatoid pains are amenable to treatment. Syphilitic tumor of the muscles has been well described by Bouisson,2 who divides the affection into three stages. In the first, the muscle becomes the seat of a perceptible, circumscribed swelling, without pain. The second stage sees the gradual softening of the tumor, the contents of which become a gummy and stringy liquid. Sometimes the tumor, instead of following the •ordinary chronic, indolent course, assumes acute symptoms, becomes painful, hot, red, etc., presenting every appearance of an acute abscess. Bouisson thinks that some cases of pelvic abscess, of psoitis, and of inflammation of the iliac muscle, may be referred to this disorder. In the third stage, the tumor no longer softens, but becomes of an almost cartilaginous hardness, and even bony. These muscular ossifications may occasionally be accom- panied exostoses. The tumors under consideration may be observed in the muscles of the thigh or calf, in the trapezius, sterno-mastoid, pectoralis major, etc. They are commonest, however, in the tongue, though they may be met with any- where. Occurring in the larynx, they may be mistaken for laryngeal phthisis. 1 See p. 487. In addition to the references there given the following may he mentioned: Notta, Sur la Retraction Musculaire Syphilitique. Archives Gen. de Med., Dec. 1856. 9 Arch. Gen. de Med., DSc. 1850. 432 SYPHILIS. As already mentioned, bony transformation is the occasional result of mus- cular syphilis. The course of this affection is slow and insidious. Very often the patient himself is not aware of its existence even after it has lasted a considerable time. The pains which are frequently experienced in the earlier stages of the disease, are apt to be considered rheumatic. Afterwards, in the case of gummata, when the tumor softens it is taken for an abscess. I have seen this mistake made repeatedly, and have had patients present themselves with gummata of the muscles which had been treated with poultices for a consider- able period, without the true nature of the lesion having been suspected. As a rule, syphilis of the muscles tends to get well under appropriate treat- ment. The diffuse form, however, may result in atrophy or destruction of some of the muscular fibre, and thus lead to permanent retraction. The diagnosis of the syphilitic lesions of the muscles is not difficult when the concomitant symptoms, usually among the later manifestations, are taken into account. Abscess and cancer, for which the softened gummatous lesions are occasionally mistaken, may be distinguished by the characteristics pointed out under gummata of the skin. Tendons.—The syphilitic affections of the tendons resemble closely those of the muscles. They consist either in a partial thickening, or in the presence of small gummatous nodes in the structure of the cord-like tendons, or of the membranous aponeuroses. Those tendons which are most thick and firm are most frequently attacked. Thetendo Achillis and the tendons of the femoral biceps and quadriceps are most apt to be the seat of the affection. Aelaton observed two gummy tumors developed in the latter tendon which simulated a foreign body in the knee. In another case the tumor, which occupied the rectus muscle of the thigh, became the point of departure for a hydrarthrosis, which might easily have been mistaken for a white swelling.1 The syphilitic affections of the aponeuroses are not usually painful. Those situated in the tendons of muscles give rise to pain when the muscle is used, sometimes to a greater or less extent preventing movement. Usually sub- cutaneous, these lesions show themselves at first as abrupt, sharply-defined, hard, small nodules. At a later period they soften, the skin covering them becomes red and inflamed, and ulceration sets in, giving exit to the softened gummatous product, which, it must be noted, is not purulent, but is thin and colorless, or slightly tinged with blood. The ulcers thus formed are slow to heal, but finally they get well without retraction having taken place in the tendon. After suppuration has occurred, it is not difficult to make the diagnosis, but in the earlier stages of syphilitic disease of the tendons, it is often difficult to distinguish the lesions from the ordinary “ ganglions” found in the same localities. They are reducible, however, under appropriate treat- ment, and also run a very different course. Neuromata, which may some- times be confounded with syphilitic lesions of the tendons, are painful, and their seat also is usually different.2 The prognosis of these affections is favorable. They do not lead to any permanent injury of the parts affected. 1 Saint-Arroman, These de Paris, 1858. 2 See Notta, Recherches sur une affection particuliere des Gaines Tendineuses de la Main, caract6risee par le developpement d’une nodositS sur le Tendon des FRichisseurs des Doigts. Arch. Gen. de M6d., t. xxiv., 4e ser., p. 142. SYPHILIS OF PERIOSTEUM AND BONE. 433 Syphilis of Periosteum and Bone. Lesions of the periosteum and bones are frequent in syphilis. Formerly they were supposed to belong only to the later stages of the disease, but they are now known to occur quite early, in some cases being coincident with the papular syphilodermata.1 Osteocopic Pains.—The name “osteocopic” (see page 375) has been given to certain painful sensations observed in the bones, not merely in syphilis, but in other affections. However, as they are much the most commonly met with in syphilitic patients, the name has come to be associated exclusively with the idea of syphilis, particularly with the later periods of the disease. These pains occur spontaneously; they are aggravated by pressure and are commonly found in the more superficial bones, such as those of the cranium, the tibia, clavicle, radius and ulna, sternum, etc.; their constancy distinguishes them from the more wandering pains of rheumatism. One of the most marked characteristics of the osteocopic pains of syphilis is that they acquire their maximum intensity toward midnight or one o’clock in the morning. Picord said that this was due to the warmth of the bed, and asserted that individuals, such as bakers, whose occupation required them to turn day into night, ex- perienced osteocopic pains when they went to bed, that is in the daytime. This explanation, however, does not fit all cases, since in many instances the pains return at a given hour, whether the persons are in bed or not. The pains are at first moderate, but gradually become more severe, and are occasionally so excruciating as to wring cries of pain from the sufferer. In some cases they are the only sign of the disease, but more frequently are merely the indication and symptom of a material affection of the bone. It is not unusual for osteocopic pains to fix themselves at some particular point in a bone, and for periostosis or exostosis to be subsequently observed in the same situation. Although commonly occurring at a late period in the evolution of syphilis, these pains may be felt at any, even a very early stage. From the rheumatic pains of syphilis, fhe osteocopic pains are distinguished not only by their fixity, as before mentioned, but by being aggravated by pressure. The rheumatic pains are wandering, and are unaffected by pressure. Diffuse Gummatous Infiltration.—This form of syphilitic bone disease2 is characterized by a more or less general deposit of gummy matter, diffused through the deep or superficial portions of the bone substance. This is soon followed by absorptive action, which, when influenced by treatment, may lead to the disappearance of the syphilitic deposit, or, left alone, may result in the death and separation of a sequestrum of bone. Sometimes the affection takes a different line of action, and, instead of causing destruction of a portion of the bone, leads to the throwing out of new osseous tissue. In the body of the bone this process is called osteitis condensans; on the surface it gives rise to osteophytes and exostoses. Productive osteitis is a constant accompaniment of neoplastic action, occur- ring in the immediate neighborhood of the neoplastic points, and as a con- sequence of irritative action of moderate intensity. As a result of this 1 See Mauriac, Memoire sur les Affections Sypliilitiques Precoces du Systeme Osseux. Paris, 1872. 2 I have followed Jullien (Traits Prat, des Mai. Vener.), in this description of the bone le- sions of acquired syphilis. 434 SYPHILIS. productive inflammatory action, the lacunae and cavities left by the breaking down of the syphilitic deposit are filled up with new material, the normal density of the bone being by this means again restored or even surpassed. In the latter case eburnation begins, the Haversian canals are closed, and hyperostosis may take place, reaching occasionally such a degree that, in the skull, the bones may be nearly an inch thick. When this process goes a step further, nutrition is interfered with, and the affected portion of bone dies and is thrown off as an eburnated sequestrum. Fig. 335. Periostosis (node) of bones of forearm due to hereditary syphilis. When superficial, the new formation arises from the periosteum, or at least from its medullary layer, and is therefore sometimes called periostosis. (Fig. 335.) The tibia is the commonest seat of this diffuse form of syphilitic bone disease. One form of periostosis, that in which the new bony deposit adheres rather loosely to the body of the bone, is called epiphyseal exostosis. Cellular at first, this deposit becomes in time compacted by the deposit of new lamel- lae about the original trabeculae, so as to lead even to eburnation. On the other hand, the exostosis is called parenchymatous when the tumor, though visible externally, is the consequence of an osseous deposit in the thick- ness of the bone itself. Circumscribed Gummatous Infiltration.—On the surface of the bone, the gumma presents the appearance of a sharply circumscribed lesion. It has been chiefly studied in the form in which it appears upon the cranium. The substance of the lesion, gelatinous in appearance, accumulates between the bone and the dura mater on one side, or between the bone and the peri- osteum on the other, and penetrates the osseous substance like a wedge, caus- ing its progressive absorption. When two gummata happen to occur oppo- site one another, and to meet in the diploic structure, perforation is the result. (See Fig. 336.) Under treatment, circumscribed gummata of the bones gradually undergo lardaceous or caseous metamorphosis, and are ab- sorbed, leaving, however, a depressed stellar cicatrix, rendered more con- spicuous by the plastic deposits about the periphery caused by the irritation. Virchow considers this the result of a process to which he has given the name dry caries, but in the opinion of some other syphilographers the gummatous process is sufficient to account for the appearances presented. The evolution of the gumma, as this takes place in the interior of the bones, particularly of the long bones, is not very well understood. Ricord’s plates, however, show that the lesion may occupy the medullary cavity, where it presents the appearance of a lardaceous mass around which the compact tissue is redder and more porous. Occurring in the substance of the spongy SYPHILIS OF PERIOSTEUM AND BONE. 435 tissue of the ends of the long bones of the hand and foot, especially in very young children, the gumma may often assume the appearance of spina ventosa. Fig. 336. Necrosis of cranium with loss of entire thickness of bone, in places, following gummatous disease. (From a specimen in the Mutter Museum, College of Physicians of Philadelphia.) The compact tissue and the periosteum, forced outwards,distend like a globe of molten glass at the breath of the glass-blower, and form a shell with extremely Fig. 337. Hereditary syphilitic disease of bones of hand. (Dactylitis syphilitica.^ thinned walls, as shown in Fig. 387, which represents a case occurring in a young colored girl under my care at the University Hospital. This lesion of 436 SYPHILIS. slow evolution disappears, under prompt treatment, by resorption of the neo- plasm, leaving no trace of its former presence. Left alone, it may lead to serious disfigurement. As has been observed, necrosis is a not unfrequent result of gummatous affections of the bones. Suppuration, phlegmonous swellings, openings with everted edges, fistula;, loss of substance in the skin, etc., are among the visible results of syphilitic necrosis, not differing, however, in this respect from the effects of other forms of necrosis. Sometimes a sequestrum is surrounded and inlaid as it were in the hypertrophied superjacent tissues, as in a portion of eburnated bone surrounding it. Syphilitic necrosis may extend by the formation of new gummatous deposits, giving the edge of necrosed bone a peculiar “polycyclic” appearance, which is quite characteristic and most apt to be observed in the skull (Fig. 338). Fig. 338. Necrosis of cranium following circumscribed gummatous disease. (From a specimen in the Miitter Museum, College of Physicians of Philadelphia.) An absurd superstition still prevails among the ignorant regarding the influence of mercury in causing bone troubles. It is hardly necessary to say that this is entirely without foundation. On the one hand, abundant statistics exist to show that untreated syphilis is more likely to show bone disease; and, on the other hand, it has been found that miners and workers in mercury are not any more subject to osseous affections than other persons. The following tables from Jullien show the comparative frequency of the various syphilitic bone affections and their commoner localization:— Comparative Frequency of Various Forms of Syphilitic Bone Disease. (Jullien). Osteitis and osteo-periostitis . . 12 cases Circumscribed gummata 11 U Necrosis (elimination of bone) 20 u Exostosis ..... 15 44 Periostosis ..... 7 437 SYPHILIS OF PERIOSTEUM AND BONE. Nose . . . . . . . . 19 cases Tibia ....... 15 “ Palate ....... 15 “ Sternum ....... 5 “ Clavicle, maxillary, each .... 2 “ Frontal ....... 2 “ Parietal, vertebra, each .... 1 case Scapula, ulna, radius, each ... 1 “ Locality of the above lesions, Syphilis of the Cervical Vertebral — When the lesion is seated in the body of a vertebra, towards its anterior aspect, it forms a tumor in the pharynx. Together with difficulty of deglutition, which may even amount to danger of sutfocation if too large a bolus of food is ingested, there are pain, chiefly nocturnal in character, difficulty of motion, and the characteristic attitude of cervical anchylosis. Death from inanition or dyspnoea may result if the tumor does not soften and break down into a pharyngeal abscess. The prognosis is even graver when the lesion is seated in the medullary cavity. The symptoms of compression, paralysis, or irritation of the spinal cord are very difficult of diagnosis, their cause, if not their nature, remaining obscure. If the lesion is confined to the transverse apophyses, some of the spinal nerves may be compressed, giving rise to difficulties of function, etc., according to the nerve pressed upon.1 Syphilis of the Cranium.—The headache which accompanies the appear- ance of gummata of the cranium, is so severe that it often leads to the sus- picion of deeper lesions. The patient is driven almost frantic by the pain of the bone lesion combined with that of direct pressure upon the cranium. Circumscribed gummata appear as slowly growing tumors on the forehead, temples, etc., and may attain considerable size, having hard, raised borders of bony tissue, the result of the productive osteitis caused by the irritative influence of the tumors. These tumors have little tendency to ulceration; they disappear very rapidly under the influence of iodide of potassium, but the bony growth around them, if well formed, remains. Relapse, however, takes place with great facility; the swelling begins to increase again as soon as the iodide of potassium is stopped, and these tumors may thus come and go for years. Ditfuse gummatous infiltration of the cranial bones may lead to extensive ulceration and loss of substance, with denudation of the dura mater, and occa- sionally modification in the form of the cranium, through contraction follow- ing the absorption of bony tissue (see Fig. 336). Surgical interference in these cases should be undertaken only with great caution. When, however, a sequestrum keeps up irritation by its presence, its removal is justifiable and desirable. Iodide of potassium should be per- sistently administered in the mean time. Syphilis of the Bones of the Orbit.—The recognition of these lesions is extremely difficult, especially when the symptoms are not marked, being limited perhaps to slight oedema of the eyelids with local pain. Under these circumstances simple neuralgia is often diagnosticated, and quinine is admin- istered to the detriment of the patient. This mistake may be avoided by taking note of the nocturnal character of the pain, and by exploring the interior of the orbit with the index finger, as far as possible, when increasing 1 For a striking case of involvement of the lower dorsal or lumbar vertebrae, see Fournier, Cas du maladie de Pott d’origine syphilitique. Ann. de Derm, et de Syph., n. s. t. ii. p. 19 438 SYPHILIS. tenderness of the periosteum will be observed. When the upper lid is much swollen, the eyeball projecting, and the orbital periosteum elevated, the history will generally confirm the suspicion of syphilitic disease thus aroused, and the result of treatment will confirm the diagnosis. Syphilis of the Maxillary, Palate, and Nasal Bones.—The maxilke are not unfrequently attacked, usually in the superior alveolar processes. The teeth loosen, the gums become red and swrollen, and ulcers appear, which pour out a peculiarly nauseating discharge. The fetor of the breath, and the diffi- culty of speech, mastication, and deglutition, make this affection most painful and disagreeable to the patient and to those around him. Serious deformities often result from the loss of portions of the maxillae, teeth, etc., but .these can almost always be remedied by artificial appliances.1 When the palate is attacked, the disease may be so insidious in its onset as to show no sign until perforation is on the point of taking place. Fortu- nately, if only a small portion of bone is thrown off, advantage may be taken of the tendency of the soft parts to heal and cover the deformity, and by judicious stimulation the granulating edges may sometimes be made to join and afford membranous occlusion to the nasal passages. Occasionally, how- ever, the gummatous growth penetrates with great rapidity, involving the palate and bones of the nose, and resisting all treatment until the bones are largely destroyed and until hideous deformity results. When syphilis attacks the nasal bones, it is usually at first localized in the septum. Severe osteocopic pains may accompany the appearance of the lesion, these, together with coryza, nasal tone of voice, muco-purulent discharge, ozsena, and elimination of bits of bone, being among the first symptoms of the disease. Necrosis of the various bones of the nose, with flattening of the bridge, is a common effect of syphilis, the vomer, however, usually remaining intact. The treatment of syphilis of the nasal bones should be prompt and thorough. In addition to the use of iodide of potassium internally, frequent disinfectant injections are to be employed, such as dilute liquor sod. chlorinat., solutions of salicylic acid or chloral (5 gr. to f§j), etc. Syphilitic Dactylitis.—Under this designation Dr. R. W. Taylor, of ]STew York, described in 18712 a rare affection of the lingers and toes which had previously been alluded to by one or two writers, but which had never been fully studied. The affection is caused by both hereditary and acquired syphilis, the latter form, that under consideration, being much the more rare, and less than twenty-four caseshaving been recorded. There are two varieties: (1) that in which the subcutaneous connective tissue and the fibrous structures of the joints are involved; and (2) that in which the morbid process.begins in the bones and periosteum, secondarily implicating the joints, and perhaps accompanied by deposit in the subdermal connective tissues. The lesion develops slowly, the affected member gradually increasing in size, and becoming hard and firm. When the- toes are affected, they are swollen uniformly throughout their entire length, but in the fingers a single phalanx is apt to be attacked, almost invariably the proximal one. The affec- ted member is reddish or violaceous in color, and is firm to the touch, re- sistant, and tense. The swelling is usually developed painlessly, but there is sometimes a dull aching sensation. The periosteum is affected in this form 1 See Jullien, op. cit., p. 875 ; also works on operative dentistry. 2 Am. Journ. Syph. and Derm., vol. ii., 1871, p. 1. See also Wiggles worth, Case of Dactylitis Syphilitica, Amer. Journ. Syph. and Derm., vol. iii., 1873, p. 142. SYPHILIS OF THE ARTICULATIONS. 439 of dactylitis, but the bone is implicated very slightly if at all. The joints are involved within a few weeks after the development of the affection, the movements, at first hindered by the swelling and infiltration of the soft parts, becoming unnaturally free. Sometimes there are slight hydrarthrosis and crepitation in the joint. A single finger or toe, or several, may be involved, or one or both hands or feet, one toe being attacked after another, or several simultaneously. The disease runs a chronic course. There is no tendency to ulceration. There is generally complete restoration to the normal con- dition if treatment is instituted in good time. In neglected cases, however, the joints may be rendered permanently useless, and the bones may remain enlarged. The second form of syphilitic dactylitis is sharply limited to the bone, and is due to either periostitis or osteo-myelitis. The affection may progress rapidly, slowly, or with intermissions. The earlier after infection that the lesion occurs, the more acute is its course. Usually a single phalanx, the proximal most commonly, is affected, becoming greatly swollen, assuming an acorn or balloon shape, and being hard and tense, while the superjacent in- tegument remains unchanged, or smooth and red if the process has gone on rapidly. More than one phalanx may be affected, or several fingers or toes, on one or both hands or feet. The hands are the more usually attacked. The joint structures are usually much thickened. After the dactylitis has lasted for about a mouth, the surgeon may detect crepitation from friction of the articular surfaces, the result of erosion due to impaired nutrition. Motion of the joints may be diminished or may be unnaturally free. These bony swellings are very indolent. The gummy material may be gradually absorbed after a time, or it may soften and be discharged through a sinus, while the bone itself may be permanently altered in size and shape, and the function of the finger greatly impaired. There is little or no pain. The affection is one of the late manifestations of syphilis, commonly occur- ring between the fifth and fifteenth years. Exceptionally it appears early, one case having occurred in the eighteenth month after infection. The early recognition of both forms of dactylitis is a matter of great im- portance, as early and efficient treatment is necessary to prevent permanent deformity. The subcutaneous variety in its early stage might be mistaken for paronychia., but the absence of acute inflammatory symptoms, especially pain, establishes the diagnosis. The subacute character of dactylitis will also serve to distinguish it from gout. When several joints are attacked, rheumatoid arthritis might be suspected, but here also are acute inflammatory symptoms and pain, which are absent in dactylitis. The two affections do not attack the phalanges in the same manner, and dactylitis early tends to characteristic deformity. Enchond romata or exostoses, which might be mis- taken for dactylitis, show more localized swellings, limited to a portion of the circumference of the bone. The prognosis of dactylitis is favorable if early “ mixed” treatment is employed. Pressure with mercurial plaster spread on chamois skin is sometimes beneficial. Syphilis of the Articulations. The study of syphilitic arthritis was first entered upon by Richet in his classical monograph published in 1853,1 but the knowledge of the subject has been increased since then by the publication of several papers by Lancereaux and others. 1 Memoire sur les tumeurs blanches. 440 SYPHILIS. Syphilitic arthritis is a very late lesion of syphilis, often following ten, twelve, or even twenty years after infection, and differing from the early joint affections in this point, among others, namely, that it is commonly confined to a single articulation. The knee-joint, and especially the left, is the commonest seat of the affection; less frequently the wrist, elbow, ankle, temporo-maxillary articulation, hip, etc., are affected. Pathologically, syphilitic arthritis originates either in lesions of the syno- vial and ffbrous tissues, or in lesions of the bones and periosteum. As it presents itself in the sub-synovial cellular tissue and in that of the capsule, the syphilitic lesion takes the form of small, yellowish, dry, elastic, rather soft masses. A secondary lesion is erosion of the cartilages, due in all probability to the fact that the synovial and fibrous tissues upon which they depend for nutrition are diseased. There is almost always effusion into the affected joint. In one case where an examination was made, the effused fluid proved to be thick, stringy, cloudy, and very fibrinous. Under the microscope the fluid was seen to contain amorphous globules, epithelial cells, and altered blood globules, contained in an abundant albuminous mesh-work. The bone lesions which occur in connection with syphilitic articular disease take the form of swellings—uniform hyperostoses of the spongy portions of the bones, due to a more or less intense osteo-periostitis. It is rare that the entire articulating surface is altered, the disease being usually confined to a circum- scribed portion. In Jullien’s opinion, late synovitis may occur as a remote result of early syphilitic troubles in the joint. In any event the affection begins slowly and insidiously, and is at first unrecognized. After a time, a certain stiffness or tension is observed in the joint; then effusion takes place. The intermittent disappearance and reappearance of the congestive symptoms which give rise to this hydrarthrosis are among the surest signs of the syphilitic nature of a given case. Palpation reveals in some instances the existence of sclerosed patches in the synovise—small, soft, rounded gummata of the periarticular tissues. Besides these, all the ordinary signs of hydrarthosis are present. In addition, there is very little reaction, and hardly any pain, either spontaneous or aroused by pressure, or by the movements of examination. If in addition to these symptoms there are general signs of syphilis, and if the disease yields quickly to specific treatment even although it may have lasted for some time, the case is certainly one of syphilitic arthritis. Although facts are wanting to prove the proposition, yet it is safe to say that the synovial form of syphilitic arthritis is benign, and without tendency to ulceration or suppuration. The osseous variety, however, is more serious. It may appear suddenly with severe pain, generalized at first over the joint, but soon concentrating itself. At times this may be excessive, but usualty it is not extreme, and it comes on at night to disappear with the morning. The diagnosis will be based on an examination of the osseous extremities; the roughnesses, the nodes of which they are the seat; not less than their enlargement, are characteristic. Occa- sionally some elongation of one of the bones entering into a joint takes place. The effusion about the joint is less marked than in the other form of arthri- tis, unless when both forms exist together, which is not rare. It is generally necessary to immobilize the affected limb in this form of syphilitic arthritis, and unless heroic antisyphilitic treatment is employed, serious deformity may result. The usual treatment of syphilitic arthritis is the administration of iodide of potassium in large doses, that is, from half a drachm to a drachm and a half daily. To this mercury may be added, and in many cases general tonics are also required. Locally, strapping may be resorted to with the emplastrum de SYPHILIS OF THE NERVOUS SYSTEM. 441 Yigo, or emplastrum ammoniaci cum hydrargyro, with which I have some- times advantageously combined graduated compression by means of the rubber bandage. Large blisters subsequently dressed with mercurial ointment are useful. In cases where considerable effusion has taken place, aspiratory punc- ture is recommended by Jullien. Syphilis of the Bursa:. Keyes, of Yew York,1 designates as tertiary bursitis a late lesion which is apt to follow after injury. The bursse of the knee are most apt to be involved, and the affection is very often double. The lesion is essentially a gummatous proliferation in the thickened parietes of the serous sacs. The affection begins insidiously, and is usually unaccompanied by pain, sometimes lasting thus for months, when a blow or a fall brings on acute inflammation, the lesion takes on new action, and extensive ulceration may take place. The “ mixed treatment” rapidly heals these lesions, without a scar if they are of the superficial variety, but with a cicatrix if deep ulcerative action has taken place.2 Syphilis of the JSTervous System. The greater part of our knowledge of the syphilitic affections of the ner- vous system is of recent date, and has been acquired within the last twenty years. In 1859, the Academy of Medicine of Paris offered the subject of “ISTervous affections due to the syphilitic diathesis” for competition. In re- sponse, three remarkable monographs,3 which marked an epoch in the prog- ress of this branch of medicine, made their appearance, and are still to be re- ferred to with advantage on account of the valuable clinical material which they contain. Ever since that time the medical press has been sending out papers, monographs, volumes even, on nervous syphilis, in constantly in- creasing numbers, until the literature of the subject has become extremely voluminous. It is obviously impossible, within the limits of the present article, to give an extended account of the various lesions and symptoms of syphilis of the nervous system. The utmost which can be accomplished is to give a general idea of the subject, and to refer the student to original sources for further information. Syphilitic nervous affections may be developed as early as the sixth month,4 1 Syphilis as affecting the Bursae (with a wood-cut). Am. Jour. Med. Sci., 1876. 2 The following monographs and papers on syphilis of the hones, articulations, and hursse, may be referred to for further information. “Improved Forms of Artificial Noses” (Brit. Med. Jour. 1868); Sigmund, Zur ortliclien Behandlung syphilitschen Mund, Nasen und Raclien Affectionen (Centralblatt, 1870, S. 653); Hutchinson, Syphilitic Caries of the Cranium with Abscess of the Brain (Lancet, Dec. 14, 1872); Cuffer, Fracture presque spontanee du femur droit consecutive a, un Osteo-sarcome cliez une Syphilitique (Bull, et' Mem. de la Soc. Anat., Fev. 1874); “ Dental Sy- philis” (Lancet, vol. i. p. 674, 1876); R. W. Taylor, Bone Syphilis in Children, New York, 1876 ; Richet. Memoire sur les Tumeurs Blanches (Mem. de l’Acad. de Med., t. xvii, 1853); R. W. Taylor, Two Cases of Syphilitic Synovitis of the Knee (Am. Jour. Sypli. and Derm., April, 1871); Verneuil, Lesions Syphilitiques Tertiaires des Bourses Sous-cutanees et Tendineuses (Graz. Hebd., 1873); Moreau, Affections Syphilitiques des Bourses SSreuses (These de Paris, 1870); Weil, Syphilitisclie Gelenkrankheiten (Centralbl. f. Chir. 1877, S. 329); Wigglesworth, Cases of Dactylitis Syphilitica (Am. Jour. Sypli. and Derm., 1872, No. 21). . . s Grros et Lancereaux, Des Affections Nerveuses Syphilitiques. Paris, 1861; Lagneau Jils, Maladies Syphilitiques du Systeme Nerveux. Paris, 1860; Zambaco, Des Affections Nerveuses Syphilitiques. Paris, 1861. 4 See Fournier, Lemons sur la Syphilis, 2e ed., for a full clinical description of the earliest nervous disturbances of syphilis. 442 SYPHILIS. and as late as the twentieth year after infection. They are found more com- monly among men than among women, and are apt to occur between the ages of twenty and thirty, chiefly because syphilis is most apt to be con- tracted at this period of life. It is said by some authorities that nervous symptoms are more apt to show themselves in cases where the earlier mani- festations of syphilis have been mild, while others bold the opposite view, and consider severe early symptoms the forerunners of nervous disease. In my opinion, no prognosis can be made in any given case by observation of the early manifestations. The nervous tissue is not usually attacked primarily, but as the result of lesions in the surrounding or investing structures. For instance, lesions of the meninges, or of the bones, induce softening or induration of the brain. A characteristic of the nervous lesions of syphilis is that they are peculiar in their distribution, and may occur in several places at once, thus giving rise to irregular and incongruous symptoms. Nervous symptoms of a syphilitic character are peculiarly liable to occur in individuals of a neurotic or neuropathic constitution, hereditary or ac- quired. Mental anxiety, depressing emotions, sexual excesses, the abuse of alcohol and of narcotics, are among the known predisposing causes. Dis- eases accompanied by cerebral congestion, malaria and other conditions pro- ducing cachexia, may act indirectly. Sunstroke and injuries to the skull may also be included among the predisposing causes. Pathological Anatomy.—Lesions of the Cranial Meninges.—Meningitis- may result primarily from syphilitic disease in the structure of the meninges, or secondarily from syphilitic lesions of the cranial bones. The first variety alone is at present to be considered. Either of the membranes may be affected singly, or all together. The lesions may be gummatous in character, or they may consist in diffuse infiltrations accompanied or not by inflamma- tion, or inflammation alone may occur. Lesions of the Encephalon.—Gummata of the brain present themselves in the form of irregular, variously-sized, firm tumors. These are almost invariably situated at or near the surface. Sometimes they occur in considerable num- bers, and disseminated in different parts of the brain, thus giving rise, as has been remarked above, to various and confusing symptoms. As to size, gum- mata of the brain are rarely larger than a hen’s egg, or smaller than a pea. Miliary gummata of the brain are rarely or never met with. The most common seats of gummata are the convex surfaces of the hemispheres in the- frontal region, the base of the brain near the pituitary body, and the pons Varolii. The first of these localizations explains the frequency of aphasia in syphilitic brain affections, while the latter accounts for the coexistence of trifacial neuralgia and paralysis of the motor nerves of the eye, this last being an almost pathognomonic symptom of brain syphilis. Gummata of the cerebellum are very rare. Only a few cases have been re- ported ; these presented symptoms of motor incoordination, etc. Lesions of the Spinal Meninges and of the Cord.—Lesions of the spinal meninges are almost always secondary, and due to exostoses of the vertebral walls. They are very rare as primary lesions, although such cases have been reported by Wilks, WTinge and Charcot, and Gombault. In some of these cases the cord was also involved, gummata being found in its substance. Lesions of the Nerves.—As has been said, the nerves are not usually at- tacked primarily by syphilitic disease, their troubles generally arising from pressure and atrophy, which interfere with their functions. Tumors of the nerves proper have, however, been reported by Esmarch and Jespersen, Dixon, Portal, and Delafield. Petroff asserts that the sympathetic is attacked, SYPHILIS OF THE NERVOUS SYSTEM. 443 but corroborative evidence of this has not as yet been brought forward by other observers. Symptomatology.1—Headache is met with in about one-third of all cases of syphilitic brain disease. The pain is different from that experienced in early cephalic periostitis; it is deep-seated, and is felt to be so by the patient. In some cases it may last for several months without being at any time exces- sive ; it is dull and heavy, and the patient is able to go about his ordinary occupations in spite of it. Occasionally, however, the sensation of pain is excessive; the older writers exhausted language in the attempt to express its intensity and character. Sometimes there is a sense of constriction, as if the head were being squeezed in a vise; sometimes it feels as if it were being hammered; at other times the patient feels as if a ball of fire were rolling about within his skull. Delirium, acute and even suicidal, and heavy stupor, physical and mental, are sometimes experienced. Nocturnal exacerbation is characteristic of this as of other syphilitic affections, the exceptions being rare. Another characteristic is the long persistence of the pain where medication has not been employed. Cases have been reported in which the pain had persisted for ten and even twenty-five years, and it is not infrequent to see cases where the head-trouble has resisted the entire arsenal of anti-neuralgic remedies for months, to yield in twenty-four hours to anti-sypliilitic medica- tion. The seat of this form of headache is, in seven cases out of ten, frontal or temporal; the posterior portions of the cranium are rarely affected. The pain is diffuse, and not local. Absent, as has been said, in a considerable number of cases, headache is, when present, an early and a very important prodromic symptom—a call for immediate therapeutic aid to avert almost certainly appending disaster. Un- fortunately, however, it is a symptom too often overlooked, ignored, or mis- understood. Paralysis.—Sensation and motion may be abolished in any portion of the body by the action of the syphilitic poison, but one of the marked charac- teristics of affections of this nature is their partial and often incomplete char- acter. They often succeed convulsive symptoms, aphasia or cephalalgia, and may occur at a very early stage in the syphilitic disease, showing themselves as paralyses of the cranial nerves. Paralysis of Sensory Nerves.—Abolition of olfaction is sometimes observed ; it is commonly, if not always, a sign of intra-cranial disease. The invasion of the affection is very slow and deliberate, and it yields readily to anti- syphilitic treatment. In many patients olfaction is only lost on one side. Anosmia may be due to a lesion of the seventh or of the fifth pair. In case of paralysis of the facial, the muscles of the corresponding nostril become immobile, and present a mechanical obstacle to the perception of odors. When the nasal or superior maxillary nerves are affected, the mucous mem- brane of the nasal fossae may suffer an impairment of nutrition, which may put an entire stop to the performance of the olfactory functions. Abolition of the sense of taste has been reported. Vision may be interfered with by lesions about the roots of the optic nerves.2 Clinically, the loss of vision, occurring suddenly or gradually, accompanied by subjective sensations (muscse volitantes, blue or red sparks, or circles of 1 I have borrowed largely from Jullien in the present and previous parts of this section. 2 For a detailed description of these syphilitic nervous eye affections, see Jullien, op. cit., p* 950. 444 SYPHILIS. lire), is often only partial. The patient can only distinguish a part of a single object, or of two objects sees but one. Another only sees the top and bottom of some object in front of him, the middle part remaining invisible. In some cases of amaurosis, the first effect of treatment is to make the blindness par- tial merely. A case is on record where the perception of one color after another was successively restored. A singular and, as yet, inexplicable intermittence, regular or irregular, has been noted in some cases. In one instance, loss of vision occurred daily between twelve and two, preceded by a severe frontal headache. The attack usually lasted from a quarter to half an hour, and was repeated several times. The prognosis of these eye-troubles depends upon their early recognition and treatment by means of iodide of potassium. When the tissues are secondarily involved (atrophied by pressure, etc.), it is too late to expect much advantage from treatment. Hearing.—Various disturbances of audition may occur, due to neoplasms situated in the neighborhood of the auditory centres and of the eighth pair of nerves, either along their course or in their intra-bulbar portion. Very frequently the deafness of nervous syphilis is preceded by a period of excita- tion, characterized by auditory hyperesthesia, or by the production of various subjective sensations. .It is hardly necessary to say that this ear-trouble of central origin, characterized as it is by want of regularity, its occasional intermittence, and its curability, should be carefully distinguished from that variety of continuous deafness which is brought about by local syphilitic affections of the auditory apparatus. Paralysis of the Motor Nerves of the Eye.—The three motor nerves of the eye, passing as they do for some distance along a bony canal, and in a portion of the cranium peculiarly subject to the late lesions of syphilis, are very apt to be affected by the pressure of some neoplasm, or some inflammatory swelling of the periosteum, at one point or another. In fact, a sudden and unexpected paralysis of these nerves may be said to be an almost sure sign of the existence of syphilitic disease, even when no other exists. The motor oculi, the motor externus, and the patheticus may be weakened or paralyzed either singly or together, one or two branches on the right side being sometimes affected at the same time that other branches on the left side are similarly involved. Also, the degree to which the nerves are affected varies in different cases, and occasionally at different times in the same case, a circumstance which often makes the diagnosis quite difficult. In exam- ining a case, careful analysis must be made of the muscles affected, and then, by referring to the nerves supplying these muscles and collating the facts observed, the lesion may often be located. These, like the other syphilitic affections, are very variable from one time to another, and also, it maybe added, are usually very amenable to timely treatment by specific remedies. Hemiplegia.—The hemiplegia of syphilis has been particularly studied by Van Buren and Iveyes.1 It is characterized by occurring at an earlier age than other forms of hemiplegia, eighty per cent, of the reported cases having occurred before the age of forty, while forty-six per cent, only of apoplectic hemiplegias occur before the same age. Another characteristic of syphili- tic hemiplegia .is the coincidence of fixed and persistent headache, which is an invariable symptom. Other diagnostic points are, the occurrence of the hemiplegia without loss of consciousness, and the concomitant existence of other syphilitic lesions, particularly dilatation of the pupil, showing either in the eye on the hemiplegic side or on the other, without paralysis of the motor oculi. 1 Syphilis of the Nervous System, N. Y. Med. Journ., Nov. 1870. SYPHILIS OF THE NERVOUS SYSTEM. 445 Paraplegia is a rare syphilitic nervous affection. It is usually brought about by direct or indirect lesions of the cord or its membranes. Sometimes it is due to a neoplasm involving the cerebral motor centres. Cases of acute myelitis with paraplegia occurring in syphilitic subjects, and supposed to be due to the syphilitic disease in its early period, have been reported by Mau- riac and others. Among the more prominent features of syphilitic paraplegia the following may be mentioned. Contrary to what occurs in hemiplegia, where vesical contractility is always intact, dysuria is often one of the earliest symptoms. The patient expels his urine with difficulty, and often fancies that he is suf- fering with urethral stricture. Imperfect erection with premature expulsion of the semen on attempting copulation is likewise common. The affection runs a rapid course, soon reaching its full development, and then remaining unchanged for a long time, sometimes indefinitely; it is rare, however, to observe complete palsy of the lower limbs; commonly there is nothing more than a difficulty of movement—paresis. Among the most important concomi- tant symptoms, from a diagnostic point of view, are headache and backache —rachialgia—very frequent and very significant signs of the syphilitic affec- tion, above all when they occur or become aggravated at night. Syphilitic paraplegia is by no means the mild affection it has sometimes been represented. Although mercury and iodide of potassium often have a marvellous influence upon it,1 and indeed are the true criteria of diagnosis, they by no means invariably cure. The rule, indeed, is that the morbid tis- sue disappears ordy to leave behind it some indelible trace of its presence, and that the patient not only does not get completely well, but is subject to relapses, each more severe than the previous attack. Left to itself, the affec- tion may give rise to serious complications; retention of urine may lead to incurable lesions of the bladder and kidneys, and the position which the patient is obliged to assume may in time give occasion to sloughing bedsores, with possible purulent infection. Epilepsy, or rather the occurrence of epileptiform attacks, is among the commonest phenomena of syphilitic cerebral disease, a fact which is not sur- prising when it is remembered that the cortical portion of the brain, the favorite seat of syphilis, is at the same time the seat of the motor centres. The epileptiform attack may occur at the beginning of the cerebral disease, or it may occur during its course as an epiphenomenon of serious import, and one usually presaging fresh complications. At present, only epilepsy as it occurs by itself will be considered. The utmost importance attaches to the diagnosis between syphilitic and non-syphilitic epilepsy, especially from a therapeutic point of view. The chief characteristics of the variety we have under consideration, are as follows: In the first place, there is nothing peculiarly distinctive with regard to the fre- quency of the attacks ; they may occur daily or they may occur monthly, or they may occur several times in twenty-four hours. Occasionally they recur at certain hours. Hight is a favorite time, as it is also for the attacks of common epilepsy. Various causes have been assigned as immediately pro- vocative of the attacks, but these are so numerous and in many cases so tri- fling that I do not think that they can be seriously considered. With regard to the crisis itself, this is sometimes sudden, the patient dropping as if shot; more frequently, however, there is an aura, often consisting of an inexpressible dis- comfort at some point, rapidly becoming generalized over the entire body. The ucry” of common epilepsy is rarely uttered- -an important diagnostic point. 1 Cases are given by Fournier and Buzzard where paralysis of all four limbs has been entirely cured. 446 SYPHILIS. Although the attacks of syphilitic epilepsy are usually precisely similar to those of ordinary epilepsy, yet certain differences in the character of the con- vulsions, or of the disturbances of ideation, exist at times, and may serve to aid in the diagnosis of doubtful cases. In the first place, the symptoms are less marked both as to generalization, duration, and intensity. The convul- sions are only partial. Consciousness in many instances remains intact, or is scarcely affected, and, in a word, the syphilitic epileptic attack is only a feeble representation—a shadow, as it were—of ordinary epilepsy. In the mildest form, a sudden flash of pain is experienced in one or more limbs, followed by torpor. A more marked phase of the disease is charac- terized by trembling. A curious group of symptoms, sometimes observed, includes spasm of certain muscles of the trunk and limbs. An individual may be suddenly seized, while walking in the street, with a violent spasm of the posterior muscles of the neck, the sensation being as if the head were being driven down between his shoulders. Now and then one or another of the contractile orifices of the alimentary or air passages is affected, and the patient is suddenly attacked by agonizing dyspnoea, pharyngo-laryngismus, or oesophagismus. Now and then involuntary emission of urine or feces occurs. The convulsions of syphilitic epilepsy are irregular in appearance and char- acter. One peculiarly characteristic variety is that in which the convulsions are confined to a single limb, generally one of the arms, or to the arm and leg of one side. Consciousness is not always abolished, and the patient may, as Jullien says, be an anxious spectator of his own epileptic attack. Sometimes there appear to be two stages to the attack, the patient being conscious during the first and unconscious during the last. In some cases torpor lasting even from one to two hours may supervene on the attack. In these cases paralysis is threatened. Subjective sensations of pain are occasionally observed. They may occur in one part or another of the body or limbs. In one case, severe pain in the testicle complicated the attacks. Syphilitic epilepsy, unlike ordinary epilepsy, does not remain at a stand- still. Left to itself, it may grow better through the relief of the causative lesion, as when a gumma of the cranium softens and opens exteriorly. Much more commonly, the attacks grow more and more frequent, and other nervous symptoms show themselves. This tendency to grow worse, and to result in disorders of intellection of one sort or another, is so characteristic of syphilitic epilepsy as to offer a diagnostic sign of the highest value. The danger of syphilitic epilepsy lies not so much in the epileptic attacks them- selves, as in the permanent morbid conditions which so often supervene. (1) There may be, in the first place, disturbances of ideation, the petit mat of the French, characterized by vertigo, momentary or brief “absence,” ecstasy, and even temporary delirium, in which the patient may impulsively do him- self or another some severe injury. The last-mentioned condition is important from a medico-legal point of view. Independently of these symptoms, gradual diminution and perversion of the intellectual facilities may be observed. Benjamin Bell tells of a woman, twenty-six years of age, who was attacked by epilepsy after suffering severe headache. The attacks rapidly acquired extraordinary frequency and inten- sity (from four to six daily). Suddenly they ceased, and the patient became insane. She had been in this condition for two years when Bell, who had been called in to treat her for ulcers and cranial osteitis, administered mercury, and to his great astonishment saw the mental alienation entirely disappear in the course of a few weeks. SYPHILIS OF THE NERVOUS SYSTEM. 447 (2) In liis statistics, based on the examination of 306 patients suffering with haut mal, without distinction as to their character, Echeverria1 has noted the occurrence of paralysis in 68 instances—about 22 per cent. Ho doubt this proportion would be increased, if non-syphilitic epilepsies were excluded. Hothing is more frequent, in fact, than to see syphilitic epilepsy complicated by paralysis. At first the attacks leave the limbs weakened and enfeebled for a time. This period of enfeeblement becomes longer and longer, the symptom itself becoming more marked, until gradually complete paralysis steals on. Cases are known, however, in which paralysis has super- vened at once after an attack. Paralysis of the motor nerves of the eye and of those of the face is very common in this form of nervous syphilis. Sen- sorial troubles, especially an involvement of the optic nerve, which can be recognized with the ophthalmoscope, are not uncommon as the result of syphilitic cerebral disease. Aphasia.—Aphasia is one of those symptoms of syphilitic brain disease which has been studied carefully in the last few years, without, however, much light having been thrown on the obscure points connected with the production of the affection. Pathological investigation in connection with the occurrence of aphasia has shown that this almost always results from a lesion of the left third anterior convolution. The exceptions to the rule are few and obscure. The symptom itself may take on any one of the forms and modifications which are met with in common aphasia. The prognosis of syphilitic aphasia is very variable. Coming on near the beginning of the brain trouble, and promptly placed under treatment, a nearly complete cure may be looked for; some days of treatment by iodide of potas- sium work wonderful changes in the symptoms. Relapses of increasing severity are, however, apt to occur. Aphasia unaccompanied by hemiplegia implies a less unfavorable prognosis than in the contrary case. Discontinuity of symptoms is a favorable sign. When these begin to assume regularity and continuity, the patient is growing worse. Ancemic, Congestive and Apoplectiform Symptoms; Coma.—Cerebral gummata are frequently the centre and origin of more or less localized congestion. They may also give rise to anaemia by compressing an important vessel directly, or by augmenting the intra-cranial pressure generally, and thus closing some of the smaller vessels. Exudation may likewise take place as the result of pressure. It is of course impossible to separate these various conditions, and to decide which in any given case is the cause of the symp- toms observed. The earlier symptoms, which come on gradually, are those observed in ordinary cerebral disturbances of a similar character—transitory affections of the sensory organs, flashes of light, ringing in the ears, and decrease in tactile sensibility. At a later stage intellectual enfeeblement follows. At a more advanced period, the sensory troubles may be transformed into hallucinations. One of Fournier’s patients saw those about him standing on their heads, and the lamp-posts danced around him as he walked the streets. There is difficulty in coordination and loss of muscular sense, so that the patient cannot walk over a polished floor or descend a staircase without unusual precaution and anxiety, the symptoms being, in fact, similar to those of ataxy. These symptoms too often presage a more severe affection, apoplexy, which is very apt to supervene sooner or later.2 Maurice Mercier (see Ganul’a 1 On Epilepsy. New York, 1870. 2 See the valuable thesis of L. P. Granul, Les Tumeurs Grommeuses du Cerveau, Paris, 1875, containing facts not elsewhere recorded. 448 SYPHILIS. Thesis) was the first to draw attention to syphilitic apoplexy, an affection which it is of the highest practical importance to recognize, because it is in many cases curable if taken in time. The following characteristic points may be noted: 1. The affection may occur in young persons. 2. The stroke occurs suddenly, while the patient is in perfect health, without the slightest prodrome such as is commonly observed in severe brain affections. 3. The following symptoms are observed during the attack: complete coma, the eyes closed, the limbs relaxed, not paralyzed, sensibility to marked exci- tation, persistence of the reflexes, audition unaffected; the patient hears, but cannot reply, or, when pressed, replies feebly by a sign, showing torpor rather than abolition of intelligence; usually vision is interfered with by atrophy of the papillae, the lesions being unequally developed on the different sides ; the irides dilated to the maximum, the upper lids remain closed; there is sometimes strabismus; respiration calm, but stertorous, pulse regular, no fever, paralysis of the sphincters with involuntary defecation and urination,, the urine normal, and giving no sign of uraemia. Finally, epileptiform con- vulsions and vomiting rarely occur. Special attention should be paid to the presence or absence of these symp- toms in all questionable cases. There is no doubt that numbers of patients succumb to what are supposed to be apoplectic seizures, but which are in reality the results of syphilis. A careful examination, with the diagnostic and characteristic features of the disease, as above given, in mind, will in some cases lead to active therapeutic interference with beneficial result. Intellectual Disturbances.—Owing, as has been said, in speaking of syphilitic epilepsy, to the fact that syphilitic lesions are apt to be situated on the peri- phery of the brain mass, intellectual disturbances in the later phases of syphilis are among the commoner nervous affections. Sometimes they occur alone, but more frequently in connection with other nervous manifestations,, the fact being that the various symptoms rarely occur separately or in regular order, but are more frequently jumbled together.1 Among the symptoms of a depressive character may be mentioned loss of memory. This is rarely complete, and is extremely variable in its nature and in its progress, some- times being slowly progressive, and at other times occurring suddenly and completely, or in successive attacks. It is apt to be associated with other nervous disorders, such as epilepsy, etc., which may make the diagnosis less difficult. Symptoms of exaltation and perversion, amounting to true maniar are among the symptoms of cerebral syphilis. Is there such an affection as general paralysis, like the well-known general paralysis of the insane, due to syphilitic cerebral disease ? This question has not yet been decided. It is not enough I think to obtain a history of syphilis, or what passes for such; the connection between cause and effect must be drawn closer, and in addition there should be some cases at least in which antisypliilitic treatment has proved beneficial in the early stages. Visceral Disturbances due to Nervous Lesions.—As visceral sensations are commonly located in the occipital lobes, it might be supposed a priori that syphilitic lesions in these locations would be followed by visceral symptoms,, and such indeed is the case. Boulimia, polydipsia, vomiting, polyuria, and even diabetes have been shown to be dependent upon syphilitic lesions of the nerve centres.2 Diminution of the frequency of cardiac action, syncope, 1 For a more detailed description of the intellectual disturbances of syphilis, see F. Dreer, La Sifil. e la Pazzia, Archivio ltal. per le Mai. Nervose, etc., 1869, and Manssurow, Die tertiar syph. Gehirnleidern Geisteskrankheiten. Wien, 1877. 2 See the very interesting case of Perroud, Ann. de Derm, et de Syph., t. i., p. 519. SYPHILIS OF THE NERVOUS SYSTEM. 449 slowing or acceleration of the respiratory movements, cough, dyspnoea, etc., have been mentioned as possible results of cerebral nervous disturbance in syphilis, but I do not know of any accurate observations bearing on this subject. Incoordination of Movement; Ataxy.—A case is recorded by Ganul (op. cit.) where incoordination without muscular weakness occurred in a patient. At the autopsy, an almond-sized gumma was found in the cerebellum. Leven and Neumann have observed vertigo, vomiting, and strabismus in associa- tion with incoordination.1 The question has been discussed of late years, whether syphilis can give rise to locomotor ataxia. The lesion usually associated with the symptoms of locomotor ataxia, is, as is known, diffuse sclerosis of the posterior columns of the spinal cord, a lesion so different from those usually produced by the influence of syphilis upon the nervous system, as to prejudice the mind against the possibility of syphilis causing this group of symptoms. No pathological evidence of the existence of syphilitic locomotor ataxia has been brought for- ward ; but, on the other hand, the indirect clinical evidence in its favor is of the strongest. The question must for the present be considered sub judice? Prognosis and Treatment of Nervous Syphilis.—The‘gravity of the prognosis of syphilis depends upon the period at which appropriate treatment is instituted, and upon the amount and degree of secondary involvement of the affected tissues. “Against the syphiloma itself,” says Jullien, “we are all powerful; against the secondary resultant lesions we are disarmed.” Taken all in all, however, the prospects of success are discouraging. Not only is it difficult or impossible in many cases to procure any amelioration, but even when an apparent cure has been effected, successive relapses disappoint both the practitioner and his patient. Add to this that in some cases the cicatriza- tion of the syphiloma itself brings about permanent injury, and the prospect of success seems gloomy. On the other hand, in successful cases the result is often little less than brilliant. (See Van Buren and Keyes, op. cit.) As to the treatment, iodide of potassium is the best remedy. It should be used freely, often in heroic doses: as much as an ounce three times a day has been given by Broadbent. However, in some cases mercury succeeds when the iodide fails, and these remedies should be tried alternately and together when necessary. Of course the ordinary remedies employed in the various neuro- ses—revulsives, bromides, electricity, hydrotherapy, and hygienic measures —should be used in addition to the more purely specific remedies.3 1 Leven, Tumeur Syph. dh Cervelet. Gaz. des Hop., 1864. 2 See Fournier, De l’Ataxie Locomotrice d’origine Syphilitique. Paris, 1876 ; A. Reumont, Syphilis and Tabes Dorsalis. Aachen, 1881 ; also Proceedings of the Int. Med. Congress, London, 1881 ; and an editorial in the Medical Times and Gazette, Nov. 19, 1881. 3 In addition to the references given in the text, the following monographs and papers on spe- cial subjects connected with syphilitic nervous disease may be referred to. Further information of this kind may also he gained from Jullien and Lancereaux. Hubner, Syphilis of the Brain and Nervous System. Ziemssen’s Cyclopaedia, Am. ed., vol. xii. Dowse, The Brain and its Diseases ; vol. i., Syphilis of the Brain. London, 1879. Keyes, Syphilis of the Nervous System. N. Y. Med. Jour. Nov. 1870. Jaksch, Syphilitic Paralysis. Prag. med. Wochen., 1864, Bd. xxii. Nos. 3 und 4. Little, Syphilitic Tumor of the Dura Mater. Dublin Quart. Jour., vol. xlvii. 1868, p. 222. Chevalet, Asc. d’origine Syphilitique, guerie par les frictions. Bull, de Th6rap., 1869. Echeverria, G., Epilepsy. New York, 1870. Tarnowsky, B., Aphasie Syph. Paris, 1870. Gay (of Kasanj, Statistics of Cerebral Syphilis. Arch. f. Dermatol, u. Syph., 1870. Moxon, Syphilitic Disease of the Spinal Cord. Dub. Quart. Jour., vol. li. 1870, p. 449. De Meric, Syphilitic Disease of the Third Nerve with Mydriasis, without Ptosis. British Med. Jour. vol. i. 1870, p. 29, 52. H. Molliere, Myfilite Syphilitique Aigue. Ann. de Derm, et de Syph., t. ii. 1871, p. 311. 450 syphilis. Hereditary Syphilis. Etiology.—Regarding the manner in which syphilis is transmitted from parent to offspring, there is as yet no agreement among syphilologists. Whether a syphilitic father can impress his disease upon the fecundating germ, so that the resulting foetus shall be syphilitic without the intervention of the impregnated female, or whether syphilis can only pass to the foetus through the mother, are questions upon which the best authorities differ widely. Numerous cases tending to prove one view or the other, and going to show on the one hand that syphilis can come only from the mother, or, on the other hand, that it may proceed from the father alone, have been reported, but the majority of these reports are lacking in convincingly precise details, and many are ludicrously wanting in care and accuracy. To some so-called “ observers” no case can be so destitute of well-ascertained data as to be unser- viceable in proving the preconceived theory. A careful examination of the cases thus far reported by trustworthy ob- servers, and a comparison of these with my own personal experience, incline me to the belief that, while in the majority of cases of hereditary syphilis the mother has been syphilitic, yet that a certain number of carefully observed cases, reported by some among our ablest living clinicians, go to indicate that a syphilitic father may procreate syphilitic children, the mother remaining to all appearance, and in all likelihood, perfectly healthy. The chief champion of the paternal influence in this county is Dr. R. W. Taylor, but although most of our syphilographers, as far as they have expressed themselves in print, are inclined to take this view of the subject, there are not wanting others, prominent among whom is Dr. F. R. Sturgis, who stoutly deny the possibility of syphilis being transmitted to the ovum in utero by the semen of the male parent, without the mother being infected either by the husband or by the ovum. D. Molliere, Cas d’Anosmie Syph. Ann. de Derm, et de Syph., t-iii. 1871, p. 74. Lunggren, Syphilis of Brain and Nerves. Archiv fur Derm. u. Syph., 1872. Owen Rees, Cerebral Syphilis. Guy’s Hosp. Reports, 1872, p. 249. Cross, T. M. B., Clinical Observations upon Syphilitic Diseases of the Nervous System. Am. Jour. Syph. and Derm., vol. iii. 1872, p. 216. Petroff, Ueber die Veranderungen des sympathischen Nervensystems bei const. Syph. Vir- chow’s Archiv, lvii. ; Cbl. f. Med. 1873, p. 510. Charcot and Gombault, Syphilis des Centres Nerveux. Arch, de Physiol., 1873. Hughlings Jackson, Syphilis of the Nervous Centres. ' Med. Times and Gaz., 1873. Delafield, Syphilitic Tumors of the Spinal Nerves. Am. Jour. Syphilog. and Dermatol., vol. iv. 1873, p. 26. Buzzard, Clinical Aspects of Syphilitic Nervous Affections. London, 1874. Broadbent, Lettsomian Lectures on Syphilis. Brit. Med. Jour., vol. i. 1874. Balfour, Neuralgia as a symptom of Syphilitic Cerebral Disease. Edin. Med. Jour., Oct. 1875. Mauriac, Memoire sur les Affect. Syph. precoces des Centres Nerveux. Ann. de Derm, et de Syph. t. vi. 1875, p. 161. Mauriac, Lecjons sur l’Aphasie, et De l’Hemiplegie Droite Syph. a forme interne. Gaz. Hebdom., 1876. Servantie, Des Rapports du Diabete et de la Syph. These de Paris, 1876. Huguenin, De la Syph. Cereb. Corresp.-Bl. f. Schweitz. Aerzte, 1876. G. Homolle, M6ningo-myglite Subaigue a la fin de la p6riode sec. de la Syph. Mem. et Bull, de la Soc. Anat., p. 514, 1876. Fournier, De l’Atax. Loc. et de Epilepsie Syph. Ann. de Derm, et de Syph., t. vii. 1876, pp. 187, 228. Fournier, Paral. dir Mentonnier, par lesion syph. du Maxillaire Superieur. Gaz. des Hop. No. 34, 1877, p. 271. R. H. Alison, Some Cases of Syphilitic Chorea. Am. Jour. Med. Sci., vol. lxxiv. 1877, p. 75. Fournier, Syphilis du Cerveau. Paris, 1879. Heumont, Syphilis and Tabes Dorsalis. Aachen, 1881. R. W. Taylor, Clinical Notes on Neuralgia of the Sciatic Nerve, caused by Syphilis. New York Med. Jour., March, 1880. Haubem A. Vance, Syphilitic Epilepsy. Am. Jour. Syph. and Derm., vol. ii. 1871, p. 208. HEREDITARY SYPHILIS. 451 The two following cases, which I select as illustrating the difficulties of the subject, show the strongly convincing facts which may be brought forward for either view :— Mireur1 gives the following striking illustration of syphilis in the father failing trans- mission in procreation, only to be conveyed to his child by direct contact after birth. M. C. sutfered with chancre and generalized symptoms, for which he was treated, and was apparently cured. About ten or eleven months after the chancre he married. His wife at once became pregnant, and gave birth to a healthy child who remained well up to the age of two years. Meantime M. C. had now and then some “ vague souvenirs” of his former disease, and at the end of this period showed a slight erosion on his lower lip. As he thought nothing of this indolent lesion, he continued to fondle and kiss his child as usual. A short time after, however, the child showed a well-marked labial chancre, followed by generalized symptoms. Taylor,2 on the other hand, gives I his equally convincing illustration of the exclusive paternal transmission of syphilis : A woman to all appearance healthy, under the careful scrutiny and observation of Dr. Taylor himself, but whose husband was and continued to be the subject of syphilitic disease, gave birth to four syphilitic children in succession. Then, her husband coming under treatment, she gave birth to a healthy child. After- wards, the husband having neglected treatment meanwhile, and having suffered a relapse of his syphilitic disease, the wife gave birth to a syphilitic child. Finally, a year or two subsequently, the husband having once more submitted to a thorough course of treat- ment, the wife gave birth to a healthy child. The wife remained without treatment, excepting the use of quinine and iron, through the whole period of this history, and at no time showed any signs of syphilitic disease. A few cases have been reported going to show that even when both parents present the evidences of syphilitic disease, the infant may be free from syphi- lis ; but these observations must be regarded as doubtful, excepting where the parents have both been under treatment at the time of conception, and the mother subsequently, or where the disease is of long standing, only manifest- ing itself in sluggish local affections. A certain immunity to the child exists in late syphilis of the mother. I have at pre- sent under observation a woman in her twelfth year of syphilis, who conceived while suffering from a gummatous ulcer of the arm, for which irregular and insufficient treat- ment was pursued, with intervals of no treatment, a month or more in duration. This woman gave birth to a child which now, sixteen months old, has as yet shown no sign of syphilitic disease, but is fat and flourishing. The mother’s lesion is gradually heal- ing under more regular treatment pursued of late. As regards the influence of father and mother after conception, that of the former may be dismissed as nil. The so-called cases of infection of the foetus by syphilitic semen are now known to be incorrectly reported, since repeated experiments have shown that semen cannot convey the syphilitic virus. It is otherwise with the mother. If she has conceived a healthy child by a healthy father, and is subsequently contaminated, the foetus will suffer. How long and to what period this susceptibility of the foetus to the syphilis of the mother exists, cannot be accurately stated. Most observers agree in admitting that if the mother is infected with syphilis before the seventh month of pregnancy, the foetus can hardly escape. After that date, it is un- certain whether or no the maternal influence can be reckoned as giving rise to syphilis in the infant. Most of the cases of later infection lack the essen- tial data to be convincing. The idea formerly entertained that the child could contract syphilis during birth from chancre, mucous patches, etc., upon the external genitals of the mother, has been dispelled by the result of practical observation, which shows 1 Essai sur l’Heredite de la Syphilis. Paris, 1867. 2 A Contribution to the Study of the Transmission of Syphilis. Archives of Clinical Surgery, Sept. 1876 452 SYPHILIS. simply that such is not the case. Xo instance has ever, to my knowledge, been reported where an infant has displayed a chancre derived from contagion during the process of birth. In connection with the etiology of hereditary syphilis, u Colles’s law” may be mentioned. It is well known that a diseased child almost invariably in- fects a healthy wet-nurse who suckles it, but the infection of a mother by suckling her own diseased child is as yet unknown. This fact was first noticed by Abraham Colles, of Dublin, in 1837. It has been called by Mr. Jonathan Hutchinson “ Colles’s Law.” The doctrine of choc en retour, or the transmission of syphilis from the foetus to the mother, was taught by Ricord, and lias been more recently main- tained by Hutchinson and Dickinson, who assert that a man may beget an infected child which may convey the syphilitic virus to the mother. The chief ground for the acceptance of this view is found in the fact that mothers having produced syphilitic children, themselves develop specific symptoms during or soon after pregnancy. I think that, although there is nothing improbable about this theory, no conclusive evidence has as yet been brought forward to sustain it. Pathology. Syphilis of the Placenta.—The syphilitic lesions of the pla- centa are as yet only imperfectly understood. According as it is circum- scribed or not, syphiloma gives rise to gummatous placental endometritis, or to diffuse interstitial placentitis. Commonly both forms are associated. In the circumscribed form, the lesions often present the appearance of papular or condylomatous neoplasms, implanted in the free portion of the decidua, and formed of a very vascular mucous tissue. Sometimes they resemble hard tumors, and penetrate the tissue of the placental cotyledons like wedges. The fatty degeneration which results in these gummatous deposits makes it easy to confound them with tuberculous masses. The absence of vessels, the presence of refractive granulations, like those observed in syphilis of the liver, together with the sclerosis and concomitant external symptoms, will settle the diagnosis. Symptomatology of Hereditary Syphilis. Date of Appearance of the Lesions.—The only certain way of ascertain- ing the appearance of the earliest symptoms of hereditary syphilis is to watch for skin eruptions. Earlier visceral lesions there may be, but of these we can take no certain cognizance during life. The statistics of Diday and Roger, comprising 172 cases, show the following various dates after birth of the appearance of hereditary syphilitic symptoms:— Before the end of the first month in . . . .92 cases. “ “ third “ 67 “ “ “ fourth “ ..... 7 “ “ “ fifth “ ..... 1 case. “ “ sixth “ ..... 1 “ After the sixth month ........ 4 cases. It is thus seen that in the great majority of cases hereditary syphilis shows itself before the end of the third month. A few cases have been reported where the appearance of the symptoms has not occurred until the fifteenth month, and Diday gives one case where the visible outbreak was delayed until the end of the second year; but these cases are very exceptional. 453 SYMPTOMATOLOGY OF HEREDITARY SYPHILIS. Of late years our knowledge of the subject of hereditary syphilis has been much enlarged, and various affections occurring in late infancy and in child- hood. formerly unclassified, are now included under this head. In some reported cases, it appears that these late lesions have not been preceded by any earlier symptoms, but the difficulty in obtaining facts in regard to such points can easily be understood. It is certain, however, that in many of these cases good results have been obtained by antisyphilitic treatment. The mortality of syphilitic children is very great, fully one-third failing to reach maturity. Abortion resulting from the death of the foetus usually occurs about the sixth month, while that caused by infection of the mother during pregnancy takes place somewhat later. An aborted foetus is usually in a macerated condition, the skin being easily detached, and the surface having a livid, purple color, while various lesions will be found in some of the viscera.* The integument may show nothing characteristic, or large bullse may be found on the soles and palms.1 (Bumstead and Taylor.) Syphilitic children generally present a healthy appearance at birth, and for a week or two all seems to go well. Then symptoms of debility and decreased vitality show themselves, the infant begins to emaciate, and grows wizened and aged in appearance. Catarrh of the nasal passages—“ the snuffles ’’—shows itself, interfering with respiration, and thus sometimes itself alone being the cause of death. The skin becomes yellow, loose, and wrinkled. It is drawn tight over the bones of the face, which becomes sallow and earthy, with promi- nent eyes and a peculiar senile expression, the infant presenting the appear- ance of decrepit old age. Usually the symptoms of failure of nutrition, and of disease, occur at an earlier date if the affection is severe. Now and then, however, excessive emaciation is not observed even when the syphilitic poison has affected the system to a marked degree, just as we see adults who go through a course of syphilis in its various manifestations without appearing to suffer thereby in general health. Skin Manifestations in Hereditary Syphilis.—The syphilitic eruptions of infants are in all respects the same as those of adults, excepting in so far as their appearance is altered by the peculiarities of structure of the infantile integument. The erythematous syphiloderm is that which is earliest and most frequently observed. It generally makes its appearance about the third week of life, often accompanied by coryza, and showing itself first on the abdomen in the form of minute, round or oval, pink macules. It spreads rapidly over the sur- face of the body and limbs, and the patches grow larger and darker, until they may be half an inch in diameter, slightly or not at all elevated above the ■surface, coppery red in color, and no longer, as at first, disappearing under pressure. There is usually little or no scaliness, excepting upon the hands and feet, where slight desquamation may be present, especially if the eruption is well marked. This eruption is very liable to be confounded with the simple erythematous rashes of early infancy. The most important diagnostic points are the ten- dency to infiltration, and the formation of papules in places where the skin comes together in folds, as about the neck, and also especially in the region of the genitalia and nates.2 In addition, the tendency to scaliness about the palms, soles, and occasionally the nates, is more or less characteristic. Occasionally this eruption is extremely difficult to distinguish from erythe- 1 See Plate XXIII. Fig. 2. 2 Plate XXIII. Fig. 1 gives a fair representation of this form of eruption running into the papular variety. 454 SYPHILIS. matous eczema; and I have in several instances met with cases where a diagnosis was at first impossible, and was only arrived at after holding the patient for some time under observation, the simplest local remedies being used, and the development of the ease being carefully watched. Of course the syphilitic eruption, were it such, would be apt to go on from bad to worse, and to be accompanied by other symptoms, while the eczematous eruption would either get well under the simple local treatment, or would develop some characteristic signs, such as weeping, papulation, vesication, etc. The papular syphiloderm is not unfrequently met with in connection with the erythematous form of the disease. It is sometimes the first eruption to be observed. The lesions are large and small, flat papules, with a dull-red, afterwards a coppery, color, and a smooth surface. Occasionally they may exfoliate to some extent, especially upon the palms. Sometimes a number of papules fuse together, and form a patch of a dull-red color, much thickened and occasionally scaly. Such patches may occur, covering the entire foot or hand, or a portion of the thigh (as in Plate XXIII. Fig. 1). When they are seated about the anus or genitalia, the heat and moisture of the parts, with the frequent maceration in urine and fecal discharges to which infants are subject, conduce to the formation of mucous papules. These skin lesions, which are among the commonest of hereditary infantile syphilis, are quite characteristic. At times they tend to condylomatous outgrowth, and may resemble the simple acuminate condylomata of infants from which they are to be carefully differentiated. The chief distinctive feature of syphilitic condylomata in infants is that the acuminate excrescence springs from a previously existing papule, similar ones usually being visible in the immediate neighborhood. There is also usually a certain amount of extremely fetid discharge of a characteristic odor, in syphilitic condyloma acuminatum, while in the simple condyloma this is not so marked a feature. When the papules are situated about the mouth or at the commissure of the lips, they are usually moist, and in this position are the most frequent carriers of contagion to the nurse, in nursing, and to other children, or adults, in kissing. It is hardly necessary to say that the moist papule in the infant, as in the adult, is one of the most frequent mediums by which syphilis is propagated. The abominable habit,prevalent in this country and perhaps in others, of submitting infants to the caresses of every chance comer, is responsible for many cases of mysteriously contracted disease; and it seems to me a part of the duty of the family physician to warn mothers of the dangers thus incurred. When the papule occurs in the commissure of the lips, it leaves in healing slight linear or radiating scars, which may subsequently aid in the diagnosis of previously existent syphilis.1 The vesicular syphiloderm is a very rare affection, sometimes resembling vesicular eczema to a certain degree. It generally occurs in connection with other lesions, pustular, bullar, etc. The vesicles are usually distinct, seated upon firm infiltrated or papular bases, and show no inclination to coalesce, though they sometimes tend to involve the deeper layers of the skin.. The pustular syphiloderm may occur before the eighth week, in children profoundly affected with syphilis, but usually shows itself at a later period. According to the severity or mildness of the disease, the pustules are large, numerous, and deep; or small, few, and superficial. The lesions are com- monly most abundantly met with on the thighs, buttocks, and face, although 1 I regard this as a more certain testimony of previously existing syphilitic disease than the so-called “ Hutchinson’s teeth,” to he presently described, because it is not likely to be con- founded with any other cicatrix. I do not know of any affection capable of leaving such traces. PLATE XXill tdhi |a 111 i (<’ .) ij |>’ l1 i li*>. SYMPTOMATOLOGY OF HEREDITARY SYPHILIS. 455 they may occur in any part of the body. About the face they often tend to group, and to form crusted patches resembling at first sight the lesions of con- tagious impetigo, or of impetiginous eczema. From the latter, however, they are to be distinguished by not itching, by the thickness and greenish-brown color of the crusts, those of impetiginous eczema and impetigo being thinner and lighter yellowish-brown, like honey. The eroded surface underneath the crusts tends in eczema to heal over, and always without a scar, whereas the syphilitic erosion is more inclined to be ulcerative. The base of the lesions in syphilis is thickened, and they are surrounded by a violaceous red areola. Syphilitic acneiform lesions are sometimes met with on the scalp, in infants, while ecthymatiform pustules are encountered about the limbs in severe cases. These last are apt to result in loss of tissue. The Furunculoid Syphiloderm.—Bumstead and Taylor describe a furuncle-like eruption which may occur as early as the sixth month, or as late as the third year of hereditary syphilis. The lesions may occur alone, constituting the only symptom of the disease, or they may be accompanied by other eruptions. Their number varies greatly in different cases. They begin as small nodules in the corium, and gradually increase to the size of half a nutmeg, ulcers form on the summit, sloughs are thrown off, and irregular, unhealthy cavities with scanty effusive secretion are left, the lesions subsequently running a chronic course. They often result in cicatrices. The tubercular syphiloderm is a rather rare manifestation of hereditary syphilis. It may occur as early as the sixth month, or as a recurrent affec- tion at two or three years. The tubercles begin as deeply seated papules or nodules; the skin is involved afterwards, and finally ulcers of greater or less size result, with abundant secretion, and often covered with crusts. Occa- sionally vegetations may spring up from the surface of the ulcer as in the following case reported by me several years ago.1 An infant of eight months with a well made out syphilitic history showed progressive emaciation, snuffles, and an eruption, situated chiefly upon the face, though observable elsewhere. The lesions when recent consisted of discrete, indolent, tubercular eleva- tions, of pin-head to pea size, roundish, well-defined, firm, and elevated. Older lesions were seen to have coalesced into elevated coin-sized patches, with here and there pus- tular points, coalescing in places into ulcerated patches covered with brownish lami- nated crusts. One of these, larger than the others and situated on the cheek, showed a rough, uneven, warty, mammillated surface, covered with a crust. On poulticing this, a shining red surface, covered with vegetations, could be observed. The abundant secretion was horribly fetid. The eruption closely resembled a patch of impetiginous eczema, but the infiltration of the skin, the mammillated surface, the abundance and fetid character of the discharge, and the thick, opaque, brownish crusts, served to make the diagnosis plain even without considering the characteristic lesions elsewhere. The tubercular syphiloderm is to be differentiated from the scrofulodermata, of the skin sometimes found in infants and young children. The lesions resemble one another closely, and a careful investigation of the history of the case, with a close examination of the lesions in the light of the description given under the head of syphilodermata in adults, will be required to make the diagnosis. Gummata of the skin are not very unusual among children affected with hereditary syphilis. They are usually among the later lesions to show themselves, and sometimes a single lesion alone exists to mark the presence of the disease. They resemble in all respects the gummata found in adults. Bullar Eruptions.—The bullar eruptions of new-born children (“pemphigus 1 A case of Vegetating Tubercular Syphiloderm in an Infant. Archives of Dermatology, vol. iii. 1877, p. 211. 456 SYPHILIS. neonatorum”) have given rise to much discussion, and it was at one time con- sidered that all such eruptions were of a syphilitic character. A true pem- phigus neonatorum is now admitted, although this is a very rare disease.1 It commonly occurs at a later date than the syphilitic bullar eruptions. The latter are most usually found upon the palms and soles (see Plate XXIII. Fig. 2). The skin shows patches of a violet color; in a short time small confluent vesicles make their appearance upon these spots, and then coalesce and grow larger until the fully formed bull* show themselves, varying in size from that of a pea to that of a herds egg, with a yellowish-green, opalescent color,and purulent contents. Occasionally the lesions are brownish or even hemorrhagic. The areolar are large, dark, and violaceous. Within twenty-four or thirty-six hours the bulhe break or dry up, leaving whitish crusts covering shallow ulcers. The eruption is of grave import, and rapid cachexia with general enfeeble- ment leads rapidly to a fatal termination. The bullar syphiloderm is to be differentiated from the pemphigoid eruption by its earlier appearance, by its usually more serious character, and by the concomitant symptoms and his- tory. Sometimes impetigo contagiosa of young infants is mistaken for the bullar syphiloderm, but this eruption is of trifling import, its -early appear- ance is different, and the crust when removed shows only a slight erosion. Moreover, the places of election of impetigo contagiosa are the face and mouth, the backs of the fingers and hands, and less frequently the wrists; the feet usually escape. Affections of the Mucous Membranes.—One of the earliest symptoms of hereditary syphilis commonly observed is coryza or “snuffles,” due to struc- tural changes in the mucous membrane of the nasal passages, at first of an erythematous, and later of an ulcerative character. This may be slight, or it may be so severe as to interfere with respiration, particularly during sleep and nursing. At first serous, the discharge soon becomes purulent, and some- times bloody and very offensive, excoriates the angles of the nasal opening, becomes inspissated, and plugs up the nasal passages. Sometimes the dis- ease penetrates to the bony structures, and produces necrosis. Mucous patches of the mouth in infantile hereditary syphilis do not pre- sent the typical opaline appearance seen in the adult. The lesions tend to coalesce and ulcerate, and, when occurring at the angles of the mouth in connection with moist papules of the outer surface, deep fissures sometimes supervene. The serous secretion of mucous patches is highly contagious, and their early recognition is a matter of the utmost moment in order to prevent the risk of contamination. The infant must not be permitted to nurse at any breast but that of its mother, and must be placed in a rigid quarantine; all kissing and fondling, the use of utensils employed by others, etc., must be guarded against. The infection of the nurse by a child having mucous patches of the mouth is particularly liable to occur in hospitals, lying-in asylums, and the like.2 The mucous patches of hereditary syphilis are to be distinguished from the lesions of simple stomatitis, by the fact that in the latter the inflamma- tion is generally more diffuse, the whole tongue in particular being intensely affected, and often covered with vesicles, which are not seen in the syphilitic affection. The tendency to the development of mucous patches at the corner 1 A very good description of the various non-syphilitic bullar eruptions of the skin in infants, generally classed as pemphigus, will be found in an article by Gustav Behrend, of Berlin. Bei- trag zur Lehre von Pemphigus. Vierteljahrsschr. f. Derm. u. Syph. Jahrg. vi. 1869, S. 191. 2 See an important paper by Dr. R. W. Taylor, The Dangers of the Transmission of Syphilis between Nursing Children and Nurses in Infant Asylums and in Private Practice. (Am. Jour. Obstet., Nov 1878.) Also Fournier, Nourrices et Nourrissons Syphilitiques. Paris, 1878. symptomatology of hereditary syphilis. 457 of the mouth is also a valuable diagnostic sign. In stomatitis, the gums and the sulci between these and the cheeks are often the seat of the lesions, while those of syphilis are not found in that locality. Of course the history of the case and the concomitant symptoms must be taken into consideration. Gwnmata of the mucous membranes are occasionally met with, but not in the earlier periods of hereditary syphilis. The features which these present in the infant are not different from those described as occurring in acquired syphilis of the adult. They are liable to be mistaken for strumous ulceration, but the history and general character of the lesion—being irregular, less sharply defined, and spreading more rapidly—will aid in the diagnosis. Affections of the Viscera in Hereditary Syphilis.—As in tlie acquired syphilis of the adult, so also in hereditary syphilis, the disease spares no organ or viseus. Our space, however, does not permit the discussion of the various affections in detail, and the lesions of the bones and the nervous system alone will therefore be described. Affections of the Bones.1—These are described by Bumstead and Taylor under the heads of osteo-chondritis, periostitis, and dactylitis syphilitica. The former is the most common osseous affection, and frequently its presence de- cides the syphilitic nature of coexisting lesions. The bones most commonly attacked are those of the forearm, the leg, the arm, and the thigh. The clavicle, sternum, and ribs are also attacked, as well as the metatarsal and metacarpal bones. In these cases of osteo-chondritis, a swelling, often imper- ceptible in fat children, is observed at the diaphyso-epiphyseal junction. There is a ring or collar around the bone at this point, or in some cases a less dis- tinctly defined swelling. When two contiguous bones are affected, they •often seem to be fused together. The swellings may be developed slowly or rapidly; they are commonly indolent, and do not interfere with the movements of the joints, although these may become secondarily involved. The lesion may break down, soften, .and ulcerate, the ends of the fragments of bone protruding through the open- ing. Separation of the epiphysis from the diapliysis is not uncommon. When resolution occurs, if tlie diseased action has progressed to any con- siderable extent, the cartilage having been destroyed, shortening of the bone takes place. Sometimes, however, the bone appears to be restored in its in- tegrity. A curious condition of pseudo-paralysis of the involved limb often occurs in connection with this affection.2 Periostitis is a later affection, attacking the bones of children who have already begun to walk. The femur and tibia are first attacked, the greater part of the shaft being often involved, with general thickening and bowing anteriorly, producing marked deformity. The fibula is sometimes attacked, and both legs are apt to be affected. Occurring later in life the affection is more apt to be unilateral. Sometimes the bones of the skull are attacked, and the nodes occasionally break down and form troublesome abscesses. Periostitis usually occurs before the twelfth year, but may, in exceptional cases, be seen at a later period.3 1 Oar knowledge of these lesions is comparatively recent, and derived from the labors of Wegner, Ueber hered. Knochensypliilis bei jungen Kindern (Arch. f. path. Anat. Bd. 1. 1870) ; Waldeyer und Kobner, Beitr. z. Kenntniss der hered. Enochensyphilis (Arch. f. path. Anat. Bd. lv., 1872) ; Parrot (Arch, de Physiol. Norm, et Path. 4me Ann., 1872) ; and R. W. Taylor, Syphilitic Lesions of the Osseous System in Infants and Young Children. New York, 1875. 2 I recently reported an interesting case of this affection, in which the pseudo-paralysis was a marked symptom. A case of Bone Syphilis in an Infant accompanied by Pseudo-paralysis, etc. (Phila. Medical Times, Oct. 11, 1879.) 3 Two marked cases of hereditary syphilitic disease are shown in Figs. 335 and 337. 458 SYPHILIS. Dactylitis syphilitica is usually observed in very young children, but may occur as late as the twentieth year. It is characterized by swelling of the phalanges, followed in some cases by absorption. The metacarpal and meta- tarsal bones are likewise the seat of similar affections. The swellings in the latter case usually form rapidly, and attain considerable size; the integument may ulcerate. The treatment of all bone swellings should combine the administration of both mercury and iodide of potassium. The following ointment may be used externally:— R Ung. hydrarg., Ung. zinci ox. aa Bals. Peruv. 5j- M. Graduated pressure is often advantageous. In connection with diseases of the osseous system in infants, reference may be made to the recent discussions on the relationship between rickets and hereditary infantile syphilis. The writings of Parrot, and the debate on the subject in the London Pathological Society, a year or so ago, may be referred to in this connection. As the subject is as yet confused and obscure, not- withstanding the recent attempts to shed light upon it, I do not think it profitable to enter into its discussion here. Cornea and Teeth.—The affections of the cornea and of the teeth in heredi- tary syphilis demand a passing notice, on account of the diagnostic import- ance which has been attributed to them. Some years ago, Mr. Jonathan Hutchinson1 brought forward the view that the peculiar inflammation of the cornea usually occurring between the ages of three and twenty, and known by the name of strumous keratitis, was always due to hereditary syphilis. This, which is a diffuse keratitis, gives rise to a hazy appearance of the cornea, causing it to look like ground glass. In connection with this condition of the cornea, certain changes in the teeth take place. The exact nature of these, and the appearances presented, having been frequently misunderstood, Mr. Hutchinson2 gives the following memoranda for the avoidance of error in diagnosis. 1 No special peculiarities are to be looked for in the first set of teeth. 2. There can be no more serious blunder than to imagine that bad teeth in propor- tion to their badness of form are to be suspected of syphilis. 3. The upper central incisors are the only teeth which are positively characteristic. The others may afford corroborative testimony, but are not to be relied upon alone. 4. The chief peculiarity is a general dwarfing of the tooth, which is both too short and too narrow, and, from its sides slanting together, presents a tendency to become pointed. This tendency to pointing is always defeated by the cutting off of the end, the truncation being usually effected in a line curved upwards so as to produce a single shallow notch. At the bottom of this notch the enamel is deficient and the dentine ex- posed, but there is no irregular pitting, as in stomatitis teeth. 5. The malformations are unusually symmetrical, and affect pairs of teeth. The two central incisors resemble each other, and the two laterals are also alike. If any defect passes horizontally across all the incisors at the same level, and affects them all alike, it is probably not due to syphilis. 6. In syphilis the lateral incisors usually show little or no malformation. 7. The occurrence of the peculiarities due to syphilis and those due to mercury in the same mouth are exceedingly common.3 The importance to be attached to the characteristic appearance of the teeth in hereditary syphilis has been disputed by some observers. For myself, 1 Ophthalmic Hosp. Rep., vol. i. p. 229. 2 Illustrations of Clinical Surgery, fasc. xi. London, 1878. 3 I do not think that this remark will apply to America. 459 SYMPTOMATOLOGY OF HEREDITARY SYPHILIS. although I have carefully examined a considerable number of subjects of in- herited syphilis, during the past few years, yet I cannot say more in favor of the diagnostic value of these teeth than that, when present in typical form, they have a certain weight in favor of the existence of hereditary syphilis in the given subject. I should hesitate to base a diagnosis in a doubtful case upon the evidence of the teeth alone. The annexed illustrations, some of which are taken from Hutchinson, and one from W. F. Norris, show several varie- ties of syphilitic teeth. Fig. 339. Fig. 341. Fig. 342. Fig. 343. Fig. 344. Syphilitic teeth. Affections of the Nervous System.—The affections of the nervous sys- tem in hereditary syphilis have been studied chiefly by English physicians, and during the past decade.1 Many cases of brain disease formerly believed to be of tubercular origin are now known or suspected to be syphilitic in character. The results of meningeal inflammation, such as thickening and adhesion of the membranes by the development of fibrous tissue and gummy material, and the endoarteritis often observed in syphilis of adults, have been noted in infantile syphilis. Gummata have also been observed, and the pre- vailing impression among investigators at present tends to the belief that the same nervous affections may occur in hereditary as in acquired syphilis. Our present knowledge of these affections is, however, very incomplete. Jackson has described the chorea of hereditarily syphilitic infants and young children, which is sometimes a slight affection, while at other times it is more severe and may lead to epilepsy. Other writers have described cases of facial paralysis. The nervous affections of hereditary syphilis, like those of the acquired disease, are disorderly and complex in the development of their symptoms ; a quite characteristic point. 1 See Hughlings Jackson, Cases of Diseases of the Nervous System in Patients the subjects of Hereditary Syphilis. London, 1868 ; and Nervous Symptoms in Cases of Hereditary Syphilis (Journ. Mental Sciences, Jan. 1875) ; also Barlow (Trans. Path. Soc. Lond., vol. xxviii. 1877) ; and T. Stretch Dowse, The Brain and its Diseases. London, 1877. 460 SYPHILIS. What is known of these nervous affections should lead to the careful exami- nation of every ease of chorea, epilepsy, etc., occurring in children, with the view of ascertaining, if possible, the presence or absence of a syphilitic taint. In this connection, the rules for examining cases of suspected hereditary syphilis given by Mr. Hutchinson,1 are of value. He says that although the teeth taken alone are the most valuable signs in adolescents by which inherited syphilis is recognized, yet there are others of importance which will aid the diagnosis or supply the lack of information from the teeth. These are :— (1) A group of physiognomical peculiarities: (a) sunken bridge of nose; (b) promi- nent frontal eminences ; (c) scars at corners of mouth ; (d) silky softness of skin with absence of color. (2) History of past attack (or evidence of present one) of interstitial keratitis. This disease usually affects both eyes and causes very great defect of sight, lasting over seve- ral months ; then it clears away, leaving the cornefe a little cloudy, or it may be per- fectly bright. Afterwards there remains a peculiar steel-gray lustre on the iris. (3) The presence in the choroid of scattered patches of absorption, especially in the peripheral regions. These will often afford conclusive evidence when other symptoms fail. (4) The presence of periosteal nodes on one or on many of the long bones. (5) The occurrence present or past of a peculiar form of phagedaenic ulceration, some- times erroneously called lupus. This may affect any part, but is often seen in the face or in the throat. Treatment.—The treatment of hereditary syphilis must begin, when pos- sible, with the foetus in utero. The surest means of preserving the product of conception and bringing it to maturity, is in beginning the treatment of the mother at the earliest possible moment, and continuing it vigorously until after the birth of the child. Mercurials are best given by inunction during pregnancy, as we by this means spare the stomach, and avoid the danger of intestinal irritation which may go so far as to cause the abortion which it is our object to prevent. There are some, cases, however, in which inunction cannot conveniently be employed, and here mercurials by the mouth, if given with due precaution, are often well borne, and may at least be tried. The infant, when born, should be placed under the best possible hygienic circumstances, and should be nourished at the mother’s breast. Xo harm can come of this to either. Bottle-feeding is a very inadequate means of nour- ishment at best, and in the syphilitic infant may determine such failure in health as to cause the disease to take much firmer hold upon the system than it would do otherwise. It seems hardly necessary to say that the syphilitic infant should not be given to a wet-nurse, unless that nurse be herself syphi- litic. This is sometimes done by mistake, in the case of infants not known to be syphilitic, with the gravest consequences—the disease being thus im- ported into a healthy'family, and infecting, perhaps, Several members.2 For the medical treatment of syphilis in very young infants, baths and inunctions are preferable. The best form of mercurial bath is made by .simply dissolving ten grains of powdered corrosive sublimate in about a bucketful of water, employing a small tub just large enough for the child to sit in comfortably. The water, of course, should be warm, and the bath should be given with due precaution against cold. A flannel skirt tied around the infant’s neck and spread over the tub, will prevent any of the 1 Illustrations of Clinical Surgery, fasc. xi. 1 See Fournier, Nourrices et Nourrissons Syphilitiques, Paris, 1878 ; and R. W. Taylor, The Dangers of the Transmission of Syphilis between Nursing Children and Nurses in Infant Asylums and in Private Practice (Am. Journ. Obstet., vol. viii., Nov. 1875). TREATMENT OP HEREDITARY SYPHILIS. 461 water from being splashed into the nose or eyes. The infant should he allowed to remain in the water at least ten or fifteen minutes, and should be then dried and powdered with starch—or, if there are any moist papules, these may be dusted with a powder of equal parts of calomel and oxide of zinc—and should then be put to bed. One bath should be given daily. Many authorities object to the use of baths .in hereditary syphilis, but I have had such good results from their use that I prefer them to all other forms of medication, where they can be used with safety and convenience. The best method of employing mercury by inunction is in the form of a dilute mercurial ointment, such as the following:— R Ung. hydrarg. 3j. Unguenti, 3j. M. This is to be smeared over a flannel roller, which is bound about the in- fant’s body and changed once in twenty-four hours. Sir Benjamin Brodie, who strongly recommended this plan of treatment, said that he had never found it to fail. The internal administration of mercury or of iodide of potassium to very young children, is neither necessary nor desirable ; in fact, I think it objection- able, as I have often seen the stomach upset by the administration of these drugs. In the case of older children, however, it may sometimes be desirable to administer the medicines in this manner. One of the best forms of giving mercury to children is in “gray powder,” as follows:— R Hydrargyri cum cret. gr. ij ad vj. Pulv. sacch. alb. gr. xij. M. To be divided into twelve powders ; one three times a day. The following formula (a modification of the well-known Sirop Gibert) is convenient when it is desirable to employ the “ mixed treatment”:— R Potassii iodidi, gr. v. Hydrargyri biniodidi, gr. T^. Syrupi, t'3iij. Aquae, ad M. Teaspoonful three times a day for a child of a year old, with an increase proportional to that of the age. The treatment should be continued for a considerable time—at least three or four months—after all symptoms have disappeared. The attempt has often been made fo give mercury and iodide of potassium to infants through the medium of the mother’s milk, but the effects have not been so decidedly favorable as to suggest this as an appropriate method. I am inclined to doubt if mercury can be given in this manner, but I believe that experiment has shown that iodide of potassium is found in the milk of nursing women to whom it is being administered by the mouth.1 1 The following papers may be referred to as giving additional information on subjects con- nected with hereditary syphilis : — Atkinson, An Account of a Case of Syphilis inherited through Two Generations (Archives of Dermatology, Jan. 1877) ; Bulkley, Rare Cases of Congenital Syphilis (New York Med. Jour., May, 1874) ; Id., Two Cases of very late Hereditary Syphilis (Archives of Dermatology, April, 1878) ; Hyde, On the Immunity of certain Mothers of Hereditarily Syphilitic Children (Transactions of the American Dermatological Association, Archives of Dermatology, April, 1878) ; Atkinson, Late Hereditary Syphilis (Am. Jour. Med. Sci., Jan. 1879) ; and Hyde, The Nurse-maid and the Mother of the Syphilitic Child (Chicago'Med. Jour, and Exam.,, Nov. 1878). 462 syphilis. General Treatment of Syphilis. Expectant Treatment.—A certain number of cases of syphilis run so mild a course that, even if left to themselves and entirely untreated, they would tend to spontaneous recovery. The observation of such cases has led a few observers to imagine that, the disease being in so many instances mild and benignant, no treatment is required, unless unusual complications should arise. But even in the mildest cases, such symptoms as do arise are, if untreated, apt to persist for much longer periods than if treatment were em- ployed, and patients thus deprived of treatment are apt to grow despondent and dissatisfied. In addition, it must be remembered that cases which may at first appear likely to run a mild course, not infrequently show severe symptoms at a later date. Considering, also, the fact that all, or nearly all, prejudice against the use of mercury has died out in the profession and among the public, there can exist no reason, in the vast majority of cases, why energetic anti-syphilitic treatment should not be employed vigorously in every case. Hygienic and General Tonic Treatment.—In order to treat syphilis suc- cessfully, careful attention must always be paid to the patient’s general con- dition and surroundings. Bad air, insufficient clothing, and scanty or im- proper food, often cause great aggravation of symptoms, which, under favor- able conditions, would be of comparatively little moment. This is strikingly observed in hospital practice in any of our large cities, where syphilitic patients, brought in from the slums in a deplorable condition, rapidly recu- perate under the influence of a carefully regulated diet and regimen. I am accustomed, in many cases where the patient’s condition is broken down and depraved, to avoid the employment of specific remedies for a time, even when threatening symptoms are present (unless the brain is attacked), and to begin treatment by the employment of nourishing diet, stimulants, and tonics, and I have not infrequently observed the happiest results from this procedure in cases which had been steadily deteriorating and growing worse under a strongly pushed course of specific medication. The patient under treatment for syphilis should live regularly, employ simple but nourishing diet, abstain from the free use of stimulants and tobacco, pay attention to the functions of the skin and bowels, and take as much exercise in the fresh air as circumstances will permit. Under the head of regularity of living, the careful restriction of the appetites and, particu- larly, the sexual desires, must be insisted upon. In nervous syphilis, above all, the consequences of venereal excesses are most deplorable. Persons who have been accustomed to the use of stimulants should not be deprived of alcohol in every shape, but may be treated with the bitter tinc- tures, such as the tincture of gentian and the like. A cheerful disposition on the part of the patient should be cultivated by the physician, not only as assisting the action of the remedies, but as tending to prevent that unfortunate melancholic habit of mind which is known as syphilophobia, and which, when firmly established, is often irremediable. Per- sons suffering with this delusion fancy themselves incurably saturated with syphilitic poison, and at times, no assertion of his perfect health, given by the physician, will set the patient’s mind at rest.1 Examination of the blood of patients in the early stages of syphilis, shows chloro-ansemia, or a diminution in the proportionate quantity of red blood 1 Cases have been repeatedly reported of syphilophobic patients having committed suicide. 463 GENERAL TREATMENT OF SYPHILIS. •corpuscles. Iron is, therefore, called for in many cases, either alone or com- bined with the specific remedies. In the majority of cases, the tincture of the chloride is the most available form of ferruginous medication, although I frequently use the dried sulphate of iron, or the tartrate, in the form of wine of iron; the tincture may be occasionally used alone, or more frequently, as with the last two preparations, combined with the specific remedies. The bitters, such as quinine and gentian, are frequently called for, and occasionally the mineral acids may be resorted to in appropriate cases. Specific Treatment.—The chief remedies in syphilis are the various pre- parations of mercury and iodine. Although in the discussion of the various manifestations of the affection in the preceding pages, some mention of peculiarly appropriate forms of treatment has been made, it remains in this section to set forth the general principles of the specific treatment of syphi- lis, and to indicate those preparations and applications which experience has shown to he generally useful in dealing with the various lesions as they may arise. Mercurial preparations are most generally useful in the earlier stages of syphilis, while the iodides come into play in the later forms. As no hard and fast line can be drawn between the “early” and “late” lesions, commonly so called, so no invariable rules can be laid down for the administration of one class of remedies or another; each case must he treated on its merits, and one or the other remedy, or both together, must be given as the occasion de- mands.1 Mercurials.—Mercury came into use in the early history of syphilis, and though violently assailed from that time to this, has held its own as an in- valuable remedy. Even its abuse in a past generation, when salivation was considered a condition to be aimed at in the treatment of all venereal disease, has never caused it to lose its hold upon the esteem of the profession. As regards the period at which the administration of mercury should begin, it is now agreed by most syphilographers that nothing is gained by its too early administration. Given on or shortly after the appearance of the initial lesion, its effect is to delay and render irregular the advent of the generalized lesions, without preventing their eventual appearance. An element of con- fusion is thus introduced into the orderly evolution of the various manifesta- tions, and occasionally the delay in their appearance gives rise to false hopes of a permanent cure, often rudely dispelled by an unexpected outbreak, or perhaps by the transmission of the disease to an innocent person. It will not do, however, to leave the patient entirely without treatment, and it is better, therefore, when the diagnosis of chancre is made, or even when the existence of the initial lesion of syphilis is suspected, to begin the administration of internal remedies, perhaps iron and quinine, warning the patient at the same time of the probable supervention of general manifesta- tions, but waiting until these actually appear before instituting mercurial treatment. The choice of the form in which mercury shall be administered is often dependent upon nothing more than personal preference. It must be remem- bered, however, that the same preparation is not suitable in every case, nor in the same case at different periods, and a trial must often be made of sev- eral different preparations before the one best adapted to the case can be selected. When any given preparation seems to lose its effect, it is generally 1 See Hutchinson, When and how to use Mercury in Syphilis. Am. Journ. Syph. and Derm., vol. V., 1874, p. 112. 464 SYPHILIS. better to change it for another rather than to increase the dose to any con- siderable extent, which might disarrange the stomach or bowels. The preparations of mercury which I am most in the habit of using are the pil. hydrarg. and the protiodide. The former preparation and the mercury with chalk are the two forms of the drug chiefly employed by Bumstead and Taylor, while the protiodide is preferred by Keyes. Whichever of these preparations is used, it should at the outset be given with caution, since the patient’s susceptibility is not generally known before trial, and salivation is to be avoided. The following formula is given by Bumstead and Taylor. I have used it, with or without the opium, in hundreds of cases, and consider it a convenient and practical prescription:— R Pil. hydrarg. gr. xl. Ferri sulph. exsiccat. gr. xx. Ext. opii, gr. v. M. Divide into twenty pills, one to be taken from two to four times a day. The following formula for mercury with chalk is given by Bumstead and Taylor:— R—Ilydrargyri cum creta, gr. xl. Quiniae sulphatis, gr. xx. M. Divide into twenty pills, one of which is to be taken from two to four times a day. The dose of the protiodide is from one-sixth to one-third of a grain, thrice daily. Given in larger doses than half a grain, it is apt to disagree, and to cause griping and diarrhoea. In order to prevent intestinal irritation, the protiodide may be taken half an hour after eating, or, if necessary, it may be combined with a little opium. The sugar-coated granules, as made by trustworthy pharmaceutists, afford a convenient method of administering the protiodide -r made as small as the one-fifth of a grain, the dose may be gradually increased and carefully regulated. The biniodide of mercury is a favorite form of administering the drug- with many practitioners, among whom I may mention my friend, Prof, Duhring, whose extensive experience with this preparation in the treatment of syphilitic skin manifestations leads him to think very favorably of it. It may be administered alone, but is more usually combined with the iodide of potassium. The following formula, the time-honored Strop Gibert, is one which I frequently prescribe:— R Ilydrargyri biniodidi, gr. j. Potassii iodidi, 3j. Aquas, f|j. Filter through paper and add Syrupi simplicis, f§v. M. Dose, a tablespoonful. Some patients object to the cloying sweetness of this preparation, in which case water alone may be employed, or wine of iron may be substituted for part or the whole of the syrup. Occasionally it is found convenient to separate the mercurial and the iodide of potassium, in which case one may be given while eating, and the other half an hour or more after meals. The bichloride of mercury is not as frequently employed as formerly; nevertheless it is a good remedy, though it does not generally act as quickly as the other preparations mentioned. I usually prefer to prescribe it in solution, and commonly make use of the formula known as the “ liquor of Van Swie- ten,” which is composed as follows:— GENERAL TREATMENT OP SYPHILIS. 465 Bichloride of mercury, 1 part. Water, 900 parts. Alcohol, 100 parts. Dose, a tablespoonful, given in a wineglassful of pure or of sweetened water, accord- ing to the taste of the patient. The bichloride may also be given in one of the hitter infusions, or in com- bination with the tincture of the chloride of iron, as thus:— R Hydrargyri chloridi corrosivi, gr. ij. Tinct. ferri chlor. f'3iv. Aquae, ad M. Dose, a teaspoonful in a wineglassful of water. If it is desired to give the bichloride in pill form, the following (Sturgis) is a good combination :— R.—Hydrarg. chlor. corrosiv. gr. j1^— Saponis, q. s. ut fiat pil. una. M. One thrice daily after meals. In order to check its action upon the bowels from one-quarter to half a grain of opium may be added to eachqnll. General Principles of the Administration of Mercury.—The method of ad- ministering mercury, the period during which it is to be given, and the pro- per average dose of the various preparations, must now be considered. In former times the object aimed at was to salivate the patient, and, this end once attained, the disease, it was thought, might he considered cured. At the present day salivation is universally regarded as a catastrophe to be avoided, and it only occurs as the result of mischance. Two plans of treat- ment are usually recommended by modern writers, the treatment by “ courses” of mercury, with intervals of rest between the series, and the so-called “ tonic,” or continuous treatment by small doses. The latter plan has been brought into prominence of late years by the writings of Keyes, of Kew York.1 The preparation usually employed by Keyes is the protiodide of mercury, and he prefers the accurately made French granules of Gamier and Lamoureux, each of which contains exactly one-sixth of a grain, although several American- made gelatine-coated pills are equally good. In the rare cases in which the French granules cause griping, Keyes recommends blue pill, according to the formula given above, only in half grain doses, with a quarter of a grain of the dried sulphate of iron. To bring a patient under the tonic treatment, if there be time, Keyes recom- mends the following course:— “ Let him take one standard dose of mercurial (one granule of the protiodide, for example) after each meal, for two or three days. On the fourth day one extra standard dose is added at the mid-day meal; now four standard doses (granules) are taken daily, and this is to be continued for three days [when a fifth is added]. “ On the succeeding fourth day another standard dose is added, two standard doses being now taken after each meal—six granules a day.” The dose is thus increased every third or fourth day, the patient living regularly, and taking bland food until the gums are touched, or until diarrhoea and griping are experienced. When the symptoms are urgent, or when for 1 (a) The Effect of Small Doses of Mercury in modifying the number of the Red Blood Corpuscles in Syphilis. (Am. Journ. Med. Sci., Jan. 1876.) (b) The Internal Treatment of Syphilis. An essay read before the International Medical Congress in Philadelphia in 1876. (Transactions of Int. Med. Congress, Phila., 1877.) (c) Tonic Treatment of Syphilis. New York, 1877. (d) The Venereal Diseases. New York, 1880. 466 SYPHILIS. any other reason it is desirable to make a rapid impression, fumigation, inunc- tion, or the administration of grain of the corrosive chloride in tincture of bark, taken diluted after meals, may be employed, and then, when the urgent symptoms have fairly declined, all medication may be suspended for a week or two, after which the course sketched above may be regularly instituted. “ When a dose of six, nine, or even twelve granules a day, in some cases, has been reached, it will produce a very positive attack of diarrhoea, with pain in the intestines, and occasionally at the same time the breath will begin to have the mercurial fetor, and the livid line will begin to show faintly along the edge of the gums, while the teeth themselves become a little sensitive on being snapped sharply together, and the saliva flows more freely.” Diarrhoea and griping, however, are more apt to be met with in using the protiodide than are the mouth symptoms. When either set of symptoms occurs, the patient is taking what Dr. Keyes calls his “ full dose,” which is anything but tonic, and which is only to be kept up, with the aid of bland food and a little opium, until the urgent symptoms are overcome. It is then dropped to one-half, which is the “tonic dose,” and may be continued steadily during several years without injury to the patient, indeed to his advantage as regards his general condition. When, however, the syphilitic symptoms have subsided, a still less quantity, perhaps one-third of the “full dose,” is required. This dose is also tonic, and is to be persisted in daily, year in and year out, alterations being made from time to time, according to the varied necessities of the particular case. During the existence of moderate symptoms the tonic dose may be con- tinued, but if special outbreaks occur, more active measures, in the shape of increased doses, fumigations, etc., may be resorted to temporarily. When the period of late lesions arrives, if an outbreak occurs, the iodides are to be used temporarily, and the tonic course again resorted to when the emergency is past. As regards the period during which the tonic course should be given, this must vary in different cases. About three years is a full course for most people, while two years and a half, or even two years, answers well enough in some cases. Six months—or better, an entire year—of immunity from symptoms is desirable, before the tonic treatment is stopped. I have given Dr. Keyes’s plan of treatment at some length, both because it is not as well known as the older plans, and because it has commended itself to me, after some years of personal experience, as decidedly the best and most rational. It is often difficult, to induce patients to follow out such a pro- longed course of treatment. The symptoms once fairly gone, the patient gradually forgets the serious nature of the affection from which he has suf- fered, and this diminishes in importance in his mind while the continual dosing becomes more and more irksome. For this reason I have frequently failed in inducing patients to prolong the treatment for any considerable length of time after the disappearance of all visible signs of the disease. I have, however, succeeded in some instances; and even when the course of treatment has not been prolonged to the extent which I should have desired, the effect has been so satisfactory that I employ this to the exclusion of all other methods. ,Salivation.—Although mercury is rarely given in large doses at the pre- sent time, and salivation is consequently of very unusual occurrence, yet this •complication does occasionally arise, owing to some idiosyncrasy of the pa- tient, or to some other cause, and it must be dealt with and relieved as quickly GENERAL TREATMENT OF SYPHILIS. 467 as possible. It is a good plan to employ a mouth-wash during the adminis- tration of mercurials, such as the following :— R—Potassii chlorat. 5j* Aquae, f§vj. M. Sig.—Use as a mouth-wash three or four times daily. This may be combined with an aromatic astringent, as in the following elegant preparation:— Chlorate of potassium, 3ss. “ Eau de Botot,” f^ij. A teaspoonful in a wineglassful of water, as a gargle. If salivation has actually set in when the patient is seen, the first of these formulae may he administered internally in teaspoonful closes four or five times daily, or belladonna may be given as in the following (Sturgis):— R Tinct. belladonnas, f‘3iv. Aquas, f3 ij. M. Sig.—Teaspoonful four times a day in water. Atropia may be preferred in severe cases:— R Atropiae sulphat. gr. y1^. Alcoholis, f^ss. Aquae, q. s. ad f3ij• M. Sig Teaspoonful three or four times daily. The chlorate of potassium may be employed simultaneously. When the gums are spongy, and the teeth are loosened and appear ready to drop out, nitric acid should be given internally and locally. R.—Acid, nitric, dil. f‘5iv. Aquae, M. % Sig Teaspoonful four times a day in water; also use locally, diluted with water. Keyes recommends chlorate of potassium, in solution in cold tea, about one nr two drachms to the pint, with a scruple of carbolic acid. The carbolic acid is particularly called for by the fetor of the breath, and to sweeten the foul secretions of the mouth. He also recommends the employment of hypodermic injections of a solution of atropia (gr. j to f§j), five minims of which may he thrown under the skin—the influence on the pupil being watched, and the dose repeated every four or six hours until the pupils are widely dilated. The effect of this remedy upon the salivary secretion, says Dr. Keyes, is often very prompt, and the general influence over salivation quite marked. Sulphide of calcium, in from one-tenth to one-fifth grain doses every three hours, is a remedy which has been highly commended, but which, in my expe- rience, has not proved very satisfactory. Fumigation.—Mercurial fumigation, formerly much employed as a remedial agent in syphilis, fell for a time into disuse, hut has been revived again of late years, chiefly through the efforts of Mr. Langston Parker, of Birmingham, England, and more lately through those of Mr. Henry Lee. The vapor may be generated from metallic mercury, calomel, mercury with chalk, the bisulphuret, the gray oxide, or the binoxide. The amount to be used varies from twenty to one hundred and twenty grains, according to the effect desired. Calomel is the best agent for ordinary employment, and the simpler the apparatus used the better. Water is usually vaporized simultaneously with the mercurial. Bumstead and Taylor give two cuts illustrating the best apparatus for vaporizing by means of an alcohol lamp or by gas. An 468 SYPHILIS. extemporaneous apparatus can readily be arranged, or the corrosive subli- mate may be dissolved in water, and subjected to ebullition by any ordinary process. A simple apparatus may be made by bending a' piece of tin into a table, or a brick may be heated, and the calomel sprinkled upon its surface, a pail of boiling water being at the same time placed by its side under the chair on which the patient sits. The patient should be clothed in a long sleeveless flannel gown of ample dimensions, over which should be placed a somewhat similar garment of India-rubber “ Mackintosh” cloth. He should sit upon a cane-seated chair, under which the fumigating apparatus should be placed, the flannel gown and Mackintosh covering the whole seat and apparatus. The lamp being lit, vapor of water is first generated, enveloping the patient in a steam which soon provokes a free perspiration. As the temperature of the apparatus rises, the calomel also becomes vaporized, and is readily absorbed by the skin. As soon as the mercury has disappeared, the light is put out, and the patient remains seated and covered with his bath-clothes until the body begins to cool slightly. The rubber coat is then removed, and the patient is wrapped in blankets until'all perspiration has ceased, and the body has become cool and tolerably dry, when he may put on his ordinary clothes again. But it is better to give the bath at bedtime, and let the patient retire imme- diately, sleeping in his flannel gown. The fumigation treatment is one which it is not always easy to employ in private practice, but it is I think the best and most efficient form of medica- tion when there is an extensive and stubborn eruption of the skin which fails to yield readily to internal treatment, when the greatest rapidity of cure is desirable, or in cases where the patient’s stomach is weak, and it is desirable to save it in every way. Occasionally patients complain of a feeling of de- bility and headache, which may be obviated by using less steam, and by dimin- ishing the length of the bath. Diarrhoea, and occasionally, though rarely, salivation, are also observed in some cases. The frequency of the baths should be determined by the strength of the patient and by the degree of mercurial action desired. In early syphilis, when the patient’s strength is fair, the bath may be given every night, but in late syphilis, when a rapid effect is not required and when patients are debilitated, two or three times a week is suf- ficiently often.1 Inunction.-—Inunction, though an uncleanly and to many persons repugnant form of treatment, is one which is very efficient, and in some cases invaluable, as a means of rapidly impressing the system, or of producing the effects of mercury while saving the digestive organs. The plan formerly employed, and still not uncommonly resorted to, is that of rubbing a quantity of un- guentum hydrargyri into various portions of the integument in succession. Taking the groin, for instance, on the first day, and rubbing a piece of the ointment the size of a hazel-nut or a small walnut thoroughly into the skin, the other groin is selected for the next day’s operation, then one axilla, and the other, etc., until the surface is entirely gone over. The constant state of greasiness thus produced is very disagreeable, and almost intolerable to a fastidious person, and the evil is only mitigated in part by the use of the more elegant preparations of the oleate of mercury. For this reason I have of late years usually employed the following method, which was first brought to my notice by one of Dr. Sturgis’s writings. The patient bathes the feet thor- oughly in hot water the night on which the first inunction is made, when half a drachm of oleate of mercury of 20 per cent, strength is rubbed briskly into 1 A very good article on mercurial fumigations is that by Prof. D. \V. Yandell, published in the American Practitioner, Louisville, Sept. 1877. 469 GENERAL treatment oe syphilis. the sole of the right foot; this is repeated the next night on the left foot, and eo on alternate nights the right and left foot are anointed with half a drachm of the preparation. This may be increased to a drachm or more if the patient stands the mercurial well. The stockings should be worn continuously night and day for a week, at the expiration of which time the feet may be thor- oughly cleansed with hot water and soap, and the treatment suspended for a few days, and then recommenced. The unguentum hydrargyri may be used instead of the oleate of mercury, and in fact I commonly prefer it to the more eiegant preparation, because it seems to me that it is absorbed more readily. During the inunction treatment, the condition of the mouth and gums is to be carefully looked after, and it is well to use one of the astringent washes given above. Mercurial suppositories, composed of about half a drachm of mercurial oint- ment and a sufficient quantity of butter of cacao, introduced into the rectum at night, have been employed. I have never used them, and as they give rise to local irritation, I think they not to be recommended. Hypodermic Injection.—The hypodermic injection of mercurials for the treatment of syphilis has been highly recommended by a number of European authorities,1 but has never found extensive employment in this country, since the injections are followed by considerable pain, often lasting for some hours, and since, in spite of every precaution, abscesses will occasionally form at the point of insertion of the needle. Bumstead and Taylor recommend the following formula:— R Hydrarg. chlor. corros. gr. iv. Glycerinse, f'3j. Aquae destillat, M. Twelve drops of this solution contain about one-eighth of a grain of the sublimate, and are used for each injection. In employing mercury by hypodermic injection, a comparatively insensitive portion of the skin should be selected, and a locality where abscesses are not very apt to form. The infrascapular regions, the loins, and the upper portions of the nates are the best points for the introduction of the needle. As it is supposed that mercury exerts a local action in hastening the disappearance of the lesions, it may in some cases be advisable to employ the injections in or near affected parts. The same syringe should never be used on syphilitic and non-syphilitic persons. The point of the needle should be kept sharp and polished. The hypodermic method is objected to by patients in private practice, and it is best to confine its employment to such cases as from some cause may contra-indicate the use of other methods of treatment, or where it is desirable to get the full effect of the drug with great rapidity. Patients are unquestion- ably relieved from external symptoms with more rapidity by this method than by other modes of treatment. Iodine and its Compounds.—Iodine and its compounds are ordinarily useful in direct ratio to the duration of the disease. Their action on the early 1 See Wiggles worth, Subcutaneous injection of corrosive sublimate in syphilis (Boston Med. and Surg. Jour., Aug. 2(5, and Sept. 2, 1869); Lewin, Beliandlung der Syphilis rnit subcutaner Sublimat-injection. Berlin, 1879 ; Staub, Traitement de la Syph. par les Injections Hypoder- miques de Sublime a l’etat de Solution Cbloro-albumineuse. Paris, 1872; Bamberger (Zeit. d. best. Ap. Ver., 1876, 147, 177 ; and New Remedies, New York, 1876, pp. 167, 175) ; Giinz, Ueber subcutane Injection mit Bicyanuretum Hydrargyri bei sypliilitischen Erkrankungen (Wien. med. Presse, 1880). 470 SYPHILIS. lesions of syphilis is slight, but on the later lesions, especially gummatous tumors, affections of the bones, brain-troubles, etc., the influence of iodine is sometimes almost magical. The iodine compounds alone do not, however, as a general thing, possess the power of permanently removing the lesions which they cause to disappear so quickly, and mercury must usually be resorted to in order to obtain a permanently favorable result. The dose of the iodides must vary greatly with different cases. In mild cases, the iodide of potassium—which may be taken as a representative of the class—may be given in doses of from two or three to eight or ten grains three times a day; but in brain-troubles, it is sometimes necessary to give the remedy immediately in large doses, and frequently as much as an ounce or more is taken thus by the patient in the course of twenty-four hours. The iodide of potassium may be given in five-grain compressed pills or in solution. I think it less apt to disagree in the latter form. As it is very soluble in water, this fluid may be used as a menstruum with or without any adjuvant. I commonly give the iodide of potassium in water alone, as I think that the various flavoring substances which are employed, often fail to do more than partially disguise the nauseous metallic taste of the drug, and not infrequently give a strange and repulsive flavor to the mixture. The fol- lowing formula is one of the best when it is desired to hide the taste and appearance of the drug, as far as may be, and when a ferruginous tonic is required:— R Potassii iodidi, 3VSS* Vini ferri, f§iv. M. A teaspoonful contains ten grains of the iodide of potassium. The action of iodide of potassium appears, I think, in some cases, to be increased by the addition of the carbonate of ammonium, as in the following formula:— R.—Potassii iodidi, 3iij- Ammonii carbonat. 3iss. Vini ferri, M. A teaspoonful contains six grains of iodide of potassium and three grains of car- bonate of ammonium. Iodide of potassium agrees best when given from half an hour to an hour after eating. Griping, which is sometimes experienced, may often be obviated by the addition of a syrup containing tannic acid, added in substance, or as it occurs in cinchona or in orange peel, as in this formula:— R.—Potassii iodidi, 3j- Syr. aurantii eorticis, M. Dose, a tablespoonful, containing five grains of iodide of potassium. When giving iodide of potassium in large doses—and, in fact, when giving it in any case in which it is found to have a tendency to disorder the stomach— I add Vichy water, as suggested, I think, by Keyes, directing the patient to pour into a small tumbler the dose desired to be taken of the simple aqueous solution of the iodide, and then to turn in a wineglassful or more of artificial Vichy water, from a portable fountain, such as is sold in the shops. This combination makes the iodide easier to take, and causes it to agree better with weak stomachs. The usual dose of iodide of potassium is from five to ten grains thrice daily, but this may, and often should be, surpassed in serious cases, especially when threatening symptoms show themselves. Symptoms will often yield to drachm doses which have stubbornly resisted ten-grain doses, and no case should be pronounced intractable to the iodide until this has been pushed to large amounts. GENERAL TREATMENT OF SYPHILIS. 471 rITie iodides of sodium and of ammonium may occasionally be substituted for the iodide of potassium, where they agree better with the patient, or where a change is for any reason desirable. Iodide of iron is not very effi- cient, but may occasionally be employed as a tonic or succedaneum, or in the case of children. Iodine, in the form of the tincture, may occasionally be employed when the iodides disturb the stomach. Keyes suggests the administration of the tinc- ture in doses of ten drops in a tablespoonful or more of starch-water, and increased up to eighty drops in a claret-glass of the diluting fluid. The contra-indications to the use of iodine in any of its forms are, acute or chronic inflammations of the digestive organs, plethora, and a predisposition to hemorrhages. Acute catarrh sometimes comes on at the very beginning of a course of iodide of potassium; the patient sneezes and coughs, the eyes grow red and watery, the nose runs, and sometimes there is a severe headache across the brow. Very often the patient gets accustomed to the remedy, and these symptoms wear away, while in other cases, a temporary stoppage of the iodide, and a beginning again in smaller doses, gradually increased, will ena- ble him to take the medicine with impunity ; in other cases, however, the idio- syncrasy is unconquerable, and the drug must be stopped. The headache may sometimes be remedied by adding a diuretic, a little bromide of potassium, or a small quantity of opium, to the iodide. The iodides produce, at times, a variety of eruptions, commonly acneiform or hemorrhagic, but occasionally closely resembling the lesions of syphilis.1 The addition of small quantities of arsenic (5 to 10 minims of Fowler’s solu- tion) to the dose of the iodide will often prevent the appearance of these eruptions. Bright’s disease of the kidneys is said to be produced in some cases by the prolonged use of iodide of potassium, but the assertion has never been supported by entirely adequate evidence. Dr. I. Edmondson Atkinson, of Baltimore, in a recent paper on the subject-,2 after reviewing the cases and arguments brought forward on one side or the other of the question, and comparing them with the results of his own experience, concludes that while the occurrence of severe alterations of the kidneys as the effect of iodide of potassium is prob- able in rare cases, yet that there is no constant tendency on the part of the kidneys to resent its employment. Mixed Treatment.—The combination of mercury and iodine has been a favorite form of administering these remedies for many years. It has its disadvantages, however, and should never be resorted to without reason. Many practitioners prescribe mercury and iodide of potassium in every case of syphilis, or even in every suspected case, upon the principle of the sportsman who shuts his eyes and fires both barrels of his gun, hoping that something will he hit somewhere. But in the earlier stages of syphilitic disease mercury is not only a sufficient, but is the best remedy, and iodide of potassium, if added to it, not only does not hasten the cure, but by tending to upset the stomach and interfere with digestion, may lose the surgeon the aid of this important organ, just when it is most required, to digest the food with which the patient’s strength is to be kept up, and to absorb the drugs which cannot be admin- istered conveniently in any other way. The“ mixed treatment” therefore should be reserved for stubborn cases where one or the other remedy has failed, or where, as in late syphilis, the appearance 1 For a description of these, see a paper, by the author, on Medicinal Eruptions, read before the American Dermatological Association. (Archives of Dermatology, Oct. 1880.) 2 May Iodide of Potassium excite Bright’s Disease ? Amer. Journ. Med. Sci., July, 1881. 472 SYPHILIS. of gummatous lesions calls for direct medication to resolve them, while at the same time the tonic treatment of mercury is to be kept up. Among the various forms in which iodide of potassium and mercury may be administered in combination, the “ Sirop Gibert” (the formula for which has already been given), is, I think, as good as any. Keyes recom- mends the following:— R—Hydrarg. biniodid. gr. ss ad i. Potassii iodidi, 3ij. Ammonii iodidi, 3SS* Syr. aurantii corticis, ffiij. Tinct. aurantii corticis, i 5.1- Aquae destillat®, q. s. adl3iv. M. Dose, a teaspoonful, containing grain to a grain of the biniodide of mercury, and four grains of the iodide of potassium. When it is desired to give the corrosive chloride of mwrcury combined with iodide of potassium, this formula may be employed:— R.—Hydrarg. chlor. corrosiv. gr. j. Potass, iodid. 3iiss. Yini ferri, f§iv. M. Dose, a teaspoonful. I sometimes give protiodide of mercury pills at the same time as the solu- tion of iodide of potassium, or the pills before and the iodide after meals. Another method of employing the “mixed treatment” is to prescribe mercury by inunction, and the iodide of potassium internally. Local Treatment.—I have said something about the local treatment of the various syphilitic affections when dealing with the latter in the earlier por- tion of this article. At the risk of some repetition, however, I think it well to give some general suggestions and formulae for the treatment of such lesions as can be reached by local agencies. The local treatment of chancre has already been sufficiently described, as have also the local applications employed in alopecia, and in the lesions of the mucous membranes. (See pages 368, 402, 404.) I may add here, however, a very elegant, and also a quite useful formula for a mouth wash, to be used by way of prophylaxis in the earlier months of syphilis:— Eau de Botot, f^vj. Tincture of cochlearia, f^iiss. Tincture of cinchona, f5'j* Tincture of catechu, f 3,j- Tincture of benzoin, fjss. A small quantity is mixed with water and used as a gargle morning and evening, and after meals. The necessity of absolute cleanliness need hardly be mentioned. Where there is any discharge, whether from a suppurating lesion upon the skin, or from any of the cavities of the body, that discharge should never be allowed to accumulate. There is no “ laudable” pus in syphilis: the discharges are all poisonous. In addition to the free use of soap and water, disinfectant washes, such as Labarraque’s solution of chlorinated soda, may be employed, or those containing carbolic acid; such as the following:— R—Acid, carbolic, f Glycerinm, f.^ss. Aqum, ad. f J viij. M. To be used in a state of more or less dilution, according to the locality. LOCAL TREATMENT OF SYPHILIS. 473 Labarraque’s solution, diluted with from three to six times its bulk of water, forms a good disinfectant wash in ozsena. Of other washes which may be employed in suppurating lesions of the skin, to stimulate to healthy action, lotio nigra or black wash, and lotio flavci or yellow wash, are the most generally useful. The latter is much the more stimulating of the two, and forms an admirable dressing for suppurating gummata and tubercular ulcerative lesions. A still stronger, almost caustic, wash is the following:— R Hydrarg. chlor. corros. gr. iv. Alcoholis, f sj. M. This should be used with caution on delicate surfaces, but is an admirable means of hastening the cure of moist papules. It may be rubbed without fear into the palm and sole, where the epidermis is thick. Certain powders come into play in the treatment of moist and suppurating syphilitic lesions, prominent among which is iodoform. The disagreeable odor of this drug almost forbids its use in private practice, and its employ- ment in syphilis is now so well known that the individual who goes about smelling of it is a marked man, and might almost as well bear a placard about his neck worded “ syphilis.” I have observed such persons in passing them on the street. For this reason the drug should not be employed except in case of dire necessity, that is, in late, deep, or serpiginous ulcerative lesions, when we must strain every nerve even to keep the patient from relapsing and going back. In hospital practice iodoform may be used freely and with great advantage. When it gives pain, as it sometimes does, although ordinarily its effect is just the reverse—distinctly anaesthetic—the iodoform may be mixed with two or three parts of tannic acid powder. The following snuff is re- commended in the nasal catarrh of syphilis:—■ R—Pulv. iodoformi, Pulv. camphorae, aa 5j- Pulv. acacia3, 3ij* M. Other powders are those of calomel, and the powder of savin and burnt alum, used in vegetating syphilodermata after these have been carefully cleansed with Labarraque’s solution. The latter is composed as follows:— R—Pulv. sabinae, 3j- Pulv. aluminis, 3iv. M. Tannic acid and chromic acid are also occasionally employed in powdered form. The latter should be used with caution, and only when a distinctly caustic effect is desired. The ointments employed in the local treatment of syphilitic lesions are very numerous. A comparatively small number, however, are in reality sufficient, and all beyond this are required only in the interest of variety or individual fancy, or occasionally to meet particular indications. The early generalized skin eruptions require no local treatment by oint- ments. The erythematous syphiloderm is unaffected by outward applications. The papular and pustular eruptions, as these occur upon the face, may, how- ever, be treated locally with a view to hasten their removal, and ointments may also be advantageously used for the speedier resolution of moist papules about the genitalia and anus. Among the milder preparations, ammoniated mercury ointment may be employed, as thus :— R—Hydrarg. ammoniat. gr. xx-xxx. Ung. aquae rosae, §j. M. 474 Calomel may also be used in ointment of half the above strength, that is, from ten to twenty grains to the ounce. A very good, drying ointment, which may be used in moist papules or small ulcers, is the following :— R—Hydrarg. clilor. mitis, gr. x-xxx. Pulv. zinci oxidi, 3j- Ung. aquas rosae, 3j- M. Oleate of mercury in the strength of from five to ten per cent, is a very good application in the dry and scaly eruptions, particularly those occurring on the palms and soles, while an ointment like the following may often be used with advantage in ulcerative lesions:— R—Hydrarg. oleat. (5-20 per cent.), Yaselini, aa §ss. M. I rarely employ the unguentum hydrargyri as a local application, because it is a dirty looking substance, and no more efficient than the white preci- pitate ointment given above. In addition to the plasters which have been mentioned in previous parts of this article, the following may be recommended as particularly useful in those chronic and indurated scaly eruptions of the palm which are so rebellious ta treatment of any kind:— R—Hydrargyri, 5j. Terebintliinae, 3j- Emplast. plumbi, 3fiss* Resinse, 3ss* M. This makes an exceedingly tenacious plaster which may be applied to the palm, previously softened by repeated dipping in very hot water. It may be rubbed in, or, better, spread upon one or more strips of muslin arranged so as to wrinkle as little as possible, and changed once a day or oftener. I have found this to succeed in obstinate eases when all else has failed. Tuberculous and gummato-tuberculous ulcers of the leg are frequently benefited by strapping, bandaging, elastic stockings, etc., and when, as is sometimes the case, they tend to erysipelas-like inflammation, cold lead- water on cloths or in poultices should be temporarily employed. Finally, let me once more urge the necessity of extreme cleanliness and the removal of all crusts, scales, and discharge, before the application of local treatment of" any kind. SYPHILIS, Syphilis in its Relations to Marriage. Physicians are not infrequently consulted by individuals who have con- tracted syphilis, or who believe themselves to have contracted this affection, regarding their intended marriage; and it is of great importance that the answer given should not be misleading, for the health and happiness of two persons at least may be affected by it, and the consequences of a mistake ma}~ influence an unborn generation for evil. It will not do, on the one hand, to sternly repel such persons with the simple and categorical refusal to give medical sanction to the intended union. Sometimes this is done when the history of infection dates back to a remote past, and when no symptoms of syphilis have shown themselves for years. How and then even the suspicion of the patient’s having had syphilis is suffi- cient to induce his physician to forbid the banns. The misery and immorality to which such restriction almost necessarily tends to give rise, should cause the conscientious physician to hesitate before SYPHILIS IX ITS RELATIONS TO MARRIAGE. 475 washing his hands lightly of the whole business by declining to sanction the marriage of a former or of a presumptive syphilitic. On the other hand, to sanction marriage when the syphilitic disease is still active in the system, even although it does not for the moment show itself by any outward sign, is to lure an unsuspecting victim to the committal of a crime against himself and others, of which he cannot appreciate the con- sequences. It therefore behooves the physician who is called upon to pronounce an opinion in such a case to examine the patient with the utmost care, to go into the history of the case, with minute examination of every point which can throw light upon the presence or course of pre-existent syphilitic disease, and not to pronounce his opinion until fully satisfied of the exact condition of his patient. As formulated by Langlebert,1 the various cases which present themselves may be grouped under one or another of the following heads : (1) An indi- vidual2 previously without syphilitic disease shows one or more lesions, apparently chancroids, and asks whether he may marry, and how soon. (2) An individual having had six months or longer previously one or more venereal soreS, as to the character of which he cannot speak positively, but for which mercurial treatment was followed, asks the same question as (1). (3) An individual who is or lias been the subject of an infecting sore (chancre),, afterwards followed by generalized symptoms, which may or may not now show themselves, asks the same question as (1). (4) A man marries after having had syphilis, but at so remotely previous a date that there is reason to hope that he will show no future signs of the disease—what has he to fear for his future offspring? (5) An individual marries, having present syphilitic manifestations, or contracts syphilis after his marriage—what shall be done to avoid, or at least to lessen as much as possible, the consequences of his misconduct? Under the first head, when a patient displays one or more venereal sores resembling chancroids, and asks how soon he may marry, the advice should be given to wait for six months. If by the end of this time no generalized lesions have made their appearance, the marriage may be consummated with- out fear.3 For, as has been shown in the earlier portion of this article, the longest period of incubation elapsing between the appearance of the initial lesion and the explosion of the general symptoms, does not exceed six months. Of course it is understood that during this period the patient should submit himself to the frequent inspection of his physician, for otherwise the earlier general symptoms may pass unnoticed. In addition, the patient should be directed to examine himself carefully from day to day, and especially to look for the erythematous rash, which so often appears and disappears without having been perceived, as well as for papules, mucous patches of the mouth,, etc., crusted lesions of the scalp, and enlargement of the cervical glands. Under the second head, where a person who has had a suspicious sore or sores six months or more previously, for which mercurial treatment has been fol- 1 La Syphilis dans ses Rapports avec le Mariage. Paris, 1875. 2 Women so rarely present themselves for examination and opinion that I consider here the case of men only. There is, of course, little difference between the sexes regarding the manifesta- tion of the disease, excepting the far greater difficulty of finding whether or no a woman has had a chancre. I fail in ninety-nine cases out of a hundred to get any history of an initial lesion on the genitalia in women, though I rarely meet with cases where there is any apparent intent or desire to deceive. 3 Under such serious circumstances no reliance can or should he placed upon the classical, descriptions of chancre and chancroid. In these cases the chancroid is the lesion which is found not to be followed by general syphilis, after six months of careful watching, and no decision can be arrived at until the expiration of this period. 476 SYPHILIS. lowed, asks if lie may marry, an element of great uncertainty is introduced into the question by the course of treatment which the patient has under- gone. For, as is known, mercury given between the appearance of the initial lesion and the advent of general symptoms, has the power to adjourn the ap- pearance of the latter without preventing their ultimate manifestation.1 In these cases the physician should go very carefully into the history of the patient, and should endeavor to extricate from his answers some data upon which to base a diagnosis. Failing this, a postponement for at least three months must be enjoined, the patient remaining under observation meantime, and, of course, no treatment being employed. The following scheme gives a guide to the questions which should be asked in eliciting the history of former syphilitic disease:— Scheme for the Examination of Persons supposed to have contracted Syphilis.2 (1) The individual has had venereal sores (chancres). (2) Ascertain precisely the date at which these sores were contracted. Were there •one or more ? In the latter case, did they come out simultaneously or consecutively ? (3) Supposing but a single sore to have existed, what was its seat, its form, its dimen- sions ? How long a time elapsed between the date of supposed exposure and that of the appearance of the sore? Was it soft or indurated? (4) Examine the point indicated as having been the seat of the sore in question. Ho not forget that the specific induration may last a long time after the sore has healed ; that in some cases it may be noticeable even after some years. Remember also that the cicatrix of chancre, when it occurs upon the skin, as on the outside of the prepuce, may present a characteristic bronze tint, which disappears very slowly.3 (5) What took place in the neighboring lymphatic ganglia ? Were the glands swollen at any time ? If so, were, there a number in the groin (supposing, of course, that the suspicious sore was on the genitalia), on one or on both sides, a hard and indolent group of nodules; or did the glandular involvement take the form of a red, painful, inflam- matory tumor, having a single ganglion as its centre ? (6) In the latter case, did the ganglionic tumor suppurate, or did it terminate by resolution ? If it suppurated, did the opening by which it discharged heal up promptly, or did it grow larger and itself become a virulent sore ? (7) Examine the inguinal regions, where possibly the vestiges of a specific adeno- pathy may still be found, persisting, as it sometimes does, for months and years after the initial lesion has disappeared. (8) If the patient has had a suppurating bubo, the cicatrix should be recognizable, and should show' by its extent whether the suppurative opening had closed quickly or whether there had been a virulent open sore. In the latter case it is almost certain that general infection has not taken place. (9) Inquire how long the sore or sores persisted, what treatment was followed, and wdiat physician attended the patient. The treatment of a competent physician will, ot' course, throw light upon the nature of the disease. (Unfortunately, too few physicians are competent to interpret any but the plainest symptoms of syphilis with certainty, wdiile too many give anti-syphilitic treatment in all doubtful cases, of whatever nature. Too much reliance must not, therefore, be placed upon the answer to this question.) (10) What followed the sores in question? Does the patient remember to have experienced weakness, fatigue, or pains in the head or limbs, wmrst at night, during the three months previous ? (11) Has the patient observed the appearance of a rash, coming out in small, reddish 1 This is not admitted by all syphilographers, but statistics show, I think, conclusively, that the view here taken is correct. 2 This scheme is founded on the one given by Langlebert, in his work already quoted. 3 See Leon Montaz, Recherches sur la Trace Indelebile du Chancre Syphilitique, ses Caracteres. Paris, 1880. STRillLIS IN ITS RELATIONS TO MARRIAGE. 477 patches, or round, red, flat, lentil-sized pimples, over the chest, abdomen, and forearms,, unaccompanied by any sensation ? (12) Has the patient had, about the same time or a little later, certain grayish patches, with or without ulceration in the throat, on the lips, or on the tongue ? (1 find patients call these either simply “sores” or “fever-blisters,” “cankers,” or “ulcerated sore throat;” they are among the most constant symptoms noted and remembered by patients when questioned as to their previous history.) Has the hair thinned or fallen out? Have there been any lentil-sized blackish crusts in the scalp at different points? Have the mastoid or cervical lymphatic ganglia been enlarged at any time, or are they now ? (13) Examine by palpation *the occipital region, where there may possibly still be found some ganglionic enlargement; these enlarged glands sometimes persist long after the disappearance of other syphilitic symptoms. (14) Examine the hair of the scalp: observe if this is thin, especially in the occi- pital and temporal regions ; if it preserves its natural suppleness, or if it has become dry and harsh ; also see if there are any cicatrices, or small white patches, deprived of hair, here and there. (15) Examine the throat. If the tonsils and velum palati have been the seat of ulcerated mucous patches—a symptom rarely lacking in early generalized syphilis—the indelible vestige of these lesions can generally be recognized. The mucous membrane, instead of being smooth as it ordinarily is, presents an irregular surface of a rugous and shagreen-like appearance ; the edges of the velum and half arches have lost the sharpness of their contour ; they are rough and irregular, with more or less deep in- dentations. This symptom has only a relative value, since cauterization for any other affection of the fauces will produce the same effect. It should have weight as corrobo- rative evidence, however, when it is present. (16) It should be remembered that with many persons who have had syphilitic symp- toms, even long previously, the lips, the buccal mucous membrane, and particularly the edges and point of the tongue, show small whitish patches of a roundish or irregular contour. These patches are very persistent, and when present furnish very strong pre- sumptive evidence of former syphilis. (17) Examine the body, and particularly the back, shoulders, and legs, to see if there are not some cicatrices of former pustules. The scars are usually rounded, reticulated, and sharply circumscribed, this feature serving to distinguish them from burns; the latter are always more or less irregular. (Furuncles and acne pustules often have cicatrices quite undistinguishable from those of syphilis; the latter are very common over the back and shoulders, but are rarely found on the arms or legs.) The chest, the abdomi- nal region, the lower limbs, the palms of the hands, and the soles of the feet may like- wise present some spots or macules, with or without a depressed surface, their yellowish or coppery tint showing their age to a certain extent, being darker the more recently the lesions have existed. (18) The patches of tinea versicolor found on the trunk are sometimes taken for the erythematous syphiloderm, but a moment’s inquiry will show them to have lasted months or years, while the syphiloderm is acute and comparatively transient. The same may be said of the pigmented macules left after acne in dark-skinned persons. These will be found on inquiry to be connected with lesions often dating back to puberty. As to the third question, whether an individual who has had chancre, fol- lowed by subsequent generalized symptoms, may marry; of course, the answer must be negative if the symptoms are still manifest. But if they have dis- appeared months or years ago, then the question more difficult to answer, and the first problem to resolve is this: is syphilis curable ? Without going into that question from a general point of view, I do not hesitate to say that for our present purpose syphilis is curable. Whether, however, any given case can he said definitely to be cured at a stated time, is a different question. And yet some such statement must he made if the patient is to he authorized to marry. Mild cases of syphilis, when the early symptoms follow one another at a normal interval and in a benign form, are not apt to relapse. The disease 478 SYPHILIS. may be said in these cases to rnn a definite course, and to exhaust itself in the course of perhaps eighteen months or so, on an average, under judicious treatment. Now arid then some slight localized eruption may appear subse- quently, but in a majority of cases no lesions which can be called contagious make their appearance. While it is true that mild early symptoms do not insure the patient against the occurrence of late visceral lesions, yet a case of benign syphilis which has been carefully treated is not one where wife or children are apt to sutler if the patient allows a sufficient time to elapse after the appearance of the last lesions, before marrying. In the few cases of this kind which I have had under complete control from the beginning, I have permitted marriage after eighteen months of treatment, followed by from six months to a year of immunity, and I have followed up the history of several persons thus permitted to marry, and have known them to procreate healthy children. But even benign syphilis, if not treated at an early period, and thoroughly, tends to relapse, and I should not be inclined to authorize marriage in a pa- tient, particularly a woman, who had taken mercury irregularly, and who had suffered a number of relapses. Such cases are those in which healthy and diseased children are procreated alternately for a series of years, as the patient may or may not be under the influence of mercury at the time of conception. But in cases of more severe syphilis, where the earlier symptoms are pus- tular instead of erythematous, where the disease is stubborn to the influ- ence of mercury, and where there is a tendency to relapse and to ulceration, I should be inclined to prolong the treatment very considerably, not permit- ting the patient to marry until eighteen months or two years after the disap- pearance of all outward signs of disease, and the cessation of a mercurial course which had also lasted for at least eighteen months or two years, making about four years in all. This practically amounts almost to a prohibition, but if the physician is not firm in these cases, he may have cause to bitterly regret his complaisance at a subsequent date. Patients will marry, if they decide to do so, in spite of the doctor’s warning; but it is a thousand times better to risk the reputation of over-cautiousness, than to have a diseased being brought into the world, which has been begotten under the sanction of the physician. Regarding the fourth proposition, which is closely connected with that just discussed, the question here is pushed farther, and it is desired to know what injury can occur to the children of a parent who has had syphilis long before his marriage, who presents no signs of the disease afterwards, and whose offspring in consequence cannot be expected to show any of the symp- toms of syphilis in its ordinary form. Can the syphilitic taint so influence such offspring as to induce rickets, scrofula, and the like ? In answer to this question I should say that not only is it contrary to all our experience that one disease should give rise to another entirely distinct from it, but that in spite of the fascination which this theory of scrofula as a derivative of syphi- lis has exercised over the minds of able observers, it has never been possible to bring forward a sufficient number of cases in proof of the theory to con- vince those who had not previously made up their minds on the subject. No, as has been said in the earlier part of this article, syphilis is a distinct entity, and can beget syphilis alone. It may appear alongside of scrofula, and may run a parallel course with that affection. It may predispose by its cachectic influence to the development of the so-called scrofulous maladies, or the scro- fulous taint may cause the subject to suffer the severer ravages of syphilis. But as for a combination such has been fancied, analogous to that between two chemical elements (e. g. the “ scrofulate of syphilis,” of Devergie), this has never been shown to exist. LEGAL MEASURES TO PREVENT THE SPREAD OF SYPHILIS. 479 So far from syphilis gradually tapering off into scrofula, it is in reality cur ■short and extinguished. Many children and adults are alive and in blooming health at this day, one or even both of whose parents were the subjects at one time of syphilis. In the case of an individual who marries with symptoms of syphilitic dis- ease already manifest upon his person, or who contracts syphilis during mar- ried life, the considerations which present themselves are different from those which have thus far been discussed. The question here is to prevent the transmission of the disease to other members of the family, and chiefly to the husband or wife, as the case may be. When a man has a genital chancre, he seldom knowingly exposes his wife to contagion, and of course it is necessary to avoid sexual intercourse entirely at such a time. While the physician, consulted by such a person, should posi- tively interdict all commerce of the kind, he should, at the same time, when circumstances permit, adopt either such treatment as frequent coating of the lesion with collodion or light cauterizations with nitrate of silver, or the application of some such remedy as may suggest itself to prevent the possi- bility of coitus. For the married man who places himself in a position to ■contract syphilis, is not a person of such nice sensibility as to balk at the prospect of infecting his wife when his own selfish indulgence is in question. If we can persuade him that some injury to himself may possibly accrue, we may be able to arouse him to caution and self-denial; but I have found it unsafe to appeal to any but selfish motives in such cases. The danger from chancre past, the next, and in practice indeed the com- monest danger, is from mucous patches about the mouth and lips. The mar- ried man who has suffered with chancre should examine his mouth and fauces daily during many months, in order to detect the first appearance of these ■extremely common lesions. When present, they should be cauterized lightly every day with nitrate of silver, with the view of coating their surface and rendering them less virulent, and at the same time the patient must be warned against kissing any one of the family, and against permitting the use after him of such utensils as spoons, cups, etc., by other persons, without pre- vious cleansing. Should the wife of such a person by chance become pregnant, she should undergo a course of mercurial treatment to prevent the development of syphilis in the foetus. The earlier and more thorough the treatment of the mother, the more likely will she be to bring forth a healthy child.1 Legal Measures to prevent the Spread of Syphilis. The continuance and generally increased diffusion of syphilis have attracted the attention of the medical profession more and more to the necessity of employing some means of arresting the spread of the disease. The measures proposed have been: (1) that of Auzias Turenne,2 who conceived the idea that syphilis might be inoculated in the same manner as smallpox was inocu- lated before the discovery of vaccination, and thus immunity gained in case of subsequent exposure. (2) The supervision and examination of prostitutes 1 For a careful examination and treatment of this subject, reference may be made to the following works :— Langlebert, La Syphilis dans ses rapports avec le Manage. Paris, 1873. Diday, Le Peril Venerien dans les Families. Paris, 1881. Fournier, Syphilis et Mariage. Paris, 1880. A translation of this work into English has lately appeared. 8 De la Sypliilisation, ou Vaccination Syphilitique (Arch. Gen. de Med., 4e Ser. t. xxxvi., 1851) 480 SYPHILIS. with the view of arresting the spread of the disease, at least at one of its sources. The first method of prophylaxis has proved a failure, because the disease contracted by syphilization is precisely the same as that gained in other ways, both in character and degree. The second has been tried in various localities with varying results, but with as yet no decided advantage to the community at large, except in the case of some garrison towns in England, where a de- cided lessening of syphilis has been the result. The question of the regulation of prostitution must inevitably be dis- cussed in connection with that of the prevention of syphilis, and here of necessity the moralist must be interested as well as the physician. If pro- stitution could but be looked at from a purely medical standpoint, and only in its relation to the production of syphilitic disease, the matter would be- greatly simplified. As it cannot be so in the present state of human nature,, and as the moralist and theologian consider it as much within their province as that of the physician, the problem is much complicated, and must, I thinkr in the end, be solved by taking into consideration both points of view. Unfortunately there has been a controversy here upon points on which no- controversy as it appears to me is necessary, and both sides have dealt largely in vituperation where cold facts alone are required or can be at all convincing. Almost every contribution to the subject has been made with the view of proving a pre-supposed theory, rather than of indifferently recording facts no matter what conclusions may be drawn from them. For this reason I consider that the time has not yet come to advocate the regulation of prostitution, at least in our American cities, where the muni- cipal government, already notoriously inefficient, would certainly be unable to devise a satisfactory method of coping with the evil, and where a break- down in the administration of the law would be worse than having no law at all.1 1 The following works and papers, chiefly of a statistical character, may he referred to as giving information especially with regard to the prevention of syphilis in European countries :— Lecour, C. J., Be la Prostitution et des measures de police dont elle est l’objet a Paris, etc. (Arch. G6n. de Med., t. ii. p. 711 et 736, 1867). Id., La Prostitution it Paris et a Londres de 1789 & 1870. Paris, 1870. Crocq et Rollet, Prophylaxie Internationale des Maladies VenSriennes (Ann. de Derm, et de Syph., t. i. p. 353, 1869). Cambas, De la Prophylaxie de la Syphilis (ElSigloMed. Translated in Annales de Derm, et de Sypli., t. iii., 1871-72). Nevins, J. B., Protection from Venereal Diseases in America (Sanitarian, vol. viii. p. 252). Hong-Kong, 1878 (contagious diseases ordinance). Return to an address of the House of Commons, Feb. 13, 1880, for copy of report of the Commissioners to inquire into the workings of the Contagious Diseases Ordinance, 1867 (ordered by the House of Commons to be printed, March 11, 1880). London, 1880. Thomson, W., Some Results of the Contagious Disease Acts (Med. Press and Circ., N. S., vol. xxxii., 1879, p. 341). Gihon, A. L., Report of the Committee on the Prevention of Venereal Disease, presented at the eighth annual meeting ot‘ the American Public Health Association. New Orleans, 1880. Sturgis, F. R., Relations of Syphilis to the Public Health. New York, 1877. Sims, J. Marion, Legislation and Contagious Diseases. Phila., 1876. Vintras, A., On the repressive measures adopted in Paris, compared with the uncontrolled prostitution of London and New York. London, 1867. Henry, M. II., Discussion on the Prevention of Syphilis at the Int. Med. Congress at Vienna, 1873, with remarks (Am. Jour. Syph. and Derm., vol. v., 1874, p. 17). Swayze, G. H., Shall the spread of Syphilitic Poison be prevented ? (Phila. Med. and Surg. Re- porter, Oct. 6, 1877). The Regulation of Prostitution as a Sanitary Measure (Editorial, Med. Record, vol. xvi., 1879, p. 205). White, J. Wm., The Prevention of Syphilis : an address prepared at the request of the Phila- delphia County Medical Society, and read before it Dec. 14, 1881 (Phila. Medical Times, Jan. 14, 1882). This last is an especially able review of the entire subject from a point of view favorable to the regulation of prostitution. VENEREAL DISEASES: BUBON D’EMBLEE, VENEREAL WARTS OR VEGETATIONS, PSEUDO- VENEREAL AFFECTIONS, VENEREAL DISEASES IN THE LOWER ANIMALS. BY H. R. WHARTON, M.D., INSTRUCTOR IN CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA ; SURGEON TO THE CHILDREN’S HOSPITAL, PHILADELPHIA. Bubon d’Emblee. Bubon d’Emblee, “or bubo at the first onset” (Primary Bubo), is a name applied to an inflammation of the glands of the groin, occurring after sexual intercourse, and apparently not depending upon any lesion of the genitals— the theory of those writers who introduced the term being that the peculiar virus of the chancre or chancroid might enter the lymphatic vessels of the skin or mucous membrane, and be conveyed to the nearest group of glands,, there to excite its characteristic inflammation, without producing any lesion of the tissues at its point of entrance. This manner of origin was considered possible by many of the older writers upon Venereal Diseases, among whom may be mentioned, John Hunter, Vidal (de Cassis), Gibert, and Castelnau—. the latter authority reporting several cases of the so-called bubon d’emblee, in regard to all of which, however, there is ground for doubt, either the examina- tion of the genitals having been incomplete, or deferred too long, or the ante- cedents of the patient not having been sufficiently inquired into. Ricord1 believes that the theory of the bubon d’emblee is unfounded, and Cullerier2 declares that the bubo which has received this name is nothing but a simple adenitis, such as may result from over-exertion or fatigue incurred in any manner whatever. Ch. Mauriac,3 in an exhaustive study of this subject recently published, in which he has carefully studied many cases of the so-called bubon d’emblee occurring under his own observation, states that not one case is complete or unassailable, and that the existence of the chancroidal and of the syphilitic bubon d’emblee cannot be admitted. Berkeley Hill4 declares that the bubon d’emblie is not followed by syphilitic eruptions; that the pus of this bubo is not of the nature of the pus of the virulent [chancroidal] bubo ; but that it often follows coitus, and is generally seen in persons of that constitutional 1 Ricord and Hunter on Venereal Diseases, p. 341. 2 Precis Iconographique des Maladies V6n6riennes, p. 304. 8 Etude sur le Bubon d’Erablee. Paris, 1880. 4 On Syphilis and Local Contagious Disorders, p. 356. 481 482 VENEREAL warts or vegetations. diathesis which predisposes to glandular inflammations from other causes. Follin, like Cullerier, suggests that the bubon d’emblee is independent of con- tagion, and is simply due to the fatigue of violent intercourse. An examination of the literature of this subject will, I think, convince any one that the existence of the bubon d’emblee, in the original acceptation of the term, cannot now be acknowledged, for none of the reported cases are free from the chance of error; in no case does constitutional syphilis start from this lesion, and the results of inoculation of its pus are negative. What, therefore, is called the bubon d’emblee must be considered as either a simple adenitis, due to irritation; an inflammation of the glands due to pre-existence of a chancre or chancroid which has escaped observation, or which has healed before the glandular affection has become marked; or a gummatous affection of the glands occurring during the course of syphilis. Dr. Sturgis reports a case of the latter affection which closely resembles many of the recorded examples of bubon d’embUe, and I have myself had a case under observation in which symmetrical buboes occurred without apparent cause, in a patient who had been for some time suffering from constitutional syphilis, and in whom the inguinal affection rapidly disappeared under con- stitutional treatment. Mauriac1 reports three cases of gummatous inflamma- tion of the inguinal glands, and Verneuil2 has observed several cases of the same nature. Treatment.—The treatment of the so-called bubon d’emblee consists, first, in putting the patient at rest, and then making counter-irritation around the inflamed area with tincture of iodine, after the manner of Mr. Jordan, apply- ing the drug not over the affected part, but over the “next vascular area;” poultices may also be applied, and, if the inflammation goes on to suppuration, a free incision should be made as soon as the presence of pus can be detected. From the fact that these buboes frequently occur in persons of strumous or debilitated constitutions, tonics are indicated, and of these, cod-liver oil and iron are to be preferred; the use of iodide of iron, either in the form of the syrup or of the officinal pill, is often followed by the most satisfactory results. In cases which point to a gummatous inflammation of the glands of the groin, the administration of the iodide of potassium will generally effect a rapid cure, and preclude the necessity of any operative interference. Venereal Warts or Vegetations. Venereal Warts or Vegetations are highly vascular, papillary growths, springing from the mucous membrane or the skin; they occur most fre- quently on the genital organs, and are identical in their nature with warts seen in other parts of the body. “ They are exceedingly vascular, and are made up of connective tissue elements, which make a mass of firm consis- tence ; the papillfe are much hypertrophied, and are covered with an exten- sive mucous layer; the horny layer may be found developed in warts in cer- tain localities.”3 Nature of Vegetations.—The term “venereal” is not, strictly speaking, correct, as these growths are sometimes seen in children, in pregnant women free from venereal taint, and in persons who have never had sexual inter- course, seeming, in these cases, to arise from the irritation produced by the 1 Gazette des Hdpitaux, 1879. 3 Duliring, Diseases of the Skin, p. 467. s Hill, op. cit., p. 203. PLATE XX Vi’ (jdalii' u.3 v | *VJ t'd (111(1 ohniA. APPEARANCE OF VENEREAL WARTS. 483 decomposition of the natural secretions of the parts; but, on the other hand, it must be acknowledged that the irritating discharges arising from venereal diseases are a frequent cause of their production. The occasional occurrence of these vegetations in the lower animals also furnishes additional evidence of their not necessarily being of venereal origin. The special susceptibility of the mucous membranes and skin of certain persons to the production of warts, has been attributed to constitutional peculiarity or inherited predisposition, and by Martin to the presence of a “ lymphatic diathesis.” Diday,1 from an investigation of fifty-five cases of warts upon the genital organs, found that, in forty-seven cases, the patients had suffered during childhood from warts occurring elsewhere. The favorite seats for the production of these growths in the male are, the internal surface of the prepuce, the furrow behind the corona glandis, the glans penis itself, and the edge of, or just within, the meatus; in the female, they appear on the labia, the vagina, and about the anus. Heat and moisture •—conditions which exist in the above-named localities—are elements favorable for the development of vegetations. The condition of phimosis acts as a pre- disposing cause in the production of these growths, the concealed condition of the parts rendering the removal of the natural secretions, or of the dis- charges due to venereal disease, difficult or impossible. Appearance oe Venereal Warts.—When situated upon the genitals, warts are generally attended with a whitish or yellowish discharge, due to the irri- tation caused by friction, or to positive ulceration; from the heat of the parts, the discharge undergoes decomposition, and gives rise to a peculiarly offensive odor. In shape and size the growths may pre- sent great variety, this depending much on their location; on the glans penis, and on the inner surface of the prepuce (Plate XXIV. Fig. 1), they may occur as elevated masses, granular in ap- pearance, and either sessile or pedunculated; or they may exist singly, as slightly flattened cones. When they occur on the skin of the prepuce or on the body of the penis, they are apt to be con- ical in shape, and to show a predominance of the horny layer; in the neighborhood of the anus they may occur as elevated masses, flattened by pressure (Fig. 345); and in the female genitalia they are frequently seen as large masses, resem- bling cauliflower excrescences (Plate XXIV. Fig. 2). The extent to which these growths may in- vade certain localities is only limited by the area of surface favorable for their production; the anus and vulva may be completely sur- rounded the vagina may be almost occluded; and the configuration of the glans penis and pre- puce may be entirely masked. Fig. 345. Causes of Yegetations ; Question of Conta- gion.—These growths are more common in women than in men ; the large extent of mucous surface liable to be irritated by the secretions Vegetations around anus in a child. 1 Diday, Therapeutique des Maladies VSueriennes, p. 346, 1876, 484 VENEREAL AVARTS OR VEGETATIONS, disordered through venery, or by the unhealthy discharges from the parts,, offering a fruitful soil for their production. The existence of pregnancy also favors the production of warts, probably on account of the engorged state of the genital mucous membrane, dependent on the pelvic congestion normally seen in this condition; under these circumstances, the growth of vegetations may be so rapid and extensive as entirely to fill up the vaginal canal. The occasional presence of these growths on mucous patches has caused some authorities to consider them as syphilitic in nature; hut their coexistence seems rather accidental than otherwise, and that they are not due to syphilitic contamination is shown by the fact that they are cured by local treatment only, and are not affected by constitutional remedies. As regards the contagiousness of these growths, much difference of opinion exists, some authorities considering them eminently contagious, while others believe them incapable of being transmitted in this way. In many instances they certainly seem to be communicated by direct contact, as in a case recently brought under my notice, in which four young men had each a pro- fuse development of vegetations, after intercourse with the same woman, who was herself suffering from warts at the time. Whether, however, in such cases, the growths are caused by direct contact with the growths existing in the woman, or by exposure to the irritating vaginal discharge which itself produced the original crop, is a question which cannot be definitely settled; but, on the whole, the weight of evidence favors the former view, and it is probable that, as believed by Bumstead, the contagious property resides in the secretions from the warts themselves. Treatment of Vegetations.—The removal of venereal warts may be effected in various ways, either by excision, by the use of caustics, or the cautery, by ligation, or by the application of astringent or desiccating powders. Ligation is a tedious method, and is now seldom employed. Excision, one of the most popular methods, is accomplished by shaving or snipping off the growths with knife or scissors, the cut surface being then touched with some caustic or astringent; this method has the disadvantage of being followed, in some cases, by profuse hemorrhage, which, if the growths removed have been extensive, may be difficult to control. The actual cautery may also be applied for the removal of these growths, either in the form of the hot iron, or the hot loop of the galvano-cautery, or in the form of Paquelin’s cautery; it presents a method of treatment which is both efficient, and at the same time free from the risk of troublesome hemorrhage. Caustics and Astringents.—In other cases the growths may be simply touched with nitric acid, chromic acid, or the liq. plumbi subacetatis, or, when small, may be dusted with calomel, tannic acid and lycopodium, or dried alum. The use of chromic acid has been highly recommended by Mr. Fro- mer,1 Mr. Marshall,2 and Dr. Crawcour,3 and is, by Prof. Ashhurst, preferred to any other mode of treatment; it is in many cases followed by the most satisfactory results. Both Dr. Keyes and Dr. Bumstead recommend a prepa- ration consisting of corrosive sublimate, 3j, with collodion, f§j, to be painted on the growths; they consider this a particularly efficacious remedy in the dry form of the disease. Treated by any of these means, warts will sometimes recur, in which case the same procedure should be repeated. Keeping the parts clean, and as dry 1 Dublin Journal of Medical Science, vol. xiii. p. 250. 2 Ranking’s Half-Yearly Abstract, vol. xxv. p. 183. 3 New Orleans Medical News, Nov. 1857. 485 PSEUDO-VENEREAL AFFECTIONS. as possible, after the growths have been destroyed, is an important adjuvant in effecting a permanent cure. The large growths which occur during pregnancy should not be subjected to operative interference; the treatment here should be palliative, consisting in keeping the parts clean by the use of a disinfectant lotion, such as Labar- raque’s solution, since a spontaneous cure may take place after delivery; if, however, the growths persist, they may be dealt with at the proper time, as in other cases. The treatment of warts, when complicated with phimosis, generally requires operative interference, either by splitting the prepuce, or by a formal circum- cision, so as to afford the necessary exposure of the growths; when made accessible by either of these methods, the warts can be excised, or touched with caustics or astringents in the way already described. Circumcision has the advantage of leaving the parts in a condition less favorable for the repro- duction of the disease. Pseudo-Venereal Affections. Under this name may be included several diseases which are transmissible by contact, and, therefore, by sexual intercourse when the generative organs happen to be affected, but which have no necessary or even habitual depend- ence upon such intercourse, and are not, therefore, strictly entitled to be called venereal. Some of the affections to be described under this head are, however, probably really identical with syphilis. Yaws. (Synonyms: Framboesia, Plan.)—These names have been given to an ■affection which is endemic among the negroes on the west coast of Africa, -and which has from that locality been transported by slave traders to the West Indies, and to the Southern States of America. This disease was described by the Arabian physicians as early as the tenth century, and from them received the name of Sahafti.1 According to Lancereaux,2 it is met with as an endemic disease from the left bank of the Senegal River to Cape Negro, in Senegambia, Congo, Sierra Leone, and Nigritia, and in the colonies which have drawn their slave supply from those regions. Milroy3 believes that the geographical distribution of the disease is much wider than is gene- rally supposed, and that it occurs not only on the west coast of Africa, but in the islands of the Pacilic, in South America, in the Melanesian Islands, and on the east coast of Africa. Symptoms.—The symptoms of yaws, according to most authorities, are lassitude, malaise, more or less fever, pain in the joints, and a papular erup- tion which goes through various phases of development, and which in certain ■stages, from its resemblance to the wild raspberry, has caused the disease to receive the name “ framboesia.” At a later period the patient suffers from ulcerations, osteocopic pains, and various affections of the bones—exostoses, necrosis, and caries—and in rare cases from gangrene. Imray4 declares that little constitutional disturbance is manifested at the outset of the disease, and that it is not until the affection has existed for some time that the general health suffers, when the patient becomes emaciated and debilitated from the attending pain and ulceration. 1 TheodOric, lib. viii. cap. xviii. 2 Lancereaux, Treatise on Syphilis (New Sydenham Society’s Translation), vol. i. p. 31. 3 Medical Times and Gazette, June, 1880. 4 Tilbury Fox, Diseases of the Skin in Hot Climates, p. 407. 486 PSEUDO-VENEREAL AFFECTIONS. “The eruption,” according to Duhring,1 “consists of variously sized papules, tubercles, and tumors, which are present in all stages of development; they begin in pin-head sized points, which enlarge until they become the size of split peas, resembling in appearance currants and raspberries ; as they grow they incline to become flat on their summits, and become studded with* yellowish points. In time they may become as large as cherries, become softer, are apt to break down and ulcerate, discharging a thin, fetid, yellowish fluid. These lesions may be round or semi-globular, or may coalesce, forming patches of a vegetating or fungoid nature.” Mr. Hutchinson,2 in describing a case of yaws which occurred under his own observation, says that the eruption consists of small red tubercles, pre- sent in various stages of development; when they first appear, they are small red pimples, afterwards shining red vesicles, and, when more fully developed, round elevations with flat tops, of a bright pink color, glassy, and semi-trans- parent, but possessing more the consistence of raspberries than of currants. The substance of the tubercles is solid, they do not collapse when pricked, but blood or bloody serum oozes from them when their surface is broken. Some become pustular, and others, when fully developed, ulcerate at their bases and drop oft*; their bases are not surrounded by an areola of redness. Dr. Imray3 says that if yaws are observed as they first make their appear- ance on the surface, one or more whitish or yellowish spots will be perceived, not larger than a pin’s head; these spots are seen very distinctly on the dark skin of the negro. Gradually the spots enlarge and begin to project from the surface, retaining for the most part their circular form, and having much the appearance of small globules of yellow pus. The skin remains unbroken until the yaws attain the size of small peas, when a spongy yellow surface, from which a thin fluid oozes, presents itself, and this spongy body continues to enlarge until it projects considerably from the surface. The most common seats of the eruption are on the face, neck, genitals, perineum, and anus ; upon the vulva and upon the lips, the eruption may be so profuse as to form a complete ring around the orifices. The lesions show no regularity of distri- bution, and are neither painful nor itching. When, however, the fungous excrescences appear on the soles of the feet, where they are prevented from rising by the thick epidermis, they cause those parts to become painful and swollen, and thereby offer a great impediment to walking. In this situation they are called by the natives of the West Indies tubb(E, or crab yaws; the case observed by Mr. Hutchinson presented this lesion. When the eruption disappears without ulceration, dark spots are left which gradually fade away, but when there has been much ulceration deep scars are produced which are permanent. The disease is acquired by direct contact with those suffering from yaws, or by means of eating or drinking utensils, etc. From the almost constant presence of the eruption on the genitals, coitus is a frequent means of its transmission. In the West Indies, it is said also to be produced by the bite of a large fly, which, from its supposed agency in producing the disease, has received the name “yaw fly.” The period of incubation of the disease is from three to ten weeks, and its duration is from nine to thirteen months; one attack is believed to protect the patient against further invasions, although on this point as well as on that of hereditary transmission, it must be acknowledged that there is some difference of opinion among various observers. Imray4 considers yaws a contagious, but not an infectious disease, and be- 1 Treatise on Diseases of the Skin, p. 467. 1 Descriptive Catalogue of the New Sydenham Society’s Atlas of Portraits of Diseases of the- Skin, p. 148. 8 Fox, op. cit., p. 468 4 Fox, op. cit. YAWS, 487 lieves that it can only be communicated by contact of the sound with the dis- eased, or by the application of the discharges of those suffering from yaws to an abraded surface or wound. John Hunter1 regarded this affection as conta- gious, and cited the case of a physician who was inoculated with yaws from a wound received while operating on a patient suffering from the disease. Thomson2 believed yaws to be freely communicable by inoculation, and gave examples from his own practice of women being inoculated by suckling children who were suffering from it; he also inoculated children with yaw matter to ascertain if the disease could be modified by this procedure, but his results showed that the artificial production of yaws neither shortened its duration nor diminished its severity. These experiments of Thomson were confirmed by an observation of Paulet,3 Who inoculated a child with the matter taken from the pustules of yaws; the operation was followed in three weeks by an attack of the disease which lasted for nine months. Bowerbank4 acknowl- edges only the contagiousness of yaws by direct contact of the secretion with a wound or abraded surface, and says that in Jamaica patients with yaws are admitted into the general hospitals without the disease being communicated to the other patients or to the attendants. From the fact that yaws is frequently contracted during sexual intercourse* from its peculiar manifestations on the skin and mucous membranes, and from the fact that it is often followed by sequelae much resembling those of syphilis, it is not surprising that the older writers considered it to be identi- cal with that disease. Indeed, John Hunter5 stood almost alone among the surgeons of his time in maintaining that yaws was a distinct and sepa- rate affection. Hor can it be said that the more modern writers are unani- mous in their opinions upon this point; Lancereaux6 and Berkeley Hi IF consider the identity of the two diseases well established, and adduce the fact that they are both amenable to mercurial treatment as furnishing additional evidence in support of their view. Milroy,8 Bowerbank, and Imray, on the other hand, while they acknowledge certain points of resemblance with syphi- lis, believe yaws to be a distinct and separate disease. I think that the weight of authority and the evidence of recent observers certainly point to the non-identity of the two affections, a view which is sus- tained also by the fact that both diseases can exist in the same patient at the same time ; Milroy mentions a case where yaw-ulcers and syphilis existed simultaneously, and Dr. Ross also cites a case of syphilis and yaws being found in the same patient, the syphilis getting well under mercurial treatment* while the yaws remained. Treatment of Yaws.—Thomson says that the natives of the West Indies looked upon this disease with peculiar disgust, and that patients suffering from yaws were isolated on remote parts of the estates, receiving little care except from negro attendants, and being seldom brought to the notice of European physicians. The natives employed in the treatment of this disease the flowers of sulphur, dusted on the ulcerated parts, and the contused leaves of the physic-nut (jatropha curcas), and the juice of the bitter cassava (janipha manihot). The treatment of yaws, according to Imray, consists in the use of baths to encourage the full development of the eruption, and in the exhibi- tion of sulphur and of the bitartrate of potassium, for the first six or eight days. Mercury is then given, with decoction of sarsaparilla or sassafras, but 1 Works, vol. ii. p. 471. 3 Lancereaux, op. cit., vol. i. p. 33. 5 Op. cit. 7 Op. cit., p. 15. 2 Edinburgh Med. and Surg. Jour., vols. xv.-xviii. 4 Medical Times and Gazette, June, 1880. 6 Op. cit., p. 33. 8 Leprosy and Yaws in the West Indies, 1873. 488 PSEUDO-VENEREAL AFFECTIONS. it is stopped as soon as the gums begin to show the slightest evidence of its constitutional action. Tonics should be given to persons of enfeebled consti- tution in conjunction with the mercury. The patient should be allowed a generous diet, and the greatest attention should be paid to cleanliness, upon which indeed Thomson, who disapproved of the mercurial treatment, de- pended almost exclusively. Locally, a weak ointment of the acid nitrate of mercury, or a solution of carbolic acid, may be used with benefit; the latter remedy Dr. Murray1 has also administered internally with good results. Bowerbank speaks well of the mercurial treatment as shortening the course of the aftection, but thinks that the disease is more apt to be followed by sequelae when it is used ; he also says that the iodide of potassium is effica- cious in certain cases, especially those in which the mucous membranes arc- involved. Parangi.—Mr. Kynsey2 describes a disease which has existed for many years in Ceylon, and to which the name of Parangi is given. It presents a stage of incubation in which a sore is found on some part of the body, and which is followed by a stage of invasion, characterized by the develop- ment of slight fever and dull pain in the joints. The eruptive stage follows this, and lasts for several weeks or months, ending either in convalescence or in the development of certain sequelae, among which may be men- tioned ulcers, by which the eruption may be succeeded. The aftection is contagious, through the secretions from the eruption or ulcers coming in con- tact with an abraded surface, or even with the healthy skin, and it is also supposed to be capable of hereditary transmission; one attack seems to con- fer immunity from others. Mr. Kynsey points out the similarity of this dis- ease, in its clinical history, to syphilis; but believes it to be allied to, if not identical with, yaws. The Parangi disease of Ceylon is also described by Tilbury Fox.3 Verrugas.—Under the name Verrugas, Dr. "Ward,4 of Peru, describes a disease existing in that country, which bears some resemblance to yaws; it is usually preceded by an initial fever, lasting from ten to thirty days, and is accompanied by excruciating pain of a rheumatic character, finally culminat- ing in an eruption of warty growths upon the body ; these occasionally proceed to suppuration or ulceration. By reference to Dr. Ward’s article it will be seen that this aftection lacks many of the symptoms and characteristic fea- tures of yaws, of which disease Dr. Duhring nevertheless considers it a variety, as he does a somewhat similar aftection which occurs in the valley of the Amazon. Sibbens or Siwens.—This is a disease peculiar to the west coast of Scot- land, occurring in the districts of Galloway, Dumfriesshire, Ayr, etc. It was first described in the seventeenth century, and was supposed to have been introduced by the troops of Charles the Second; the disease is now al- most if not entirely extinct. Gilchrist5 describes the disease as beginning with a sore throat or inflam- mation of the palate, the tonsils being covered with white sloughs, or ulcer- ated. In other cases there are elevated patches of a red or whitish color, resembling the eruption of yaws; this resemblance is pointed out by Berkeley Hill, who does not consider sibbens entitled to be regarded as a distinct 1 Milroy, op. cit. 2 Report on the “ Parangi Disease” of Ceylon, 1881. 3 Skin Diseases of India, p. 95, 1876. 4 Trans, of Internat. Med. Congress, Philadelphia, 1876. 8 Craigie, Practice of Physic, vol. i. p. 682. SCHERLIEVO OR FIUME. 489 affection. Wills1 speaks of the disease as originating in the form of condylo- mata or tubercles, which may ulcerate; the latter manifestations of the dis- ease are confined to the skin and bones. Skae2 reports an epidemic of condy- lomata under his own observation, which he considered identical with sib- bens; it was characterized by the appearance of whitish or yellowish elevated patches on the mucous membranes of the mouth, genitals, and anus. The most frequent seats of the eruption of sibbens seem to have been the tongue, palate, lips, cheeks, and genital organs. The disease was contagious, and was communicated by coitus, or by using the same eating and drinking utensils. Some authorities have considered this disease to be identical with syphilis; among these maybe mentioned Adams,3 Berkeley Hill, Lancereaux, and Hill4 of Dumfries. On the other hand, Skae and Gilchrist believed it to be a distinct affection. The treatment of sibbens consisted in the exhibition of mercury, and in the application of astringents to the condylomata and ulcers. Radesyge or Radzyge is a disease occurring on the sea-coast districts of Norway, Sweden, Iceland, and Greenland, and first noticed about the year 1710. “ It is a disease beginning with fever and catarrhal symptoms, more or less violent, and terminating in the eruption of papules and tubercles on the skin, and patches on the mucous membrane of the nose and throat; these may go on to ulceration ; the pa- tient may suffer from wandering pains in the joints resembling rheumatism, which are aggravated at night.”5 Charlton6 describes radesyge as a disease chiefly characterized by ulcera- tions of the nose, mouth, and fauces, which considerably resemble the ulcera- tions of syphilis. The palate and nasal bones are in some cases destroyed. The patients complain of burning pain, and perspire freely; hectic and colliquative diarrhoea set in, and frequently cause a fatal termination of the case. The disease is said to be contagious through the perspiration, saliva, and discharges from the sores. The cold, damp, and inclement weather of the districts where it prevails, the poor quality of the food, consisting princi- pally of oily fishes, and the imperfect ventilation of the dwellings, are impor- tant elements in its production and spread. Hubener,7 Hiinfeld, Struve, Craigie, and Lancereaux believe that this disease is identical with syphilis, and mention the affections of the mucous membrane, mouth, skin, and bones in confirmation of their opinion; Charlton, on the other hand, considers it a distinct affection. Some authorities are disposed to consider it a form of leprosy. Treatment.—Struve8 speaks highly of the employment of corrosive subli- mate combined with sarsaparilla or sassafras, and believes that cleanliness, good food, and the use of flannel clothing, are important elements in the cure of the disease; as a local application to the ulcers, he recommends corrosive sublimate and lime-water, or yellow wash. Scherlievo or Fiume.—This was an endemic disease which existed on the eoasts of Illyria, Dalmatia, and Croatia, during the last century. The disease 1 Edinburgh Med. Journ., 1844, page 282. 3 Observations on Morbid Poisons, London, 1807. 4 Cases in Surgery, Edinburgh, 1772. 5 Craigie, Practice of Physic, vol. i. p. 690. 6 Edinburgh Med. Journ., vol. xlviii. p. 101. 7 Ibid. 2 Skae, Ibid. p. 615 3 Craigie, op. cit., p. 695. 490 PSEUDO-VENEREAL AFFECTIONS. attacked the face and skin generally, in the form of malignant pustules, which were followed by ulceration and by caries of the bones.1 It was described by MM. Percy and Laurent2 as commencing with lassitude and pains in the hones, which increased at night: the voice became hoarse, deglutition was difficult, the uvula, tongue and pharynx became red and aphthous; ulcers formed, and were followed by caries of the bones, and by the discharge of fetid pus. The disease was said to have been imported by four sailors, who came from the banks of the Danube after the war against the Turks. The disease was probably identical with syphilis. Falcadina.—A disease which appeared in the year 1786, in the village of Falcado, contiguous to the Tyrol; its occurrence was attributed to importation through a female mendicant with ulceration of the pudendal mucous mem- brane. After general uneasiness, lassitude, sickness, osteocopic pains, and fever, a pustular swelling of the lips and mouth appeared, which proceeded to ulceration, affecting the velum palati, uvula, tonsils, and nasal mucous membrane; an eruption of a livid red color also appeared upon the skin. This disease was probably identical with sclierlievo and syphilis.3 Amboyna Pimple.—A disease occurring in Amboyna and the Molucca Islands, described by Bonetus in 1718, characterized by ulceration of the soft parts, and by exostoses and caries of the bones, and transmitted inde- pendently of sexual intercourse.4 Lancereaux5 considers it identical with syphilis. Disease of St. Euphemia.—Under this name is described b}T Lancereaux6 a disease which was observed in 1727 in St. Euphemia. A midwife had a pustule on her hand, followed by a general eruption of herpes; in the prac- tice of her profession she communicated the disease to many women, whose bodies became covered with pustules, ulcers, and hard tubercles. The dis- ease is considered by Lancereaux to have been a variety of syphilis. Pi an of Ferac.—This disease showed itself in Ferae in 1752, and is sup- posed to have originated from suckling a syphilitic child; the disease was first communicated to the nurse, and then to other children which used the same breast; it very much resembled the preceding disease.7 Disease of St. Paul’s Bay.—Swediaur8 described under this name a dis- ease which appeared in Canada in the year 1760, among the fishing popula- tion of St. Paul’s Bay. The disease first manifested itself in pustules on the lips, mouth, and tongue; these pustules were filled with -a whitish fluid which was very contagious. At a later period the patients suffered from large ulcers, glandular swellings in the groin and throat, and violent noc- turnal pains in the osseous tissues, with caries of the nasal, palate, and cranial bones, and sometimes loss of sight and hearing. Dr. Stratton, who observed the disease among the Forth American Indians, found that it was most common among children and females, and that when it first appeared it was quite fatal. lie did not consider it identical with syphilis, in this respect differing from Swediaur, Lancereaux, and Berkeley Hill. 1 Lancereaux, op. cit., p. 41. 3 Craigie, op. cit., p. 725. 6 Lancereaux, op. cit., p. 38. * Ibid. 8 Copland, Diet, of Pract. Med., vol. iv. p. 133&- 4 Copland, op. cit., p. 1339. s Ibid. 8 Treatise on Syphilis, p. 451. VENEREAL DISEASES IN THE LOWER ANIMALS. 491 The treatment employed consisted in the use of sarsaparilla and a decoc- tion of the hemlock spruce. Disease of Chavanne Lure.—This is described by Lancereaux as a disease beginning with weakness, and followed by nocturnal pains in the joints of greater or less severity; the mouth and throat were affected, and a pustular eruption appeared on the whole surface of the body, especially marked on the head. The use in common of eating and drinking utensils was the chief means of propagation. Lancereaux regards this affection, as he does all the others which have been mentioned, as actually identical with syphilis. Venereal Diseases in the Lower Animals. The question of the susceptibility of the lower animals to venereal diseases has for a long time claimed the attention of syphilographers, and numerous experiments have been made, by inoculating animals with the discharges arising from venereal sores in man, to prove or disprove their susceptibility to this class of diseases. Hunter,1 Ricord, Cullerier, and others experimented upon the lower ani- mals by inoculating the discharge from the true chancre, with negative results as far as the production of constitutional syphilis was concerned, although a sore resembling the chancroid could be produced. On the other hand, He Weltz,2 Auzias Turenne, and others, are said to have produced, by inoculation, sores which resembled the true chancre. M. Langlebert3 states that he saw on the arm of M. de Weltz a well-marked chancre which had been inoculated by M. Ricord himself, who took the pus from a chancre on a monkey; but as at this time the distinction between the chancre and chan- croid was not clearly drawn, and as no mention is made of the develop- ment of constitutional symptoms, little weight can be attached to this obser- vation. Recent investigations tend to confirm the observations of Hunter and Ricord, that the chancroid can be reproduced in the lower animals, while the inoculation of the discharge from the true chancre is only followed by an ulcer, local in its character, and unattended with symptoms of constitutional syphilis. Jullien,4 in speaking of the experiments of Auzias Turenne, says that they relate to the contagion of the chancroid, and that the symptoms following his inoculations were only visible to himself; and that, on the other hand, there have been too many negative results recorded by Ricord, Diday, Langlebert, Horand, and Puech—which contradict Auzias Turenne’s obser- vations—to allow us to give them the slightest credence. In regard to inocu- lations upon dogs, Jullien adduces the experiments of Velpeau, Bretonneau, Horand, and Puech, and the conclusions of Bouley, as showing that the lesions produced upon these animals are not different from the ulcerations so frequently noticed on the ears of certain hunting dogs. The same observer, in speaking of a disease which exists among horses, and which is called the disease of coitus, and will be presently referred to again under the name of “La Dourine,” says that though this malady, which is possibly venereal, and of which the oontagious character seems 1 Vidal, Treatise on Venereal Disease (transl. by Blackman), p. 36. 2 Ibid., p. 37. 3 Ibid., p. 37. 4 Traite Pratique des Maladies Vendriennes, p. 547. 492 VENEREAL DISEASES IN THE LOWER ANIMALS. scarcel}7 disputable, has some singular affinities with syphilis, yet neverthe- less, scientifically, we are not in a position to say that it is syphilis. This disease was observed by Ammon in 1796, in the North of Persia, and has since spread to Europe and Africa; it is characterized by ulcers on the genitals, followed by eruptions on the skin, various nervous symptoms, pa- ralysis, and slow death. Ballardini described the affection in 1849 as syphilis of horses. Carenzi, of Turin, in 1874, made experiments to determine the suscepti- bility of animals of the bovine species to the inoculation of syphilis, but un- fortunately the case on which he based his most positive conclusions has been interpreted in a diametrically opposite sense by Prof. Gamberini, of Bologna. The experiment was made upon a heifer which was inoculated with the pus from a patient suffering from multiple venereal ulcers; at certain intervals after the inoculation there appeared eruptions, induration of the mammary glands, loss of hair, and constitutional disturbance; at the end of 229 days all the symptoms had disappeared, and the general health of the animal was re-established. On the 131st day, Dr. Giacomini inoculated a young girl with the detritus of the heifer’s first set of papules, and this operation was at the end of a week followed by the appearance of small distinct papules of a copper color, identical with those on the animal. According to Gamberini, the patient who furnished the pus for the first inoculation was suffering from chancroids, and the heifer did not present the symptoms of constitu- tional syphilis, the loss of hair being a common occurrence among ruminants during the month of March; the patient also who was inoculated from the heifer was only under observation for eight days, a circumstance which renders' the observation valueless as regards the symptoms which she pre- sented. Jullien also gives the results of inoculation in several other species of animals, all being negative as regards the production of syphilis; and concludes with the observation “that up to the present time syphilis remains entirely pecu- liar to the human race.” The conclusion of Belhomme and Martin1 is to the same effect: that the syphilitic virus is not transmitted to animals, and that its inoculation is always followed by negative results; and that, on the other hand, the pus of the simple chancre (chancroid) can be transmitted to animals, giving rise to an ulcer the discharge from which, when reinoculated on man, gives rise to a simple chancre or chancroid. The more recent investigations of Dr. Rabatel,2 of Lyons, in which animals were inoculated with gonorrhoeal pus, with chancroidal pus, and with the material of the chancre, the operation being in each case followed by a nega- tive result, confirm the observations of previous investigators as regards the immunity of the lower animals from syphilis, but differ materially as to the results obtained by the inoculation of the matter of gonorrhoea and chancroid. The experiments of most value performed by this investigator were those made by introducing sections of recently removed chancres under the skin of a bitch, and by the injection of defibrinated blood of a man suffering from well-marked secondary syphilis, into the jugular vein of a dog. Neither of these animals exhibited any symptoms of constitutional syphilis, and addi- tional evidence of their immunity from this disease is presented in the fact that, as a result of their intercourse, the former gave birth to a litter of tw«ive healthy pups. 1 Traite de la Syphilis et des Maladies Vdneriennes, p. 85. 8 Lyon Medical, Juin 8, 1882. 493 VENEREAL DISEASES IN THE LOWER ANIMALS. Although, however, the lower animals seem proof against the inoculation of syphilis, they present some forms of venereal disease peculiar to themselves. Williams1 mentions urethritis as an affection seen in stallions and bulls, as a result of frequent coitus, but does not say whether the pus resulting from this affection is capable or not of reproducing itself under favorable condi- tions. Horand and Puech,2 who made observations concerning urethritis in dogs, found that the affection was rare, was characterized by a scanty secretion which issued from the anterior part of the canal, was accompanied by an intense balanitis, and was of short duration. They found that inoculation of the blennorrhagic discharges from man gave rise to urethritis in dogs and to vaginitis in bitches, but that the disease did not present the same series of symp- toms that it does in man. They also observed that the balanitis of dogs was- much intensified by the inoculation of the blennorrhagic muco-pus of man. Ilutrel D’Arboval3 describes a disease occurring in the horse which simu- lates syphilis, and is characterized by an inflammation of the glans penis ex- tending to the sheath, causing the organ to present a tense, shining appearance, and giving rise to phimosis and paraphimosis. Under the name “ La Dourine,” Saint Cyr4 describes a disease communicable by coitus, which has prevailed among the horses of the French army. The disease was first noticed in Tarbes, in 1854, and its reappearance in 1861 was due to the importation of an infected Arabian stallion ; it has existed for a long time in Syria, and is probably the same disease which was described by Ammon (seepage 492). The disease first attacks the reproductive organs, where it presents certain local manifestations; these are followed by numerous erup- tions, and by constitutional symptoms, the most prominent of which is a paralysis of the animal’s hind quarters, sometimes becoming general. The duration of the affection is from a few months to a year ; the termination is generally fatal, the animal dying of exhaustion or hypostatic pneumonia, although recovery may sometimes occur. 1 Practice of Veterinary Surgery, p. 630. 2 Jullien, loc. cit., p. 26. 3 Williams, op. cit. 4 Annales de Dermatologie et de Syphiligraphie, 1876-77, p. 241. INJURIES OF BLOODYESSELS. , BY JOHN A. LIDELL, A.M., M.H., SLATE SURGEON TO BELLEVUE HOSPITAL ; ALSO LATE SURGEON U. S. VOLUNTEERS IN CHARGE OF STANTON U. S. ARMY GENERAL HOSPITAL, INSPECTOR OF THE MEDICAL AND HOSPITAL DEPARTMENT OF THE ARMY OF THE POTOMAC, ETC. Bloodvessels are the musculo-elastic tubes and hollow muscles which receive, contain, and convey the blood in animals, and in man. They are naturally divided into three distinct groups or systems, whereof each is cha- racterized by certain well-known features, namely, the arterial, the venous, and the capillary ; together with a central organ, the heart. In this article, then, we shall have to consider, severally, the traumautic lesions of the arteries, the veins, the capillaries, and the heart, which may chance to require the attention of surgeons. But injuries of these vessels are of no especial mo- ment to surgeons unless they cause, or are liable to cause, (1), hemorrhage; or (2), destructive inflammation of the injured vessel itself; or, (3), gangrene of the parts supplied or nourished by the injured vessel. We shall, there- fore, have to discuss not only the several kinds or modes of injury to which the bloodvessels themselves are exposed, but, likewise, the hemorrhages, the vascular inflammations, and the gangrenes which experience has shown to result from these injuries. Surgical Hemorrhage. Any effusion of blood from the vessels framed to hold it, whether attended with rupture (wound), or occurring without rupture (wound) of their walls, is, in the broad or unrestricted sense of the term, a hemorrhage. How, such effusions of blood may, in respect to origin, be spontaneous, or they may be traumatic. The first belong, for the most part, to the domain of medicine; the latter, exclusively to the domain of surgery. But not all the extravasa- tions of blood which are caused by injuries, and, therefore, are properly called traumatic, should be denominated examples of surgical hemorrhage. For instance, it is hardly worth while to dignify a simple ecchymosis of the skin, or a common “ black-eye,” by styling it surgical hemorrhage, although the discoloration is wholly dependent on the extravasation of blood from vessels ruptured by violence. So, too, with most, perhaps with all traumatic hemorrhages, that are essentially trivial and require no treatment. It seems analogous cases.1 But, before doing even this, he should try the effect of compressing the common iliac artery, on the same side as the wound, with his fingers, firmly, against the last lumbar vertebra or the brim of the pelvis. If in this way the bleeding were controlled, as in most cases it probably would be, as indicated by diminished tension and swelling, with disap- pearance of pulsation in the tumor, he should direct the compression to be continued digitally, or by a suitable tourniquet, or by Esmarch’s elastic bandage, applied in some of the ways already described, until the blood had coagulated in the tumor itself and in the canal of the wounded artery, lie should most earnestly strive to obliterate the wounded artery by compressing the common iliac, or, if that were impracticable, by compressing the adjoin- ing aorta; for he could not ligate the bleeding artery in the external wound ; it would not be justifiable to reach it by opening the belly as in ovariotomy; and the operation of tying the common iliac, on the plan of Hunter, would be far too serious and uncertain of result to be resorted to at the outset. Again, the arteries are sometimes pierced from within the body by sharp fragments of bones that have been broken by the impact of gunshot projec- tiles, as happened in the following instance:— A soldier2 was admitted to hospital September 20, 1864, with a gunshot wound of the right side of his neck, received on the previous day. He was very weak from hemorrhage from the wound and from haemoptysis. Notwithstanding plugging of the wound, etc., the hemorrhage and the haemoptysis continued, and on October 5, death resulted. Necroscopy. A conoidal musket-ball had entered the right inferior triangle of the neck, fracturing obliquely the tirst rib at its middle, and depressing the sternal Fig. 420. Fig. 421. Perforation of the right subclavian artery by a sharp fragment of the adjoining first rib, fractured by gun- shot. (Spec. 3377, sect. 1, A. M. M.) First rib fractured obliquely by gunshot; a fragment perforated the right subclavian artery. (Spec. 3376, sect. 1, A. M. M.) portion thereof into the apex of the right lung ; the other fragment stuck upward with a sharp-pointed end, which perforated the subclavian artery in the second part of its course. The missile emerged from the back above the spine of the scapula. The mediastinum and the right pleural cavity were filled with extravasated blood. The right intercostal spaces bulged outward. The heart was pushed toward the left. The right lung was collapsed. There were marks of periostitis on both portions of the rib. The appearance of the artery, well represented in Fig. 420, indicated that the lacera- tion of its walls had occurred either at the time of impact of the missile, or from some sudden movement of the shoulder, rather than from gradual attrition. The broken rib is drawn half size in the accompanying illustration (Fig. 421). 1 American Journal of tlie Medical Sciences, April, 1881, pp. 366-373. 2 Medical and Surgical History of the War of the Rebellion, First Surgical Volume, p. 521. PUNCTURED WOUNDS OF ARTERIES. 565 But minute missiles discharged by fire-arms, such as bird or squirrel shot, •may themselves infiict on large arteries minute lesions which closely resem- ble, if they are not identical with, punctured wounds. The following example occurred in the practice of Prof. S. 1). Gross:— A strumous lad, aged 14, was wounded in the neck by the accidental discharge of a fowling-piece, loaded with large-sized squirrel-shot, which entered the neck at four or five different points. The casualty was attended with but little hemorrhage, and the symptoms of shock soon passed away. The wounds healed without any application, and everything went well until thirteen days after the accident, when the patient was seized, suddenly and without warning, by a protracted epileptic convulsion, affecting chiefly the left side, and died the following day, without return of consciousness. Autopsy. One shot had perforated the subclavian artery, and had lodged in the first rib. The calibre of the vessel was unimpaired, and the apertures were closed by small clots extending around the exterior of the vessel, upon the removal of which the margins of the wounds appeared as if they had just been inflicted. The artery presented no marks •of inflammation. Another shot had perforated the anterior wall of the right internal jugular vein, and had lodged on the inner surface of the opposite wall, where it had become completely encysted. The vein bore no evidence of inflammation. The opening in the anterior wall was perfectly closed, and there was no external nor internal clot. The lumen of the vein, however, was somewhat diminished by the projecting cyst.1 It is of interest to observe that, in this case, the shot-hole in the great jugu- lar vein was found, after the lapse of fourteen clays, perfectly closed or healed without the aid of blood-clot, and without inflammatory engorgement. This wound had therefore united by the first intention, as usually happens after venesection. The minute apertures in the subclavian artery were closed by small clots extending around the exterior of the vessel, without invading its canal. J. L. Petit long since pointed out that in such cases clots form which fill the apertures in the wall of the artery, and exactly close them, without encroach- ing upon the canal of the artery. He says these clots are shaped like nails, the points of which equal in length the thickness of the arterial wall, while their extremities, which correspond to the moving column of blood, are worn off by the friction they undergo. Their heads, which correspond to the ex- terior part of the artery, are very broad; they contract adhesions with the external surface of the artery and the adjacent cellular tissue. These adhe- sions become stronger, and when they are well cemented the artery is healed, and the clots cannot be displaced by the impulse of the blood which con- tinues to pass through the artery, as before the injury. Exactly such as Petit describes, were the small clots found in the case just related, closing the minute shot-holes or punctures in the subclavian artery. Had the boy lived, it is highly probable that these clots would soon have become fully organized, and thus have effectually sealed the minute punctures with newly formed tissue. Hodgson, also, remarks that when an artery is punctured the hemor- rhage is sometimes arrested by the formation of a thin layer of coagulum over the orifice in the vessel, and that the edges of the wounded artery are subsequently united by an effusion of lymph, in the same manner as wounds in soft parts in general are healed by adhesive inflammation. This mode of reparation, by which the continuity of the tube is preserved, takes place more readily when an artery is wounded longitudinally, as well as to but small extent, than when the wound is transverse or oblique; for in the latter ■cases the retraction of the artery causes the orifice in its wall to assume a ■circular form, in consequence of which the effusion of lymph is greater than 1 American Journal of the Medical Sciences, January, 1867, pp. 41, 42. 566 INJURIES OF BLOODVESSELS. when the edges of the wound are more closely approximated, or placed in contact. It is, then, by the organization of blood-clot and the effusion of coagulable lymph that minute lateral wounds of arteries may become closed without obstructing their canals: and, doubtless, those rare instances on record in which the aorta and other large arteries have been punctured without any permanently bad consequences, were of this character, and were healed in this- manner. It must be admitted, however, that such instances of perfect cure of punc- tured wounds of arteries are quite exceptional and rarely to be expected. And when we consider that most persons who have had an artery pricked, and who have been treated by compression, have also had a false aneurism, we cannot help thinking that their cure lias been only apparent. In this way circumscribed traumatic aneurisms appear after puncturing the brachial artery in venesection, when compression is used ; the patient is thought to be cured, and the surgeon feels safe ; but in three or four months, sometimes later, the clot by which nature has arrested the hemorrhage, becomes detached, or the newly formed tissue by which the aperture was closed, yields to the pressure of the blood, and an aneurismal swelling forms. Causes.—Punctured wounds of arteries may he inflicted with the sharp points of scissors, as happened in a case reported by Deschamps, where the femoral artery was pierced in this way ; with penknife-blades, as in several cases which have been reported; with lancets, in bleeding at the elbow, as has often happened in both ancient and modern times; with pocket- knives, many instances of which accident have been recorded; and, finally, with daggers, swords, bayonets, or any other narrow-bladed weapons. Arte- ries may also be fatally pierced by sharp fragments of bone, and by sewing- needles, when swallowed. Arteries may be punctured by sharp fragments of necrosed bone, as happened some years ago in New York, in a case where the popliteal artery was pierced by the point of a femoral sequestrum, and with a fatal result. Again, punctured wounds of arteries may be caused by fragments of bones that have been broken by the impact of gunshot projec- tiles ; they may also occur in comminuted fractures, simple as well as com- pound, that have been produced by other means. Puncturing of arteries from fragments of broken bone is believed to occur in the leg more fre- quently than in any other region, and this view is supported by Dupuytren’s published cases. Arteries, too, may be punctured by sharpened sticks, or by splinters of wood. Symptoms.—Punctured wounds present nearly the same phenomena as those made by cutting instruments; there is always bleeding, to a greater or less degree; but the pain is frequently much more severe, since the instrument often tears the parts. Hemorrhage takes place when the puncturing instru- ment has met in its course an artery of some size, and pierced or divided it *, in either case, blood escapes externally, when the wounded artery is super- ficial, and the wound itself has been made perpendicularly to the skin ; but when the puncturing instrument has passed very obliquely into the part before reaching the artery, the blood infiltrates into the connective tissue and produces a diffuse traumatic aneurism, unless the escape of blood from the artery be quickly stopped, by compressing the artery itself at the wound, or by compressing the main trunk above, that is, on the cardiac side of the wound, through the soft parts by which it is covered. In the latter case, there may quickly be formed at the aperture in the artery a clot of blood, which prevents further hemorrhage; but if the compression he not properly made, or if it be not sufficiently strong, or if it be not continued long enough to PUNCTURED wounds of arteries. 567 obliterate the injured vessel, the clot soon becomes detached, and the escap- ing blood forms a circumscribed traumatic aneurism. In all cases of diffuse traumatic aneurism, and in many cases of circumscribed traumatic aneurism, there is actually traumatic hemorrhage going on unchecked, but the bleeding is internal and concealed from view instead of being external and exposed to sight. When the aorta is pierced by a sewing-needle or by a sharp fragment of bone that has been swallowed, the discharge of arterial blood from the mouth by vomiting is always a prominent symptom. Consequences.—Punctured wounds involving arteries may be attended with the complications or consecutive phenomena which are common to punctured wounds in general, such as phlogosis, with acute pain and severe irritation, etc. Moreover, they are very fatal. Of the illustrative examples given above, six ended in death and only four in recovery. Of eleven stab- wounds involving the vertebral artery, collected by Kocher, only two termi- nated favorably. Punctured wounds of the femoral and axillary arteries are of not unfrequent occurrence, and often prove fatal. The first bleeding may end in death; or, if it be inadequately treated, it may recur again and again, until it wears out and finally kills the patient by exhaustion. Again, if the blood continue to escape from an artery into the connective tissue while the external wound is closed, in the primary period, there occurs a diffuse trau- matic aneurism, which is only another name for primary arterial hemorrhage taking place internally. If such an inward bleeding occur in the fore part of the neck, the resultant swelling may so compress the larynx and trachea as to cause death by suffocation. If it occur in the loose connective tissue of the armpit or thigh, the extravasated blood may burrow very widely as well as cause great tumefaction, from which there may result a suppurative in- flammation of the infiltrated connective tissue, with putrefactive changes in the effused blood, followed by septicaemia and death. Diffuse traumatic aneurisms are very liable to follow punctured wmunds of arteries, and must be reckoned among the most important of their conse- quences. They will be fully discussed in the section on Traumatic Aneurism. Arterio-venous aneurisms sometimes follow punctured wounds which simul- taneously involve arteries and their contiguous veins. They occur most fre- quently at the bend of the elbow from mistakes in bloodletting; but they have also been met with in the neck, thigh, and other regions. They will be fully discussed in the section on Aneurismal Yarix and Varicose Aneurism. Punctured wounds of arteries, when very minute, and not attended with much primary bleeding, are occasionally followed by severe secondary hemor- rhage, from ulceration of the artery at the place of injury, as happened in three instances (two related by Guthrie and one by Durham) that are men- tioned above, There is also a specimen in our Army Medical Museum which illustrates a similar occurrence. It consists of a popliteal artery, from which secondary hemorrhage took place eleven days after it was punctured by a spiculum of bone. The femur was obliquely fractured by a pistol ball, in its lower third, with slight comminution. The artery did not bleed until its coats sloughed at the place of puncture. The hemorrhage was then arrested by tying the femoral, but traumatic gangrene of the limb supervened, and death occurred three days after the operation.1 Treatment.—The course which is most likely to avert the disastrous conse- quences just enumerated, consists of promptly exposing the wounded artery at the place of injury by suitable incisions, and applying two ligatures to it, ' See Catalogue of the Army Medical Museum, Specimens 4084, 4085. 568 INJURIES OF BLOODVESSELS. one on each side of the bleeding orifice, as recommended by the ancient sur- geons. But before this operation can be performed it is often advisable to restrain the bleeding by compressing the wounded orifice and main trunk of the injured artery, with the fingers, or with a suitable tourniquet, or with Esmarch’s elastic bandage, according to methods which have already been described, whether the blood be escaping through an external wound or infiltrating the connective tissue around the artery. With regard to the employment of compression for punctured wounds of arteries, tlie rule is'to consider it a temporary expedient, since it often procures only transient relief, and leaves the patient exposed to false consecutive aneurism. There are, however, some important exceptions to this rule, which will presently be mentioned. A ligature should be applied on the distal as well as on the proximal side of the aperture, because, unless this be done, the hemorrhage is liable to occur again, as soon as the parts beyond the wound become well supplied with blood through the anastomosing branches or collateral channels. The blood then regurgitates in the distal part of the artery, and is very liable to force its way through the distal orifice, unless the artery is here also closed with a ligature. The artery should moreover be divided midway between the two ligatures, so that both ends can freely retract. Punctured Wounds of Special Arteries.— Vertebral Arteries.—We pass now to the consideration of some points in the treatment of punctured wounds of arteries which are surrounded with great difficulties. No single point, perhaps, is more puzzling than to devise a satisfactory plan of treating wounds of the vertebral artery. Almost all the recorded cases, and their num- ber is not small, have proved fatal. This vessel lies so deep, and the diagnosis of its lesions is so difficult, that in eleven instances of traumatic aneurism involving it, the carotid has been tied through mistake. The explanation is that when the carotid is compressed against the so-called carotid tubercle of Chassaignac, on the transverse process of the sixth cervical vertebra, the ver- tebral artery also is compressed, at its point of entry into the foramen of the transverse process. The deception is not removed by compressing the carotid at a higher point, for the vertebral may pass up the front of the transverse processes. In recent wounds, the best way to ascertain the vessel from which the blood issues, is to insert into the wound a finger, with which the jets of arterial blood may generally be felt, and the relation of the wouyded vessel and of the hemorrhage to the transverse processes of the vertebrae deter- mined. Ligature of the vertebral artery for practical purposes is impossible except in a portion about six centimetres, or two and three-eighths inches, long, between its origin and its entrance into the transverse foramen of the sixth cervical vertebra. In this part of its course it has been successfully tied by Smyth, of New Orleans, for regurgitating hemorrhage; in this part, also, it has been tied, together with the inferior thyroid artery, by Maison- neuve, in order to arrest hemorrhage attending a shot wound of the neck— with success, as far as stopping the hemorrhage and extracting the ball were concerned, though death occurred from infiltration of pus into the spinal canal, and consequent inflammation. But these successes, complete and partial, afford some encouragement. Having determined by exploring the wound with a finger, or by any other means, that the vertebral artery is punctured in this part of its course, the bleeding point should at once be laid bare, and a ligature should be put round the artery on each side of the aperture. But when the exploration shows that the artery is wounded above the point where it enters the foramen of the transverse process of the sixth cervical vertebra, how can we suppress the bleeding and save the patient? We can- not tie the artery in the wound; and to tie it in the first part of its course, 569 PUNCTURED WOUNDS OF ARTERIES. on Anel’s plan, would fail, because the two vertebrals unite to form the basilar artery at the base of the brain, and therefore regurgitating hemorrhage would occur in the wound whenever the direct hemorrhage might be stopped in this way. Distal ligature of this artery, between the occipital bone and the atlas, as suggested by Dietrich, would be both difficult in performance and uncertain in result. There remains, then, only the operation of plugging the wounded artery, a measure which has been successfully employed in one case by Dr. Ivocher, of Bern. On dilating the wound in the neck by suitable incisions both longitudinal and trans- verse, and removing the coagula, the blood was seen to come from a point between the transverse processes of two vertebrae, apparently the fifth and sixth. Arterial blood escaped from both the central and the peripheral portions of the artery; and the bleeding was arrested by pressure against the transverse processes, either from above ■or from below. As a ligature could not be applied, a plug of charpie of the size of a pea, soaked in solution of perchloride of iron, was introduced between the transverse processes, and left there, as soon as it had been ascertained that the bleeding was sup- pressed. The external wound having been closed by sutures, was covered with charpie dipped in carbolized glycerine, Lister’s carbolic-acid paste was applied, and the dressing was retained in place by a bandage. The head was kept fixed by a stiff collar. The plug in the deep part of the wound was removed on the fourth day after the operation, partly by means of a stream of water, partly by forceps; no bleeding followed. Ex- cepting a slight attack of erysipelas, the patient progressed steadily toward recovery, and was discharged cured a little more than five weeks after the operation.1 But in order to secure the success of this operation of plugging the verte- bral artery, it is essential that the bleeding point in the vessel shall be exposed to view, that the plug shall be placed exactly in the open canal of the vessel, which it must completely till, and that the patient’s head shall be held fixed, and the neck immovable, by a stiff collar. False consecutive aneurisms of the vertebral artery are not unfrequently met with; they will be discussed in the section devoted to the subject of Traumatic Aneurism. Carotid Artery.—Punctured wounds involving the common carotid artery, or its branches, are often met with, owing to the exposed situation of the parts supplied with blood by the carotid system of vessels; and, from the comparative ease of performing the operation, ligation of the common trunk for suppressing hemorrhage from these wounds, has probably been resorted to much more frequently than has been desirable. In instances too numer- ous to mention, the common carotid artery has been tied for lesions of its branches, without success, when the result would have been quite different had the wounded artery itself been properly secured. It is therefore im- perative, when branches of the externcd carotid, for instance, are opened by wounds, that they should be tied at their wounded part with ligatures placed on each side; and, in cases where the performance of this operation, as well as ligation of the trunk of the wounded vessel itself, is impracticable, it is equally imperative that the external carotid should be tied, and not the parent trunk of all. In two instances, Stephen Smith ligatured the external and internal carotid arteries, just above the bifurcation of the common carotid, for hemorrhage from various points of the face and neck, and into the mouth and fauces ; in one case it was for cancer, and in the other for gunshot injury, lie thought thus to avoid renewal of the bleeding better than by ligature of the common trunk. In neither case was there any return of the bleeding, the ligatures separated well, and the patients recovered.2 Again, in cases of hemorrhage from branches of the external carotid, such as the lingual, inter- 1 Sydenham Society’s Biennial Retrospect, 1871-2, p. 203. 2 American Journal of the Medical Sciences, April, 1874. 570 INJURIES OF BLOODVESSELS. nal maxillary, etc., when ligation of the corresponding external carotid fails to stop the bleeding, the external carotid on the opposite side should also bo tied, and not the common trunk; for ligature on both sides of the external carotid artery has hitherto, I believe, been uniformly successful in subduing such hemorrhages. In wounds involving the trunk of the common carotid, or that of the internal carotid, or that of the external carotid, the hemorrhage should be stayed, if possible, by digital compression applied in the wound or to the trunk of the common carotid, in the ways already pointed out, until a surgeon can be brought, and ligatures placed on each side of the orifice in the wounded vessel. Moreover, the application of distal ligatures is especially necessary in wounds of the carotids, as well as in those of the vertebrals, because- of the remarkably free intercommunication which exists at their terminal extremities, through the circle of Willis. In connection with the treatment of hemorrhage from a lesion of the internal carotid artery, read the successful case of the miller quoted on page 562. Occipital, Temporal, and Facial Arteries.—When the occipital artery, or the temporal, or the facial, or any other accessible branch of the external carotid is opened by a punctured wound, we repeat, the bleeding must be restrained by firmly compressing the primitive carotid artery against the transverse processes of the Vertebrae (Fig. 346, p. 518); the injured part of the artery must be laid bare by incisions, and the bleeding orifice must be distinctly brought into view; a ligature must be applied on each side of the orifice, and the artery itself must be completely divided midway between the two ligatures, to allow the ends to retract. But if the injured part of the artery cannot be thus exposed and ligated, a ligature should be applied to the in- jured artery on the cardiac side of the wound, as near to it as practicable* If this cannot be done, the external carotid artery should be tied, but not the common carotid. Should the hemorrhage still continue, the external carotid artery of the opposite side should also be tied; this procedure is said never to fail, as already stated above. Axillary Artery.—Punctured wounds which open the axillary artery are also very liable to be quickly followed by death from hemorrhage; and the internal or subtegumentary bleeding may be, and often has been, but little less deadly than the outward bleeding. Here, too, for saving the patient, our chief reliance must be placed on adequate compression, promptly applied, either with fingers in the wound, directly on the aperture in the vessel, or with both thumbs upon the subclavian artery as it passes over the first rib, or with a large door-key, or the thumb-piece of a Petit’s tourniquet, suitably covered by bandaging, in order to restrain the escape of blood from the artery, internally or liiddenly as well as externally or openly, until surgical aid can be obtained, and until the vessel can be tied where it is wounded. But, in most cases, to be successful, the pressure must be applied intelligently, ener- getically, and steadily, as well as promptly, and with a strong desire to prevent the formation of a sanguineous tumor in the loose connective tissue- of this region, as well as to restrain the outward flow of blood. The forma- tion of a large, diffuse, traumatic aneurism in this region, is to be deprecated almost as much as an unobstructed external hemorrhage. Brachial Artery.—Punctured wounds which involve the brachial artery should always be treated on the orthodox plan of ligating it above and below the wound as soon as possible, the hemorrhage meanwhile being restrained by compression, which, in this region, can readily be applied. Old soldiers have not unfrequently done it well for comrades with tourniquets extemporized from handkerchiefs. On laying the bleeding point in the artery bare for the purpose of securing it with ligatures, a stream of blood is PUNCTURED WOUNDS OP ARTERIES. 571 sometimes distinctly seen by the surgeon, issuing from the distal orifice after the proximal ligature has been tied (regurgitating hemorrhage)* which already shows the necessity of applying distal as well as proximal ligatures in these wounds. A soldier, aged 23, was accidentally wounded August 18, 1864, by a bayonet-thrust at the bend of the elbow, cutting the brachial artery. The vessel was tied on each side of the wound, and the man recovered. All the patients treated in this way did well. Not so, however, with some who were treated on other plans ; for Dr. Otis, the surgical historiographer of the war, says: “ There were one or two cases in which the reports convey inti- mations that stabs in the arm, implicating the brachial artery, proved fatal from malpractice—compression and styptics having been resorted to instead of ligation.”1 The following example, in which the brachial, artery was punctured in the bend of the elbow with a penknife, will usefully illustrate what the treatment must be in order to prove successful: A good deal of blood was lost at the time, pouring out in a stream, not in jets, for the wound was an indirect one, the knife having entered obliquely. The- patient was taken home, and the wound was strapped and bandaged ; this arrested the hemorrhage temporarily. But the bleeding recurred several times, until finally the original wound was enlarged by incisions, the coagula were turned out, a traumatic aneurism that was forming was laid open, and ligatures were passed around the artery above and below the wound. Recovery followed without any difficulty whatever.2 Arteries of the Forearm.—Punctured wounds of the radial, ulnar, and inter- osseous arteries or their branches, and the hemorrhage resulting therefrom, in recent cases where the parts are sound, will give the surgeon but little trouble,, provided he treats them on the orthodox plan of bringing distinctly the bleeding orifice into view, applying a ligature on each side of it, and dividing the artery midway between the two ligatures, so that the ends may retract. But if the surgeon should rely on styptics and compression in such cases, lie will have much trouble which could readily have been avoided by ligating the injured vessels at the outset, above and below their wounds.3 Palmar Arch.—Punctured wounds of the palmar arch always excite appre- hension, and give much trouble to the surgeon. Considerable differences exist among the.plans of treatment recommended by eminent surgeons for this form of injury. Bryant points out that “extreme flexion of the forearm, upon the arm, with forced supination of the hand, with or without a pad at the bend of the arm,” arrests completely the circulation through the brachial artery; and that “ under all circumstances, whether for injury or disease of the arteries of the hand and forearm, in which surgical interference is requisite,, it would be well to remember this treatment, it being most effective.”4 Many favor compression. The readiness with which it can be applied to the hand predisposes strongly to its use. This mode of treatment, however, is not a. good one—is not to be commended, for it very often fails. Every surgeon has seen examples of such a failure. The medical journals contain reports of many cases in which compression proved to be insufficient to control the hemorrhage from punctured or incised wounds of the palm, and ligation of the radial and ulnar arteries, and of the brachial artery, as well "as other- operative procedures, were resorted to in order to remedy this insufficiency. Compression is but ill adapted to restrain hemorrhage from wounds involving the palmar arches, because of the wonderful flexibility of the hand itself, and 1 Medical and Surgical History of the War of the Rebellion, Second Surgical Volume, p. 437. 2 British Medical Journal, May 29, 1869, p. 492; see also the section on Incised Wounds of the Brachial Artery. 3 See also under Incised Wounds. 4 Manual for the Practice of Surgery, p. 350, second Am. ed. 572 INJURIES OF BLOODVESSELS. the great freedom of communication which exists among the terminal branches of the arteries in the hand through the medium of large inosculations. Some of the conditions most essential to success with compression, are quite want- ing in the hand and wrist. Moreover, it is the treatment by compression that has furnished those instances, by no means rare, in which the patient has become pale and weak, or exhausted, from frequently recurring hemorrhages from wounds of the palm, and in which the wounded part itself has become infiltrated and boggy, and too much swollen and discolored to permit the injured artery to be laid bare and securely tied in the wound, without a great deal of difficulty. Wounds of the palmar arch or of its branches form no exception to the general law that wounded arteries must be secured by ligatures applied on each side of the lesion, and that in case the artery is not severed by the acci- dent, it must be divided by the surgeon midway between the two ligatures, so that retraction of the ends may take place. In all cases of surgical hemor- rhage from wounds of the palm, the wound itself must be explored at the outset, and the source of the bleeding at once ascertained. While doing this it must be considered that between the palmar arches and the radial, ulnar, and interosseous arteries, a free intercommunication of branches exists, which branches are singularly uniform in their size; and that, in consequence, the distal part of the injured vessel may be almost as much inclined to bleed as the proximal. When the opening in the skin or the aponeurosis is not large ■enough to allow free access to the bleeding orifice, it must be enlarged to the required extent. In making incisions for this purpose, all thrusts with the bistoury must be avoided. The surgeon must understand and call to mind the arrangement and distribution of the vessels, and with such a knowledge he may proceed with entire confidence to lay bare the deep part of the hand. The skin must first he divided, and next the superficial fascia, when the palmar aponeurosis will be brought into view, and can readily be recog- nized by its white, tendinous appearance. The important vessels all lie beneath this structure. To open this dense membrane with safety, a slight perforation should be made through its substance, and a grooved director introduced, by means of which this aponeurosis can be raised up from the bloodvessels and nerves underneath, and its division successfully accomplished, thus giving an exposure of the parts sufficiently large for bringing into view and for successfully tying any vessel that may be wounded therein, according to the precept stated above. Dr. Ogston, in a difficult case, where the deep palmar arch was punctured by a knife-blade, succeeded in exposing the aperture in the artery to view by detaching the origin of the abductor indicis from the metacarpal bone of the index finger—that is, from the outer side of that bone. Then the artery was readily tied above and below the lesion. The patient made a good recovery.1 Esmarch’s apparatus for elastic com- pression was applied to the limb in this case, so that the operation was com- pleted without loss of blood; and, in similar cases, it is generally advisable to prevent hemorrhage by the same method. After ligating the palmar arch or its branches, and especially when the tissues are infiltrated and boggy or unsound, the force of the circulation in the hand should be lessened by keeping it in an elevated position, and by applying pressure to the radial and ulnar arteries by means of oblong com- presses (rig. 351, p. 521) placed on the forearm, and secured by a roller, be- ginning at the hand, and extending up to the elbow. IIow should the neglected cases of wounds involving the palmar arch—- those in which anaemic exhaustion from frequently recurring hemorrhages 1 British Medical Journal, January 24, 1876, p. 782. PUNCTURED WOUNDS OF ARTERIES. 573 has ensued, and the tissues in the wounded palm are infiltrated and boggy, swollen, and discolored—how should such cases be treated ? For them also' the plan of treatment should be the same. The wound must be explored; the injured artery must be brought into view, and secured with ligatures in the wound. My own views coincide with those of Mr. C. I). Arnott, when he says: “The principle I wish to inculcate is that, under no circumstances, in hemorrhage from the palm, is deligation of the arterial trunks on the cardiac aspect to be deemed necessary or attempted. I am aware that this- will at present- hardly find general favor. I am, however, certain of my fact, and therefore state it boldly.”1 Femoral Artery and Branches.—Punctured wounds of the thigh which open the common trunk of the femoral artery, or the superficial femoral, or the profunda femoris, however slight the puncturing of the artery may be,, are very dangerous, and sometimes they are also very difficult to treat. A great many patients have been destroyed by these wounds. The main point in the treatment, however, is to restrain the primary hemorrhage, internally or at the orifice of the wound in the artery, as well as externally or at the orifice of the wound in the skin, without any delay, and without any tem- porizing with useless expedients. The formation of a diffuse aneurism in the femoral region is to be deprecated about as much as in the axillary re- gion. In treating punctured wounds of the femoral artery, the bleeding should be restrained, both internally and externally, by exploring the wound with a finger, and placing the end of it upon the aperture in the artery ; or by applying the elastic compression of Esmarch to the limb both above and below the wound; or by applying tourniquets or handkerchiefs tightly round the thigh above and below the wound, and thus controlling the circulation until the bleeding aperture in the artery can be laid bare by enlarging the wound, and until a ligature of carbolized catgut can be placed on each side of the aperture, and the artery itself be completely divided midway between the two ligatures to allow the ends to retract. Compression, although it is indispensable in such cases, must be looked on as a temporary expedient; as merely a very efficient means of preventing such a loss of blood as would prove fatal, or of keeping the patient, in a salvable condition until the wounded artery can be properly secured by ligatures. The following case shows in a most excellent manner how punctured wounds of the femoral artery can be successfully managed:— The subject was a young man, who, while mending a pen, accidentally let the knife penetrate his thigh at the middle. Free hemorrhage followed, which, however, was temporarily controlled by a handkerchief tied tightly round the limb. Mr. Maunder, on arriving, proceeded to search for the wounded vessel. He passed a finger readily into the wound to the depth of two inches, and felt the hole in a vessel which proved to be the superficial femoral artery. The finger being retained on this hole, the wound was enlarged upward and downward until the aperture in the artery was distinctly seen, and then a ligature was applied both above and below it. Venous-looking blood was observed to flow from the distal part of the artery. No discomfort attended the ligatures, which came away on the twelfth and thirteenth days respectively. The man made an excellent recovery.2 Here is another case in point: Mr. Messiter showed a patient who, in consequence of a punctured wound of the femoral artery, had acquired a diffuse traumatic aneurism. Mr. Houghton, three weeks after the accident, cut down upon the artery, and tied it above and below the wound. The patient made a good recovery.3 1 Lancet, vol. ii., 1855, p. 141. See also observations on Incised Wounds of the Palmar Arches. 2 British Medical Journal, November 23, 1867, p. 474. 3 Ibid., March 2, 1878, p. 302. See also section on Incised Wounds of the Femoral Artery. 574 INJURIES OF BLOODVESSELS. In punctured and in incised wounds of the thigh where apparently the femoral artery is involved, it may be found on enlarging the wound that a large branch is pierced or cut, and not the femoral artery itself. In the fol- lowing example, the internal circumflex branch of the profunda femoris was the seat of the lesion:— Private John Davis, Co. C, 41st Infantry, aged 22, received on March 13, 1869, at Fort Clark, Texas, a punctured wound of the thigh. He was admitted to the post hospital, where the wound was enlarged, and the internal circumflex artery was ligated, under ether. Five days later, the ligature was removed, and the wound was filling with healthy granulations. On May 12, he was returned to duty.1 In this case the injured artery was tied without delay in the wound ; the patient rapidly and completely recovered. But had a policy of delay been adopted, or had styptics and compression been employed to control the bleed- ing, a diffuse aneurism would have ensued among the deep muscles on the inner side of the thigh, and the consequences would Iiave been extremely disastrous. Popliteal Artery.—Punctured wounds of the popliteal artery have been caused by the sharp ends of sequestra, by the sharp points of fracture splinters, by sharp slivers of wood, and by the points of bayonets, dirks, and other like weapons. These wounds have been treated by tying the artery above and below the aperture, according to the method of the ancient surgeons, by tying the femoral artery on the plan of Hunter, and by cutting off the leg. bio one of these procedures will suit all cases. When gangrene is pre- sent or imminent, and, by the way, gangrene frequently ensues after this lesion, amputation performed without any delay is our sole resource. For hemorrhage, whether primary or secondary, the artery must be tied above and below in the wound. In some cases of traumatic aneurism resulting from a punctured wound of the popliteal artery, wThere there is a tolerably well-defined sac, it may be advisable to ligate the femoral artery on Hunter’s plan, as being less likely to be followed by gangrene than the “old operation.” Each case, however, must be critically examined, and that procedure must be applied to it which appears most likely to save the patient’s life.2 Tibial Arteries.—Punctured wounds of the posterior tibial artery are occa- sionally met with; an example of this lesion was reported during the Cri- mean war, occurring in the person of a color sergeant belonging to the 18th regiment, who had been accidentally struck in the leg by the bayonet of one of the men, and whose posterior tibial artery was wounded. The case, however, presented no peculiarities. The wound was enlarged, the bleeding aperture in the artery wTas brought distinctly into view, and a ligature was applied on each side of it. The man recovered.3 In such cases the artery should also be divided midway between the two ligatures. In many cases where the poste- rior tibial or the anterior tibial artery is punctured, the performance of the old operation for ligating the injured artery in the wound, can be facilitated by applying the elastic compression of Esmarch to the leg above and below the wound in such a way as to effectually control the circulation.4 , Plantar Arch.—Hemorrhage from punctured wounds of the plantar arch must be treated on the same plan as hemorrhage from punctured wounds of the palmar arch, which have just been fully discussed. 1 Circular No. 3, War Department, S. G. O., August 17th, 1871, p. 242. 2 See also Incised Wounds of the Popliteal Artery. 8 Surgical History of the British Army in the Crimean War, etc., vol. ii. p. 366. 4 See observations on Incised Wounds of the Tibial Arteries, and of the Arteries of the Foot -and Leg. 575 PUNCTURED WOUNDS OF ARTERIES. Gluteal and Sciatic Arteries.—Punctured wounds of the gluteal region often prove very troublesome and unsatisfactory in their management, because they pierce the gluteal or ischiatic arteries far down beneath the gl uteal muscles, or penetrate the cavity of the pelvis through its notches or foramina, and open the internal iliac artery itself, or one or more of its four or five important branches, within the pelvis. In such cases the surgical diagnosis is always difficult, and often impossible. In such cases, whenever practicable, the wound should be explored by introducing a finger into it for the purpose of locating by the sense of touch the precise point whence the blood issues by jets into the wound. If the punctured artery is found to be external to the pel- vis, the bleeding point in it should be laid bare by enlarging and cleansing the wound, and the vessel should be secured by ligatures placed on each side of the aperture. But if it be shown by the occurrence of intra-pelvic extrava- sation of blood, or by other signs, that the internal iliac artery, or some branch thereof, is wounded within the pelvis, it will be impossible to reach and tie the punctured artery in the wound. Under these circumstances, it sometimes becomes very difficult to decide what plan of treatment should be adopted. One thing, however, ought never to be done: the solution of the perchloride or the persulphate of iron must never be injected into the track of the wound through the gluteal muscles, in order to restrain the bleeding in such cases, because the internal bleeding from the wounded internal iliac artery or branch thereof cannot be restrained thereby, and the presence of these salts of iron in wounds generally does much harm. Under these cir- cumstances, the first thing to be tried, in most cases, is compression. It should be applied to the common iliac artery, and, at the same time, to the wound itself, if possible, with a view to obtain coagulation of the blood in, and obliteration of, the wounded artery. The very desperateness of these cases makes it all the more necessary to use the compression faithfully, intelligently, and persistently ; otherwise, a traumatic aneurism will form. If we are suc- cessful in applying pressure to the common iliac artery, for arresting hemor- rhage from the internal iliac artery or its branches, there quickly forms at the mouth of the wounded artery a clot of blood which prevents further hemor- rhage ; but if the compression be not properly applied, if it be not sufficiently strong, or not continued long enough to obliterate the vessel, the clot quickly becomes detached, and forms a so-called false consecutive aneurism. The accompanying wood-cut (Fig. 422) shows the arteries of the pelvis, together with the internal epigastric and circumflex iliac, in situ. I cannot better show the extremely grave importance and very difficult nature of these injuries than by relating a few cases that occurred during the late war :— ' A soldier, aged 24, was wounded in the right buttock, May 9, 1864. He did well, apparently, until June 27, when hemorrhage of an alarming character occurred, and twenty-five ounces of blood were lost. It was checked outwardly by compression, but he sank, and, on the 29th, he died. The necroscopy revealed an immense accumula- tion of blood under the gluteus maximus, and the sac of what had been an immense traumatic aneurism, following a wound of the ischiatic artery. Seven additional in- stances in which this artery was wounded, were reported during the war, all of which proved fatal.1 Two cases were treated by tying the artery itself, apparently with single proximal ligatures, one case by tying the internal iliac, one case by tying the common iliac, and one case by applying the actual cautery; but all in vain. Internal Pudie Artery.—A soldier, aged 27, received a bayonet wound of the left pelvis, April 25,1862. 1 Medical and Surgical History, etc., Second Surgical Yol. pp. 326, 332, 333. 576 INJURIES OF BLOODVESSELS. He suffered extreme pain in the left thigh and leg, which swelled largely, and he died on June 27. Necroscopy. The point of the bayonet entered the upper part of the left thigh, and passed through the sciatic notch, injuring the sciatic nerve, and wounding the internal pudic artery, whence a false aneurism formed, which became diffused through Fig. 422 The arteries of the pelvis. the whole pelvic cavity, forcing the rectum aside, displacing the sigmoid flexure of the colon, and rendering defecation difficult and painful. The aneurismal cavity held about three quarts of blood.1 The swelling of the thigh and leg resulted from the pressure on the iliac veins that was exerted by the aneurismal swelling. Four exam- ples of shot-wounds involving this artery were also reported.2 The outward bleedings were arrested by plugging the wounds with liquor ferri persulph., and applying com- presses with bandages, but they all terminated fatally. llio-Lumbar Artery.—A soldier, aged 20, received a shot-wound of the right ilium, February 14, 1862. Hemorrhage from the ilio-lumbar artery occurred on March 4, to the amount of thirty ounces, and recurred, at intervals, until the 24th, when death supervened.8 An- other fatal case of bleeding from this vessel is reported.4 There were several large hemorrhages. Gluteal Artery.—Illustrations of fatal bleeding from wounds of this artery were unhappily numerous during our late civil war. Thirteen cases were treated by applying compresses and bandages to the wounded part; and only two of them were saved.5 When the gluteal, the iscliiatie, or the internal pudic arteries are wounded exterior to the pelvis, the surgeon must, at all hazards, perform the difficult operation of tying them, on each side of the 1 Ibid., p. 323. 4 Ibid., p. 36. 2 Ibid., pp. 304, 324. 8 Ibid., pp. 327, 328. 3 Ibid, , p. 322. PUNCTURED WOUNDS OF ARTERIES. 577 bleeding aperture in their walls. In the following instance the gluteal artery was ligated in the wound with success:— Colonel A. J. Warner received, September 17, 1862, a shot-wound of the right hnttock; the missile penetrated deeply and lodged. On February 6, 1863, an ope- ration for its extraction was successfully performed. During the manipulations, how- ever, the gluteal artery was punctured ; the hemorrhage immediately became very severe and apparently uncontrollable. “ Thrusting my finger to the bottom of the wound,” says Dr. J. H. Brinton, “ I could readily feel the impulse of the jets of blood. I then requested an assistant to plug the wound with the end of a dry towel. This was done ; at the expiration of a few seconds I quickly removed the plug, and while so doing was so fortunate as to see the gaping orifice of the main trunk of the gluteal artery, as that vessel emerged through the great sacro-sciatic foramen. I immediately compressed the trunk with the end of my index finger against the upper bony rim of the notch, thus arresting the hemorrhage instantly and completely. The seizure of the vessel with an artery-forceps and its ligation was then an easy matter. No further hemorrhage, to any extent, occurred ; the ligatures separated in due time, and the patient made a happy recovery.”1 But in the cases where ligation of these arteries cannot he performed, well- adjusted compression must be faithfully applied to the trunk of the common iliac artery, and to the wounded vessel itself; and of these two modes of compression, the former is quite as important as the latter. Figs. 423 and 424 represent tourniquets for compressing the common iliac artery and the abdominal aorta. Internal Epigastric and Circumflex Iliac Arteries.—These vessels, also, are presented to view in Fig. 422, although it was specially designed for showing Fig. 423. Erichsen’s artery compressor. the arteries of the pelvis. The deep epigastric and circumflex iliac arteries may be opened by simple flesh-wounds of the abdomen, as well as by those which penetrate its cavity, and thus hemorrhages may arise which will prove 1 Ibid., p. 329. 578 INJURIES OF BLOODVESSELS, fatal, unless these arteries are seasonably and properly secured with ligatures. During our late civil war, five patients having wounds of the abdominal walls which did not open the abdominal cav- ity, were destroyed by the hemorrhages which occurred and recurred, in spite of the application of styptics and com- presses, until exhaustion and death from loss of blood closed the scene.1 In four additional cases where the circumflex iliac artery was opened by shot-wounds, the hemorrhages proved fatal, in spite, too, of the application of styptics and compresses.2 In still another case of hemorrhage from a wound of the abdo- minal wall, where styptics (Monsel’s salt) had been applied again and again with- out permanently arresting the bleeding, the external iliac artery was tied, but without success.3 These examples most emphatically teach that wounds of the internal epigastric, circumflex iliac, and lumbar arteries should not be re- garded as trivial; but as demanding the rigorous application of the rules for arresting hemorrhage from all wounded arteries of magnitude, viz., exposure of the bleeding aperture to view, and ligation of the artery on each side of it. Moreover, the application of distal ligatures is all the more necessary in these cases, because the terminal branches of the internal epigastric artery are directly continuous with those of the internal mammary, and the terminal branches of the circumflex iliac are directly continuous with those of the ilio- lumbar artery, as is shown in the accompanying wood-cut (Fig. 425); and, therefore, when proximal ligatures only are put on these arteries, when wounded, there still remains a great liability to the recurrence of hemorrhage from the regurgitation of blood through the distal part of the vessel into the wound, as soon as the blood-pressure is raised high enough by general reaction to expel the coagulum from the distal orifice in the artery. Boyer speaks forcibly of the importance of ligation for hemorrhage from these wounds, and gives particulars of an instructive case of wound of the internal epigastric artery, that proved fatal, in which this measure had been neglected. Guthrie several times saw this artery tied with success. In the ease of a Portuguese soldier stabbed in the belly with a sabre, there was profuse hemorrhage from a small wound made by the point of the weapon. This wound Guthrie enlarged until the wounded but undivided artery became visible; upon this two ligatures were placed, and the external wound was sewed up. The man recovered.4 In lesions of the abdominal walls, then, when the hemorrhage is severe, and the wound not large enough to allow the bleeding point in the artery to be seen, the surgeon must enlarge the wound until the punctured artery can be seen, and can be secured. We need not fear the hemorrhage as long as such a wound is open and we can place a finger on the bleeding point. But when the surgeon trusts to external pressure, and closes such a wound without securing the punctured artery Fig. 424. Skey’s artery compressor. 1 Medical and Surgical History, etc., Second Surg. Vol., pp. 9, 10 2 Ibid., p. 324. s Ibid., p. 10. 4 Commentaries, etc., p. 510, Am. ed. PUNCTURED WOUNDS OF ARTERIES, 579 itself, then there is abundant cause for anxiety. If these principles be important in hemorrhages of an ordinary character, they are much more important still when applied to the treatment of hemorrhages from the hypogastric, inguinal, and iliac regions. Legouest has twice had occasion to apply ligatures for profuse hemorrhage from flesh-wounds of the abdomen; once to the epi- gastric, and once to the circumflex iliac artery. Sometimes these vessels, when divided, retract greatly; it then becomes necessary to enlarge the wound considerably, in order to find and tie the bleeding mouths. This is especially apt to happen when the internal epigastric is severed near where it enters the sheath of the rectus. Sometimes, in punctured wounds of the abdom- inal parietes involving these arteries, the hem- orrhage is inter-mural, the blood either escaping into the connective tissue and forming a sangui- nolent tumor; or, burrowing between the great muscular and aponeurotic planes, the extrava- sation becoming widely spread and forming a tiattened swelling. . In both instances, the wound must be enlarged until the bleeding orifice can be seen and the artery properly tied. When from such extravasations sanguinolent abscesses result, they should be opened by timely incisions, lest there occur inflammation of the contiguous peri- toneum, or purulent infiltration of the muscular bundles; the pus, if the operation be delayed, may become widely disseminated. When these arteries are opened by wounds which penetrate the abdominal cavity, and the apertures in the integuments are closed without first securing the wounded vessels, the blood may flow inwardly and collect in great quantity in that cavity; this concealed hemorrhage may be so abundant as to prove fatal. Internal Mammary Artery.—In mere flesh-wounds of the chest, as well as those which extend into its cavity, this vessel may be opened. Moreover, this lesion is not trivial and unimportant, as some surgeons have supposed ; for, during our civil war, six cases were reported in which the internal mam- mary artery was opened, and in all of them the hemorrhage was very profuse, and the issue fatal. Wounds involving this artery, therefore, merit serious attention. Anatomically, the internal mammary is a branch of the subcla- vian artery, and the first that proceeds from the inferior aspect thereof; it descends behind the clavicle and the costal cartilages, but in close relation with the cartilages, along the front wall of the chest, but external to the pleura, alongside the margin of the sternum and about half an inch there- from, until the sixth intercostal space is reached; here it divides into the musculo-phrenic and superior epigastric branches, the latter of which enter the sheath of the rectus abdominis, and terminate in or become continuous with the corresponding branches of the internal epigastric artery. The deep mammary arteries (Fig. 425, j) are remarkable for the number of their inoscu- lations and for the distant parts of the arterial system which they serve to connect. They anastomose with each other, and their inosculations, through Fig. 425. Longitudinal plan of the arteries of the trunk. 1, Internal mammary ; 2, Deep epigastric. They are connected to the aorta by a series of intercostal, lumbar, and diaphragmatic arteries. 3, Superficial epigastric ; 4, Circumflex iliac; 5, Ilio-lunibar from internal iliac. The anatomist will notice that it is chiefly the anastomosing branches of the arteries of the wall which are shown. (Struthers, Anat. and Physiol. Obs. Edin. 1854.) 580 INJURIES OF BLOODVESSELS. the intercostal arteries, etc., with the thoracic aorta, encircle the thorax. On the walls of the chest, their branches connect the axillary and subclavian arteries; on the diaphragm, they form a link in the chain of. inosculations between the subclavian artery and the abdominal aorta (see Fig. 425); and in the wralls of the abdomen they form anastomoses most remarkable for the remoteness of the vessels which they serve to connect, namely, the arteries of the upper and lower extremities (Harrison). When the aorta becomes narrowed or obliterated, the internal mammary arteries constitute the most important of the collateral channels for conducting blood to the lower ex- tremities. Each of these arteries is attended by two‘venae comites. The hemorrhage in every one of the six cases of wound involving the internal mammary artery, reported during the late civil war, was secondary. In but two of them were ligatures applied. Judson, in one instance, tied the artery, but the method of operating is not stated ; the bleeding was arrested, and did not return, but the patient continued to sink, and died six days after the operation from anaemia and traumatic pleuro-pneumonia. Bontecou, in another instance, where there was a so-called seton-wound of the chest, enlarged the wound of entrance, passed a piece of bandage through, and tied it over the ensiform cartilage, ligating the internal mammary artery; the bleeding, however, was not permanently arrested, and the patient died five days afterward from recurrent hemorrhage with pneumonia. Four cases wTere treated mostly by inserting plugs soaked in styptics, and applying com- presses externally, but without benefit, as in the following examples:— A soldier, aged 20, was wounded June 3, 18G4, the ball penetrating at left side of sternum, near junction with second rib, and emerging above clavicle, fracturing both sternum and clavicle. Patient became much reduced from profuseness of suppuration and pleuro-pneumonia. On the 10th, profuse hemorrhage from the external wound occurred, and death followed in twelve hours. Treatment consisted in plugging the wound with lint soaked in liquor ferri persulph. Necroscopy. The internal mammary was found in the mutilated tissues with its mouth gaping; no other vessel wounded. Again, a soldier, aged 26, was wounded July 1, 1863, by a conoidal ball which fractured the humerus, passed along the clavicle, and lodged behind the edge of the sternum upon the internal mammary artery. On August 23 this vessel was opened by sloughing, and hemorrhage to the amount of thirty ounces occurred. Cold applications and compresses were applied, but on the next day the patient died. In the remaining two cases the blood flowed inwardly, and accumulated in great quantity, in the pleural cavities.1 Secondary hemorrhage from this artery, then, is sometimes hard to detect, and often exceedingly difficult to control, and these results naturally follow its situation on the inner surface of the thorax, and the important offices which it performs in the organism. No example of primary hemorrhage from the internal mammary artery was reported during the war; still this vessel must, not unfrequently, have been opened by wounds. The conclusion is irresistible that in most instances where this vessel was penetrated by wounds, the victims perished on the field of battle before assistance arrived, while in some instances where the victims survived for a time, the source of bleeding was not detected because the blood flowed inwardly, and the hemorrhage was therefore concealed. In all stabs, as well as other wounds which cross the track of this artery, the occurrence of hemorrhage from the wound, without the spitting of blood, should lead the surgeon to suspect strongly that this vessel is involved, whereupon he should at once thrust a finger into the wound, and search for the open mouth of the artery, from which he will feel the blood issuing in 1 Medical and Surgical History of the War of the Rebellion, First Surgical Volume, pp. 523, 524, 548. PUNCTURED WOUNDS OF ARTERIES. 581 jets, if liis suspicions be well founded. From tlie internal mammary artery when wounded, the blood may How outwardly, or, inwardly, into the ante- rior mediastinum, into the pleural cavities, and into the pericardium. The hemorrhage from this artery, when wounded, may soon cause death directly from loss of blood and syncope, or indirectly from asphyxia, by compressing the lungs when the blood flows into the pleural cavities, and from paralysis of the heart when the blood flows into the pericardium, so as to compress that organ. But if the external wound be not large enough to admit a finger for exploration, the diagnosis may be very difficult. When such is the case, as well as when the hemorrhage is suspended at the time of exami- nation, anatomical considerations may afford presumptive evidence; and every deep wound near the margin of the sternum, from the first to the seventh rib, when bleeding therefrom, whether external or internal, occurs, should be enlarged, by incisions if necessary, until the bleeding point is brought into view, when a ligature should be applied to the artery on each side of the orifice. Moreover, the distal ligature is needed almost as much as the proximal, on account of the great freedom with which the terminal branches inosculate, as already stated. The artery, too, must be secured by tying it without delay, lest meanwhile there should occur such loss of blood as of itself to prove fatal. "Wounds of the internal mammary artery are often attended with division of the costal cartilages. This complication was present in more than half of the cases collected by Lourdes; and it is almost always present when the vessel is wounded below the fourth rib, particularly when the wound has been inflicted by cutting instruments. Ligation of this artery is esteemed easy of performance in the first three intercostal spaces, difficult in the fourth, very difficult in the fifth, and almost impossible in the sixth. But when there is an open wound and the con- tiguous parts are much swollen and discolored by infiltration, or when the artery is much torn and displaced, as sometimes happens in those cases of gunshot fracture of the sternum, etc., which greatly disturb the relations of the parts, the operation of tying this vessel in the wound may become exceedingly difficult in any portion of its course. If the surgeon fail to secure it with ligatures under such circumstances, what then should be done ? Baron Lar- rey, indeed, taught that wounds of this sort should always be closed, and the cure of bleeding left to nature ; but there are very serious objections to this plan, which, in effect, leaves the patient to perish directly or indirectly from internal hemorrhage. ISTelaton advised that an air-compressor in the form of a bag of India-rubber or gold-beater’s skin should be introduced and inflated within the wound, but this instrument is fragile or unreliable at best, and not always at hand or within reach when wanted. It is best, then, to have re- course to the plan of Desault atid Zang, and to place over the wound a fine piece of carbolated muslin or carbolated gauze, four or five inches square, pressing the centre of it through the wound into the thoracic cavity, and stuffing the glove-finger or bag thus formed with antiseptic cotton or lint; the angles of the compress are then brought together and tied like a purse, and the pad or ball of antiseptic cotton or lint is drawn gently outward, and made to compress the injured vessel against the sternum. To keep the pad in place, it may be fastened with ligatures to a roller bandage or any other con- venient cylinder. The materials for Desault’s or Zang’s tampon are always at hand, the compress itself can be strongly made and safely applied ; and, when- ever the attempt to tie the artery in the wound fails, this tamponing is the best resource. It is approved by Velpeau and by Otis.1 At any rate, the hazard of 1 Op. cit., pp. 525, 549. 582 INJURIES OF BLOODVESSELS. exciting inflammation in the pleura and lung by the presence of the tampon in the wound is fnuch less to he dreaded than the danger of hsemothorax. When the internal mammary artery is injured, the prognosis is always very grave; the risk, too, of secondary hemorrhage is by no means small, as the cases (six), related or referred to above, clearly show. Intercostal Arteries.—These vessels, called specifically the posterior inter- costal arteries, arise from the back part of the thoracic aorta, and pass to the intercostal spaces, where, after coming into relation with the intercostal veins lying above and the intercostal nerves lying below, each of them divides into two branches, which run along the borders of the contiguous ribs between the two planes of intercostal muscles, and, finally, anastomose with the ante- rior intercostal arteries, branches of the internal mammary. The branch corresponding with the lower border of each rib is usually much larger than the other.' Posteriorly, the intercostals are quite large vessels, and, coming directly from the main artery of the body, they give rise, when wounded, to profuse and obstinate hemorrhages. During our civil war fifteen such cases were recorded, eleven of which, or 73.33 per cent., proved fatal from hemor- rhage ; and in one instance the thoracic cavity was found to contain two quarts of blood. Occasionally, these arteries are opened by stabs or incised wounds of the chest received in affrays; I have known two cases of such incised wounds. In each instance the injured vessel was promptly secured in the wound by ligatures without much difficulty, the chest-wound was then closed, and recovery speedily followTed. Sometimes, too, simple fractures of the ribs are attended with puncture or laceration of these arteries; and when the pleura costalis is also torn in such a way that the effused blood can readily escape into the thoracic cavity, death from concealed hemorrhage may soon ensue, as happened in the following instance:— An artillery-man was struck, whilst fencing, with a light cane upon the eighth rib of the right side. There was no outward mark of injury, but he became collapsed, and died eight hours afterward. On autopsy, the right pleural sac was found to contain about five pints of blood. The eighth rib was found fractured, and a twig of the inter- costal artery entering the bone at this point was torn through, while the trunks of the intercostal artery and vein were uninjured.1 Most frequently, however, the intercostal arteries are found opened by, or in connection with, fractures of the ribs that are compound ; such, for instance, as occur in gunshot-wounds of the chest. The fifteen examples reported in the Surgical History of the War were all cases of wound by gunshot missiles ; and the intercostal arteries were injured either by the fragments of comminuted bone, or by the missiles themselves. But gunshot projectiles that are small or minute may open the intercostal arteries without breaking the ribs, and thus cause fatal hemorrhage, as occurred in the following case:— A young man, aged 15, received a discharge of small shot at forty-eight paces. He instantly fell, but soon got up and ran about six hundred paces, when he again fell exhausted. He was taken home, and died thirty-eight hours after the mishap. Autopsy. One shot had penetrated his right chest between the first and second ribs, near the sternum. The right pleural cavity contained twenty-eight ounces of blood. The right lung was compressed to one-fourth of its normal bulk, and wounded. Posteriorly, the shot alsa had passed through the costal pleura at the inferior border of the sixth rib, about two inches from its head, and had lacerated the intercostal artery. From this wound had issued the fatal hemorrhage (Graefe). Here, too, the wounded vessel had considerable size, for its origin was not far away. 1 Medical Times and Gazette, Dec. 2, 1860, p; 607. PUNCTURED WOUNDS OF ARTERIES. 583 Injury of the intercostal artery may be predicated in lesions that involve its track, when the wounded person does not spit blood while the symptoms of hemorrhage, internal as well as external, are urgent. If the wound be large, bright-red, but not frothy blood may be seen issuing therefrom ; if the wound be probed with a finger, the blood may be felt issuing in jets from the aperture in the artery. When this vessel is lacerated without there being an external wound, and blood flows into the pleural sac, as happened in two instances mentioned above, the symptoms are those of rapidly occur- ring hsemothorax. Injury of this artery near its origin is always attended with dangerous bleeding. In shot fractures of the ribs it is always of very serious import, from risk of intermediary and secondary, as well as of primary hemorrhage. Of the fifteen cases reported in the “Surgical History of the War,” six had primary, five intermediary, and four secondary hemorrhage. When the intercostal arteries are punctured by stabs, it may be necessary to enlarge the external wound in order to get at and secure the injured vessel with a ligature placed on each side of the puncture. Generally, when the intercostal arteries are opened by external wounds, the hemorrhage should, if possible, be stanched by tying them on this plan; and the efforts of the sur- geon should first be directed to the accomplishment of this purpose, mean- while suppressing the bleeding by applying a finger to the aperture in the vessel whence the blood issues, on the inside of the wound, until the prepara- tions for applying ligatures can be made. Then, still restraining the bleeding with his finger in the wound, the surgeon should extend the wound poste- riorly with a scalpel held in the other hand until he lays bare the artery be- tween the two planes of intercostal muscles, and passes round it a ligature of carbolized silk or catgut, on tightening which the hemorrhage from the car- diac side of the wound will be effectually suppressed; the application of a distal ligature completes the operation. When the wound is fresh and the parts sound, no very great difficulty is usually experienced in finding and tying the intercostal artery in the wound itself. Sometimes, however, when the wound is no longer fresh and the parts are not sound, as, for instance, in secondary hemorrhages, it may be advisable to follow the old method of Gerard, and include the rib, nerve, and vein in the ligature as well as the artery ; it will be still more advisable to do so if the patient has already lost much blood. Restraining, then, at once the bleeding by inserting a finger into the wound so as to compress the open mouth of the artery (an assistant may do it if required), the surgeon should prolong the wound posteriorly in the course of the artery, that is, toward its origin, and taking the blunt-pointed, strongly-curved needle belongingto a chain-saw, of one of the many instruments which have been specially devised for this ope- ration, suitably armed with a ligature of carbolized silk, catgut, or silver wire, he should dip the point of the needle under the lower edge of the rib beneath the artery, and following closely the inner surface of the rib with the blunt point of the instrument, external to the pleura, he should, by depress- ing the handle or eye of the instrument, make the point appear, covered by the integuments, at the upper margin of the rib. The point should now be uncovered by a small incision, and protruded through it until the ligature can be seized hold of and placed; then the needle should be withdrawn. The ends of the ligature may be disposed of by tying them firmly over a roll of adhesive plaster; or they may be passed through the corresponding holes in a bone or a rubber button of suitable size, and then be firmly drawn and knotted. Another plan of dealing with the ligature is to pass the end.which was removed from the eye of the blunt-pointed, strongly-curved needle into the eye of an ordinary good-sized needle and re-insert it through the punc- ture of the integuments at the upper margin of the rib, carry it between the 584 INJURIES OB BLOODVESSELS. integuments and the external surface of the rib, and bring it out of the ori- ginal wound, where the two ends are crossed, drawn tightly, and knotted. This proceeding is not difficult to execute, and constitutes a subcutaneous ligation of the intercostal artery, vein, nerve, and rib. The upper puncture should be closed with an adhesive strip. With a little care this operation may readily be performed without piercing the costal pleura, as B. Howard has shown.1 In general, it is well to secure the artery in the same way on the distal side of the wound, as practised by B. Howard. The operation with a blunt-pointed, strongly-curved needle, described above, has one great advan- tage—the bleeding may be stopped from the first moment of seeing the patient, as it can always be controlled by pressure applied in the wound until the operation is completed. Professor Gross has suggested the drilling of a hole through the rib, and the passing, in this way, of a silver wire around the artery. Whatever plan is followed, care must be taken not to wound the pleura unnecessarily, which can be avoided only by keeping close to the inner surface of the rib, and by thoughtfully manipulating the instrument in other respects. Professor D. H. Agnew’s instrument is the best for tying the vessels in with the rib. Boyer held that lateral pressure was the only remedy for hemorrhages from wounded intercostal arteries. When from any cause ligation cannot be satis- factorily performed, Desault’s excellent method of applying lateral pressure to the artery in the wound with a tampon, described above, merits a thorough trial, being equally suited for hemorrhage from the intercostal and for bleeding from the internal mammary arteries. If the pleura and lung be intact, the risk of wounding them is avoided ; but if they be already wounded, it is the least irritating dressing that can be employed. There is no danger of dropping the tampon of Desault into the pleural cavity and thus losing it, as has happened in plugging such wounds with sponges or charpie. More- over, it has proved successful in a considerable number of cases (Begin, Velpeau, Jamain) in controlling the hemorrhage without exciting inflamma- tion in the pleura or the lung (Otis). In hemorrhage from chest-wounds which open the pleural cavity, the application of compresses externally does no special good; for it directs the flow of blood inwardly, and thus conceals the hemorrhage without abating it. Guthrie reports one case where secondary bleeding from an intercostal artery recurred several times, and was ultimately suppressed by the oil of turpentine, applied on a dossil of lint, and pressed on the bleeding spot by the fingers of assistants until the hemorrhage ceased; recovery followed. Such styptic solutions, however, as those of the perchloride arid persulphate of iron, are not any more applicable to wounds of the chest that are bleeding than they are to wounds of other parts ; and when the pleural sac is also opened by the wound, they might do much harm, if applied, by getting into the pleural cavity. So, too, with all the styptic substances which are used in a pulver ized state, even those against which, per sc, valid objections cannot be raised, as they can be against Monsel’s salt, etc.: their employment in such cases is hazardous, because they may fall into the pleural cavity. Many other plana of dealing with this exceedingly troublesome form of hemorrhage have been proposed by authors. Some of them are dangerous, others trivial, and others again more ingenious than useful. Inasmuch as bleeding from the inter- costal arteries is not unfrequently met with in cases where the pulmonary tissue also is lacerated, the surgeon, in such cases, must avoid doing anything which will increase the hemorrhage from the lung. When, however, an intercostal artery is wounded between the sternum and the middle of the ribs 1 American Medical Times, vol. vi. p. 52. CONTUSED WOUNDS OF ARTERIES. 585 —where, perhaps, the majority of wounds of the chest occur—the hemor- rhage is not always severe; but the injury of an intercostal artery, towards or near its origin, always causes very dangerous bleeding, and here the vessel is secured with much difficulty on account of its depth. A recollection of these points may assist the surgeon not a little in determining the plan of treatment to be employed. When the intercostal arteries are lacerated without there being an external wound, and inward bleeding occurs, operative skill is generally powerless to stop it. Guthrie, indeed, suggests, in commenting on a case of this sort, that auscultation would have made known the extravasation, and that relief might have been given by an incision over the spot where the uneasiness was ,felt; for the loss of blood was not sufficient of itself to destroy life.1 It is true that, had the spot been known where the artery was injured, in this case, It might have been cut down upon and tied; but it remains to be proved, in future cases, whether auscultation and the sensations of the patient can afford such sure information on this point as would authorize the surgeon to operate. As the symptoms in these cases are usually the symptoms of luemothorax, so the treatment must, in general, be the treatment of that accident. Contused Wounds of Arteries. The bloodvessels, as well as the integuments, the muscles, and the bones, often suffer from contusions. The “ black and blue” spots, called ecehymoses, which appear in all bruises, do so because the capillaries are crushed, and their contents escape. When arteries of some size are mashed by blows, large subtegumentary swellings may form from blood escaping into the con- nective tissue, of which accident I have seen some notable examples where the temporal and femoral vessels were involved. Large arteries, however, are, in some measure, protected from injury by bruising (1) by their positions, which, generally, are deep and sheltered; (2) by their capacity to flatten readily, which results from the elasticity of their walls and the fluidity of their contents; (3) by the strength of the arterial sheaths and the looseness of the connective tissue which surrounds them, whereby considerable free- dom of movement in lateral directions is allowed ; and (4) by the prominence •of contiguous muscles or other organs which serve to receive or to deflect the vulnerating forces. Contused wounds of arteries may be produced by falls and by blows with blunt instruments; I can call to mind at least two such cases; but the most common cause is injury from gunshot projectiles. Bruises of bloodvessels, which fall short of crushing them, may neverthe- less do great harm. Boyer asserts that the contusion of large arteries is sometimes followed by their rupture and the formation of a diffuse traumatic aneurism ; and if the percussion be not great enough to rupture their coats, it will weaken them to such a degree that they will afterwards yield to the impulse of the blood, and form a true aneurism. Gunshot bruises of arteries which do not directly open them are still attended with ecchymosis of the sheaths. The vasa vasorum, too, are lace- rated, and blood may be extravasated between the artery and its sheath in such quantity as to narrow considerably the tube of the vessel. ISTow, under appropriate treatment, this extravasated blood may be absorbed, the blood- stasis and local irritation may disappear, and the bruised part may be com- pletely restored to a healthy state. But if, on the other hand, there be no treat- ment at all, or that which is inappropriate, the blood effused in the sheath is 1 Commentaries, etc., p. 475, Am. ed. 586 INJURIES OF BLOODVESSELS. not absorbed, the inflammatory process is lighted up in the bruised part, the* tube of the artery is still further narrowed by the occurrence of inflamma- tory swelling, and occlusion of the artery may follow, with gangrene of the region deriving its supply of nutrient blood from the occluded vessel, as happened in the following instance:— A soldier was wounded November 27, 1863, by a minie-ball which entered the left thigh, on its antero-exterior surface, six inches below the anterior superior spinous process of the ilium, dipped beneath the integuments and deep fascia, and emerged from its inner surface four inches below the pubes, passing thence into the other thigh. Gangrene of the left foot soon followed. On December 14, the left leg was amputated at the junction of its lower and middle thirds ; the artery was controlled during the operation by pressure of the thumb alone ; there was very little hemorrhage; the tissues were dabby at the place of section. Pyaemia ensued, and on January 14, 1864, the patient died, on the forty-eighth day after the injury and the thirty-first after amputation. Autopsy.—Doth orifices of the wound in the upper part of the left thigh were closed, but the track of the ball was occupied by an abscess containing thin fetid pus. The ball had passed behind the femoral artery, impinging against its sheath, however, and bruising it. At this point the walls of the artery were much thickened, and its calibre lessened one-half. The sheath contained a firm coagulum about one inch long. The specimen was sent to the Army Medical Museum, and is thus described in the Cata- logue: “A wet preparation of the upper portion of the left femoral artery, with the walls much thickened by a coagulum in the sheath, following impingement of a ball, which induced diminution of calibre.”1 To briefly present the points of this ease: The missile bruised the femoral vessels without opening their sheath, and the hemorrhagic and inflammatory swelling constricted the tube of the artery very much at the bruised part— so much is certain ; it is highly probable also that the coagula which formed in the canal of the femoral artery, where it was inflamed and constricted, were swept onward by the blood-stream, as emboli, into the tibial arteries, and plugged them to such extent as to cause, with the lessened blood-supply from above, gangrene of the foot. Another preparation belonging to our Army Medical Museum sheds addi- tional light on the same point. It is thus described in the Catalogue: “A wet preparation of the popliteal artery, showing a clot formed in it from inflammation along the track of a ball which did not involve the arterial coats in the sloughing process. Amputation was performed to obviate spha- celus, and the patient recovered."'2 In this example, the ball, in its passage, bruised the popliteal artery ; there followed inflammation and occlusion by coagulum of the bruised- portion of the vessel; from this arrest of blood- supply, gangrene of the leg ensued. In a case reported by Guthrie, which belongs to the same category, the ball passed between the femoral artery and vein. The patient died sixteen days after the injury from gangrene of the foot and leg. After death, Mr. Guthrie obtained the specimen. The coats of the artery were not destroyed in substance, although wounded. At this spot the vessel was “ much contracted in size, and filled above and below with coagula, which prevented the trans- mission of blood." The artery was therefore impervious. The coats of the vein were but little injured, although it was “filled by a coagulum and im- passable” at the bruised part.3 In this case, too, the traumatic arteritis caused by the bruise was the chief factor in producing the arterial occlusion. 1 Catalogue A. M. M., p. 456, Specimen 2114. 2 Ibid.., p. 457, Specimen 2150. 3 Diseases and Injuries of Arteries, p. 242. CONTUSED WOUNDS OF ARTEUIES. 587 Another case is related in the “Surgical History of the Crimean War:”— P. Ryan, aged twenty-one, on June 8, received a canister-shot wound (supposed) through the left thigh at its upper part, involving the track of the femoral vessels. On the 16th, gangrene of the foot appeared, and the leg was amputated just below the knee. On the 18th, gangrene attacked the stump; on the 19th, it extended up the thigh ; and on the 20th, death occurred. Autopsy : “ The ball was found to have passed through the thigh internally to the sheath of the femoral vessels, which it had grazed, but not opened. The artery at this point was slightly contracted for a space about an inch in length, but pervious, and containing no coagulum ; and, beyond the contraction, its calibre showed no marks of inflammation. The vein, however, was not only also slightly contracted, but its internal surface was inflamed and filled with partially organized lymph, as far up as the entrance of the deep iliac vein, and downward for about two inches from the wound. Its course was thus entirely sealed ; but nothing like pus could be found in the femoral or iliac veins, nor in the venous system any- where.” 1 Here gunshot contusion of the femoral vessels caused inflammation with contraction of their walls, and thrombosis with occlusion of their canals; in the artery, however, the blood-clot appears to have been swept into the branches, producing em- bolism of the same, and consequently, gangrene of the foot, leg, and thigh, in successive stages. These four examples show very clearly what disastrous consequences may follow the bruising of bloodvessels and their sheaths by the strokes of passing bullets, or by other gdequate means. The usual ecchymosis of the bruised part may be attended with hemorrhage into the sheath, compressing and par- tially occluding the vessel itself; to be followed by inflammation of the walls of the injured vessels with thrombosis, or embolism, and gangrene from ar- rested blood supply. But if the extravasated blood he absorbed, and if the inflammatory process be not kindled in the bruised vessels, then the obstruction to the circulation may prove but temporary, and complete recovery may eventuate, as happened in the following instance:— John English, aged twenty, on June 22 received a wound from a musket ball which passed through the thigh. The wound was directly in the course of the femoral vessels. As he was reported to have lost a quantity of arterial blood on receipt of the injury in the trenches, it was feared that the femoral artery had been wounded. The temperature of the limb was sensibly diminished, and the pulsation of the arteries in the foot could not be discerned for several days. The patient was exceedingly restless, and complained of pain and numbness in the calf of the wounded limb. No hemorrhage, however,, occurred; the limb regained its natural temperature, and recovery slowly followed.2 A widely different and a comparatively frequent type of arterial contusion next claims our attention ; a type which is characterized by the occurrence of secondary hemorrhage. Among the consequences of simple contusion that are most to be dreaded, where large arteries are concerned, is ulcerative in- flammation and sloughing of the injured vessel. In some of these cases, the bruised fibres of the arterial tunics are too greatly damaged to retain their vitality ; hence they must be detached by an ulcerative process which may open the canal of the artery. Contused differ from other wounds chiefly because the stricken part may suffer a loss of vitality, and will have to' ulcerate or slough away before any reparation can be effected; inflamma- tion is supposed to be necessary to the consummation of this process. In other instances, a destructive inflammation per se is kindled in the bruised vessel, either by the depraved general condition of the patient, or by his un- wholesome surroundings, or by bad treatment, which also may open the canal of the artery and cause secondary hemorrhage. I can most clearly, and at- 1 Surgical History of the Crimean War, vol. ii. p. 343. 2 Ibid. 588 INJURIES OF BLOODVESSELS. the same time briefly, discuss this important subject by relating a few cases taken from my own note-book and from the “Surgical History” of the late War. A cavalry-soldier, aged 24, was admitted to Stanton Hospital, under the writer’s charge, from the field, June 4, 1864, for a wound of his right leg at the ankle, in- flicted by a minie-ball, on May 31. It was resolved to continue the effort, which had already been commenced, to save the limb. On the night of the 7th, arterial hemor- rhage from the wound supervened, and about a pint of blood was lost before it was checked. On the morning of the 8th, I amputated the wounded leg, at the place of election, by the flap-method, under sulphuric ether, with but trifling loss of blood, and but little shock ; and after the operation the patient’s general condition was favorable. Examination of the amputated member showed that the posterior tibial artery had been grazed by the missile, and that several small bits of bone had been driven into the walls of the artery at this place. The hemorrhage had occurred from ulceration of the bruised part of the artery, and from detachment of the minute fragments of bone that were stuck in it. The ankle-joint was full of purulent matter, the lower end of the tibia was badly comminuted, and the astragalus also was injured by the missile. The patient did well for some time; but thirteen days after the operation he died of pyrnmia. In this case, primary amputation ought to have been performed, or the artery ought to have been secured primarily with the ligatures above and below the bruise, because the injury was of such a nature that otherwise secondary hemorrhage was inevitable. A soldier, aged forty, wounded May 28, 1864, was admitted to Stanton Hospital, under the care of the writer, on June 12. A conoidal ball had passed through the ankle- joint from within outward, in such a way as to involve the track of the posterior tibial artery. On the next morning, while the assistant-surgeon was in the ward, arterial hemor- rhage from the wound suddenly occurred, and about three ounces of blood were lost before it was suppressed. I was immediately brought to the patient. There was then no pulsa- tion in the posterior tibial artery at the ankle, while that of the anterior tibial could be distinctly felt. It was evident that the hemorrhage proceeded from the posterior tibial artery. Without delay I had the patient etherized, and I amputated his injured leg in the lower part of its middle third, with but little loss of blood, and with little or no shock. Examination of the amputated limb showed that the posterior tibial artery had been grazed and contused by the missile ; and that it had been opened by exulceration of the bruised portion of its walls', whereby the hemorrhage was caused. The lower end of the tibia, the astragalus, and the os calcis had severally sustained comminuted fracture. The patient died nine days after the operation, apparently from exhaustion; but I believe that he had osteo-myelitis, and that this caused his death. In this case, too, the chance of recovery would have been much increased by primary amputation, or by tying the artery above and below the bruise in the primary period; because the nature of the arterial lesion was such that in the absence of these operative procedures the occurrence of secondax-y hemoiThage was inevitable, and only a question of time. A western cavalry soldier was wounded in the neck by a conoidal ball, which entered above the outer third of the right clavicle, and emerged above the middle third of the left clavicle, on July 4, 1864, in a brawl. Simple dressings were applied. Secondary hemorrhage from the common carotid artei’y occuri-ed on the 11th, which was ternpor- arily controlled by applying liquor ferri persulph.; but, on the 12th, the patient died. The autopsy revealed an apertux-e in the carotid, about two lines in diameter, and about three-fourths of an inch above its oi’igin.1 In each of these three cases the hemorrhage was due to the normal separa- tion and detachment of bruised tissues from the trails of an important artery. There is another form of gunshot contusion of bloodvessels which belongs to the same category,but is much more extensive: “When a limb is crushed 1 Medical and Surgical History of the War of the Rebellion, First Surg. Vol., p. 412. CONTUSED WOUNDS OF ARTERIES. 589 by shot or shell, but not carried away, the coats of the artery are often found to remain continuous, and primary hemorrhage to be thus rendered impos- sible, although their vitality may have been totally destroyed.”1 I have never seen this form of vascular contusion, but still I can readily conceive that it sometimes occurs in those terrible bruises of the extremities which are not unfrequently produced by cannon balls, or bombs, or rilled shells, without breach of the integuments. In such cases the continuity of the bloodvessels is preserved until the dead tissues become separated from the living, for the same reason that the integuments remain unbroken until this time arrives. The Army Medical Museum at Washington contains a specimen of railway injury, which must be classified under the head of contusions. It is “a wet preparation of the axillary artery, curiously obliterated at the passage of the pectoralis minor. The attached subclavian vein is ruptured. In this subject the humerus and clavicle were comminuted, and the soft parts between the shoulder-joint and the sternum pulpified by being crushed between two cars. Ao pulsation could be felt at the wrist, and sphacelus from the shoulder to the arm occurred.”2 The patient was admitted to hospital on July 20, and died on the 23d. Again, contusions of arteries not unfrequently lay the foundation for un- healthy inflammations to open their channels and thus cause secondary hemor- rhage, when, but for the occurrence of a destructive inflammation, their walls would have remained intact, as happened in the following instance. A soldier, aged 28, was wounded at Gettysburg, July 2, 1863, by a minie-ball, which passed through the inner side of his left arm, across the track of the brachial artery, about three inches below the fold of his armpit, without injury to the humerus ; and, thence, proceeding to his thorax, made a so-called seton-wound on the left side thereof. He was taken to a general hospital where, after doing well for some time, the bullet-hole in his arm was attacked with a sloughing inflammation which connected the two orifices in an open sore; and on the night of August 3, thirty-two days after the casualty, it opened the brachial artery. Great loss of blood ensued, until a proximal ligature was applied to the artery in the wound. He did well after that, and the wound healed in a short time. On October 16, 1864, when I last saw him, the wounded arm was much atrophied, blue-colored, colder than the sound limb, weak, and much restricted in the range of its movements. There was a large cicatrix on the inner side of his left arm, two or three inches below the armpit. There was a radial pulse in this limb, but it was quite small in volume, and quite feeble in strength. On the 17th, he was discharged from the service for these disabilities, at Stanton Hospital. In this case the bruising of the artery, in all probability, would not have been attended with any serious consequences, had the wound remained free from destructive inflammation ; for a month or more elapsed before hemorrhage occurred, and arterial fibres killed by contusion would have separated long before that time. An example of secondary hemorrhage from a bruised common carotid artery, occurring in a person whose vitality was much lowered by simulta- neous injury of the spinal cord, is reported in the “ Surgical History of the War.” A soldier received a shot-wound of the neck, January 3, 1863, and was admitted to hospital on the 4th. The missile passed through his neck, dividing the inter-vertebral substance and laying open the spinal cord. He did not seem to suffer much; but, on the night of the 14th, secondary hemorrhage supervened, and before any assistance could be rendered, he lost so much blood that he died on the evening of the 15th. At the necroscopy it was found that sloughing of the common carotid artery had taken place.3 1 Surgical History of the British Army in the Crimean War, vol. ii. 340. 2 Catalogue A. M. M., p. 468, Specimen 1640. * Medical and Surgical History of the War of the Rebellion, First Surg. Vol., p. 412. 590 INJURIES OF BLOODVESSELS. Treatment of Contused Wounds of Arteries.—Contused wounds of arte- ries may be complicated by hemorrhage, the presence of foreign bodies, inflam- mation,and gangrene. When,from the crusliingot arteries by blows, extravasa- tion of blood occurs in large quantity, it may be necessary to ligate the injured vessels in order to suppress the bleeding. If a considerable artery be opened, it must be tied ; compression would only increase the irritation already exist- ing. For the treatment of false primitive or consecutive aneurisms arising from this cause, consult the section on Traumatic Aneurism. When the con- tusion is very severe, and the quantity of extravasated blood very great, and when it collects in a mass in the crushed connective tissue and forms a so-called hsematoma, the part is commonly black, which might lead us to fear gangrene; but if this blackness disappear on pressure, and if it be soft, and unattended with pain or great swelling, and if the affected parts be still warm, we may conclude that life still exists in them, and that resolution may take place, notwithstanding the collection of blood in the connective tissue. There are many examples of sanguineous tumors (haematomata) which have terminated by resolution, after a greater or less time ; but it sometimes happens that all of the eft used blood cannot be taken up by the absorbents or the veins, and then we are compelled to discharge it by an incision ; but such openings are not to be made until we have waited long enough to kn'ow that resolution is impossible. To hasten the disappearance of hamiatomata, the application of lead-water generally proves useful; and if much pain be present, the applica- tion of lead and opium wash in a warm or tepid state usually brings speedy relief. Shot-wounds involving the tracks of large bloodvessels must always be the subjects of careful scrutiny and much anxiety on the part of intelligent sur- geons, although there may be no bleeding at first. If any sign of considerable injury to the artery itself be discovered on exploring the wound with a finger, if the pulsations be found much weakened in the trunk or branches of the injured vessel below the wound after full reaction, the artery should at once be secured by ligatures applied above and below the bruised part; or, per- haps, the limb should be amputated primarily ; otherwise secondary hemor- rhage or gangrene is sure to follow, as the cases related above fully prove. But, of course, a bruise on a small spot or portion of an artery may not always diminish the force of the circulation before sloughing; and, in very severe con- tusions, the canal of the vessel may be closed before sloughing has time to occur. We must not put too much confidence in any one symptom, therefore, but provide, in all suspicious cases, for the contingencies mentioned above. If it be deemed expedient to treat the case without primary ligation or amputation, we should strive to lessen the risks by abating the inflammation of the bruised part of the artery, but especially that which is ulcerative or phagedenic in character. The wounded part should be kept at perfect rest. The surroundings of the patient should all be of the most wholesome character. The practice of applying poultices with a view to favor the occurrence of suppurative inflammation, is bad in such cases, because it insures suppuration throughout the whole extent of the wound. Carbolated water-dressings (1 to 200) will allow the necessary detachment of the disorganized tissues just as well as poultices, without inducing suppuration in the parts which are disposed to undergo adhesion. Indeed, it is possible for the reparation of the parts lost by the severity of contusion to be effected under such a dressing without the occurrence of suppuration or granulation. The retention of secretions in the wound must be avoided by the thorough use of Chassaig- nac’s drainage tube. The utmost cleanliness should be observed, and all the dressings should be of an antiseptic nature. Meanwhile, we should constantly be on the lookout for secondary liemor- LACERATED WOUNDS AND RUPTURES OF ARTERIES. 591 rhage, and the attendants must be told what to do in ease it appears, until we can arrive at the bedside of the patient. When secondary hemorrhage occurs, the vessel should generally he secured in the wound by ligatures applied on each side of the bleeding orifice, as was done in the following instance:— A soldier, aged 19, was wounded on May 28, 1864, by a conoidal ball, which passed through the left axillary space. On June 12, secondary hemorrhage from the axillary artery, to the amount of twenty ounces, occurred. On the loth, the axillary artery was ligated above and below the wound, under chloroform. The vein was found injured, and was also ligated. The hemorrhage did not recur; but death ensued on the 28th, thirteen days after the operation. The autopsy revealed no evidence of phlebitis or pyaimia; and the patient appears to have succumbed to the prostration consequent on the loss of blood prior to the operation.1 The axillary artery and vein, in this case, were both opened by ulceration following gunshot contusion, and both vessels were quite properly treated by securing them in the wound with double ligatures. If traumatic gangrene occur, amputation is our sole expedient. If the lesion of the artery" be com- plicated with compound comminuted fracture, and the region involved be the lower extremity, it is sometimes preferable to amputate at once, especially if the knee or ankle joint be opened. When, however, it seems probable that the limb can be saved although the blood-supply derived through the bruised artery be cut off, we may tie the vessel above and below the lesion. Anti- septic dressings and the employment of Chassaignac’s drainage-tubes are of great utility in these cases. Fig. 426. Drainage-tube carrier of Dr. John B. Hamilton, Surgeon-General of the United States Marine Hospital Service. To emphasize the necessity which there is for thorough drainage in treating wounds attended with arterial or venous contusions, this figure of a useful instrument is presented. LACERATED WOUNDS AND RUPTURES OP ARTERIES. The lacerations and ruptures of the walls of arteries, which claim the atten- tion of surgeons, may be incomplete, as well as complete, in degree; and may occur in either form without the presence of any corresponding external lesions. In those enormous wounds of the extremities which are left behind when the limbs are plucked off by the action of powerful machinery in manufactories, or crushed off by the impact of cannon-balls in war, the arte- ries are torn completely across, and are often seen hanging out from the raw surface and pulsating quite down to their ragged and contracted ends, which, on examination, are found completely closed by plug-like coagula. When a limb is carried away by a round shot, the principal artery, vein, and nerves will almost invariably be found hanging from the wound, torn off at a point much more distant from the trunk than the remainder of the soft parts ; and the end of the artery—lacerated, contused, contracted, and gener- 1 Medical and Surgical History of the War of the Rebellion, First Surg. Vol., pp. 555, 556. 592 INJURIES OF BLOODVESSELS. ally filled, after a very brief interval of time, with coagulated blood for a few lines from its extremity—above that point often pulsates quite strongly, though freely exposed to the air, as in the following instance observed in the Crimean War:— A man had his left arm torn off at the shoulder-joint. The limb was completely- separated from the trunk, too little of the integuments being left to cover the wound. The axillary artery appeared to have bled very little, if at all, at the moment of the injury, and there was no subsequent hemorrhage. The artery and vein were laid bare for full three inches of their course by the laceration ; the ends of these vessels for three-quarters of an inch were curved, plugged with coagulum, and tapering to a point; the pulsation of the artery was full to the very base of the plug of coagulum.1 Guthrie saw a soldier who had his arm carried away by the bursting of a shell. The axillary artery as it becomes brachial was torn across, and hung down lower than the other divided parts, and pulsated to the very extremity. Pressed and squeezed between his fingers in every way in order to make it bleed, it still resisted every attempt, although apparently by the narrowest possible barrier, which appeared to be at the end of the artery, and formed by its contraction. The canal was marked by a small red point, to which a very slight and thin layer of coagulum adhered, the removal of which, how- ever, did not produce hemorrhage. In another case of like character, Guthrie cut off the end of the artery at less than one-eighth of an inch from the extremity, and then it bled with its usual vigor. In both cases the artery was contracted for that distance, so as to leave little or no canal at its orifice, and what there was was filled by a pin- shaped coagulum.2 . , With a view to illustrate the effects of avulsion on the bloodvessels, Mr. Joseph Bell showed the common femoral artery and vein of a man whose lower extremity had been torn off by machinery. The abdominal cavity was opened and the intestines protruded; but, notwithstanding, he survived thirty hours. The artery and vein were completely occluded by firm coagula, and the external coat was twisted to a fine point at the place of rupture.3 But the reader must not infer from these examples that the hemorrhage ceases spontaneously in all cases where limbs are torn oft' by machinery or by cannon-balls, without the loss of much blood; for such is not the fact. In the largest arteries, such as the common femoral, and occasionally, though much less frequently, in smaller vessels, haemostasis does not always happen when they are disrupted, unless it is aided by the occurrence of syncope; and then the hemorrhage often proceeds to such an extent as to prove fatal, as happened in the following instance, which also occurred in the Crimean War:— A soldier had his leg below the knee carried away by a round shot. He lost much blood before a tourniquet was applied, and was so much collapsed when received at the hospital that an operation was out of the question. The wound was dressed and the tourniquet removed ; but he never rallied, and died nine days after the casualty, although no further hemorrhage occurred.4 During the progress of our civil war, several cases came to my own knowl- edge in which the ragged stumps of limbs torn off by cannon-balls or shells bled profusely at the moment of injury, and afterward did not entirely cease to bleed until ligatures were applied. In some of them the loss of blood was so great as to cause a fatal result of itself, although surgical aid was promptly afforded. When limbs are plucked off from the trunk by machinery, however, as not unfrequently happens in manufactories, there is usually not so much hemor- 1 Surgical History of the Crimean War, vol. ii. p. 340. * Diseases and Injuries of Arteries, p. 224. 5 British Medical Journal, January 18, 1873, p. 77. 4 Op. cit., p. 340. LACERATED WOUNDS AND RUPTURES OF ARTERIES. 593 rliage, a circumstance which probably results from the continuance of the traction of the bloodvessels in the line of their course until they suddenly snap in two, whereupon their ends recoil, incurve, and contract at once, so that little or no blood can escape. Similar cases to that related by Cheselden, of u Samuel Wood, a miller, whose arm with the scapula was torn off from his body,’’with but very little hemorrhage, have since been witnessed repeatedly by other respectable authorities in surgery. Dr. Eve has collected three ex- amples of this injury. In each, the arm with the scapula still attached was plucked completely off from the trunk. In each, also, the lesion was pro- duced in substantially the same manner; the subject was caught by the hand or arm in powerful machinery, and then rapidly dragged upward by that member, until the trunk struck a beam, or a ceiling, which suddenly barred its progress, while the limb continued to move onward in the machine. The hemorrhage was not excessive in either case. It is stated that, in one in- stance, “the artery was seen pulsating at the bottom of the wound, and was plugged up by a coagulum of blood. The vein was distended, and lay on the torn muscles like a gorged leech.” But few ligatures were required, and in one case it seems that no vessel was tied, as “ there was no hemorrhage” when the surgeon arrived.1 But little or no sloughing of the lacerated tissues occurred, and each patient made a good recovery. Dr. F. Katholitzky relates an excellent example :2— A man, aged 37, had his right arm and scapula torn away by being caught in a water- barrel which was being drawn up a shaft by steam power. The limb was found in the water at the bottom of the shaft one hundred and thirteen days afterward. Dr. K. saw the patient one hour and a half after the accident. The wound was about twelve inches long and nine wide, and bled but little. There was no hemorrhage from the subclavian, nor from any of the arteries, and their ends could not be found in the wound. There was considerable shock. The wound was reduced by means of steel clamps to the size of a hand, and was covered with charpie. Six hours after the casualty, violent pain set in, but was relieved by the subcutaneous injection of morphia. The wound was dressed with iced compresses. During the following days, there was sloughing of por- tions of tissue, with moderately high fever. Nothing further of importance occurred during the healing of the wound, which was complete at the end of the seventh week. Two years and five months afterwards the patient was in good health, but right-sided scoliosis had appeared.3 But in lacerated wounds, the division of the artery is much oftener found to be incomplete. The Army Medical Museum, at Washington, contains several specimens of this character. One of them was taken from a wound produced by a bayonet-thrust. It shows the subclavian artery torn open for two-thirds of its circumference by the bayonet, one-fourth of an inch from the innominate.4 It was obtained from an unknown soldier, killed at Fort Wagner, S. C. This specimen proves that when a large artery is wounded by a bayonet, the breach in its walls is not always of the punctured variety. There is another specimen in the same museum which shows the popliteal vessels lacerated by a splinter of wood.5 This injury was inflicted in a rail- road accident, October 29, 1864. The patient entered hospital on November 2, and died on the 3d. His thigh was amputated at the junction of the lower and middle thirds. Abernethy relates the case of a man gored in the neck by the horn of a cow. Hemorrhage came on, and was immediately arrested by tying the common carotid artery; but the patient died about thirty hours after 1 Eve’s Surgical Cases, p. 579. 2 Allgemeine Wiener med. Zeitung, No. 45, 1873, and New Sydenham Society’s Retrospect,, 1873-4, p. 278. 3 [Fourteen cases of this injury are referred to in the Article on Amputations, vol. i. p. 654.] 4 See Catalogue A. M. M., Specimen 2721. 5 Ibid., Specimen 3761. 594 INJURIES OF BLOODVESSELS. the operation, it was said from inflammation of the brain. On autopsy, the internal carotid artery was found partly torn across, and the primary branches of the external carotid were found separated from the trunk.1 Incomplete lacerations of arteries, however, of quite another sort, occur not unfrequently, and, at the same time, are very interesting to surgeons. In these cases the inner and middle coats are torn, while the external tunic remains intact. The lacerated layers of the artery curl backward upon them- selves, and may thus Completely close the channel of the artery, as happened in the following instance, reported by Professor Verneuil :2— A man, aged 46, after being thrown from a cart, presented the symptoms of violent delirium, right hemiplegia, and cerebral compression. Externally, only numerous con- tusions could be found. He died fifteen days subsequently. The autopsy showed complete rupture of the inner and middle coats of the left internal carotid artery, with a clot in its canal extending into the branches of the Sylvian artery. There was extreme softening of almost the whole middle lobe of the left cerebral hemisphere. In these cases, the lacerated inner and middle coats hehave in a manner strictly analogous to that which we have shown above to obtain when these same coats are divided by the pressure of ligatures applied in tying arteries, or by the operation of Dr. Speir’s instrument for constricting arteries. In other words, the inner and middle coats of arteries may be torn through by accidents, while the external coat remains entire. In such cases the severed coats curl backward, or recurve upon themselves, exactly as they do in the operation of constriction or crushing of arteries performed with I)r. Speir’s Instrument for the suppression of hemorrhage, described above (see Fig. 399); and, by their recurvation, these coats may entirely close the lumen of the injured artery. Again, when in such cases of incomplete laceration of arteries, the recurva- tion of the inner and middle coats does not suffice to block up the channel, of the injured vessel, the pressure of the hlood is liable to stretch the outer coat at the place of injury, and expand it into an aneurismal sac, thus furnishing a very interesting variety of traumatic aneurism, as happened in an example recorded by Mr. T. P. Pick,3 in which there was a rupture of the inner and middle coats of the femoral artery, caused by a strain, and followed by a gradual dilatation of the outer coat, and the formation of a traumatic aneurism. Gangrene of the limb set in, and the patient died shortly after amputation at the hip-joint. Digital compression had been previously tried for the cure of the aneurism, and, for a time, with apparent success. Treatment.—In cases where a limb has heen torn or plucked completely •oft* from the trunk by the action of machinery, it is generally expedient to tie the principal vessels on the face of the stump. The arteries that project above the surface, or hang out, should always be secured by ligating them with carbolized catgut, whether they bleed or not when the surgeon arrives. The integuments should then be drawn together, and the case treated as an incised wound. A good result has not unfrequently been obtained in these cases by this plan of treatment. As a rule, no tissue is cast off by sloughing or by ulceration, unless it has happened to be badly bruised by striking against some solid body—for instance, a ceiling or a beam. When a limb lias been struck off by a cannon-ball, or a bomb, or any other form of shell, and thus its bloodvessels have been torn in two, it is always advisable to amputate the member at some higher point, if practicable ; for 1 Surgical Observations, vol. ii. p. 72, Am. ed. * Bull, de l’Acad. de M6d., Jan. 1871; and New Sydenham Society’s Retrospect, 1871—2, p. 84. 3 St. George’s Hospital Reports, vol. vi. p. 161. LACERATED wounds and ruptures of arteries. 595 the tissues ot the limb are likely to be torn and bruised, or disintegrated and intiltrated with blood, to some distance above the breach, as I once found on examining the ragged-looking stump of a forearm that had been stricken almost on by the premature discharge of a cannon. The tissues of this stump appeared to be but slightly injured, away from the wounded surface, until they were cut into, when they were found to be ecchymosed and dis- integrated, as stated above, nearly up to the elbow-joint. The amputation was therefore performed above the elbow, in the continuity of the arm. Hemorrhage from lacerated wounds that are caused by bayonets, by splinters of wood, by the horns of infuriated animals, or by other means, should in general he restrained by compression until the lacerated vessel itself can be brought into view by making incisions, etc., when it should be tied with carbolized catgut above and below the aperture in its tunics. It should also be divided midway between the two ligatures. When, however, it is impracticable to tie the bleeding vessels at the laceration, the artery from which it springs should be ligated as near the wound as possible. Again, when the parts surrounding the breach are damaged in such a way as to put the preservation of the limb out of the question, or when the peculiar nature ■or great extent of the injury renders the salvation of the limb impossible, amputation should immediately be performed. Gangrene of the extremities, when caused by the laceration of arteries, demands that recourse should be had to amputation without delay. When gangrene attacks the toes because the popliteal artery is occluded by the recurvation of its torn inner and middle coats, or because it is torn completely across, the operation should be performed at the knee-joint. When the femoral artery is the seat of the laceration, the operation should generally be performed high up in the thigh, but without permitting any delay to occur in either case. When gangrene attacks the fingers because the axillary artery is torn, the limb should forthwith be amputated near the shoulder. Aneurisms caused by the laceration of arteries should in general be treated by laying them freely open, scooping out the clots, finding the orifice, and ligating the artery above and below the opening with carbolized catgut, di- viding the vessel also midway between the two ligatures. In the after-treat- ment, antiseptic dressings and drainage-tubes should be employed. Ruptures of Special Arteries.—Femoral Artery.—The main artery of the lower extremity is rent asunder without external wound much oftener than many suppose. In the following example the common femoral artery was ruptured by a strong blow;— A robust young man, an iron-planer, aged 23, was admitted to hospital, on October 15, with an abrasion of the right groin, and a corresponding swelling of great size which extended upward almost to the umbilicus and downward to the lower third of the thigh. There was no pulsation in the tumor nor in the tibial arteries. He was evidently suffering from extreme loss of blood, being very pallid, and his radial pulse barely perceptible. His injury resulted, half an hour before admission, from being driven by a plane which struck his buttock whilst reversing, and drove him over the “ cheek-piece.” He was so low that no operative procedure was admissible, and early next morning he died. Necroscopy thirty hours after death. The swelling -was due to an immense extravasation of blood. The common femoral artery was found com- pletely severed just below Poupart’s ligament; its proximal end was filled with a coni- cal clot; its distal end had the external coat tightly twisted beyond the retracted inner and middle coats. Coagulated blood was found in the sheath of the artery up to the common iliac and down to Hunter’s canal. The femoral vein contained a clot opposite the place of rupture. The adductor longus and pectineus muscles were also torn acroes. 596 INJURIES OF BLOODVESSELS. Beneath the fascia there was an extensive coagulum which spread in the thigh through the intermuscular spaces to the back of the limb.1 Tlio cause of death appears to have been “ shock,” and an extensive hemor- rhage from the ruptured femoral artery which was hidden from view by the integuments, but mainly the latter. The next example shows that the femoral artery and vein may both be torn across when pressed upon by a heavy weight without any corresponding fracture or any perceptible breach of the integuments:— A man, aged 50, had one wheel of a cart loaded with manure pass over his right thigh. Half an hour afterward he was brought to University College Hospital in a state of extreme collapse; the limb was much swollen and very tense to above the middle of the thigh ; foot cold, with motion and sensation in it lost; no pulsation in the tibial arteries. There were scarcely any bruises visible, and the bone was unin- jured. Next morning the limb was very livid. There was no increase in the circum- ference, but the extravasation extended somewhat higher on the inner side. There was no pulsation nor bruit in the swelling. The limb was amputated about two inches below the trochanter ; but the patient sank and died soon after the operation. On dissecting the ablated member, all the intermuscular septa were found distended with coagula. On the inner side of the limb, above the popliteal space, there was a large pulpy cavity in which the femoral artery and vein were both found torn completely across; both were plugged by firm coagula at each end. The artery was much con- tracted for two inches above the rupture, and its torn end was nearly closed thereby. The artery was also atlieromatotfe, and slightly calcified here and there.2 In the following instance there was a rupture involving all the coats of the left femoral artery ; but it was cut down upon, the clots were turned out, and both ends were secured by catgut ligatures, with a good result:— The subject was a collier, aged 30, a patient at the Manchester Royal Infirmary, whose case is reported in the British Medical Journal for August 8, 1874. He ruptured his left femoral artery while straining at his work. He was admitted with a large, dif- fused, non-pulsatile swelling in the upper part of his left thigh, and no pulsation in the arteries of his leg. From the history of the case, and the condition of the limb, a diagnosis of rupture of the femoral artery was made. Lister’s aortic tourniquet was applied, an incision over Scarpa’s triangle was made, a large quantity of coagulated blood was removed, and the divided ends of the artery were seen and secured by catgut ligatures. The man progressed uninterruptedly to recovery. The proper thing to do in cases such as these would therefore seem to be to restrain the inward etfusion of blood as soon as possible by digital com- pression, or by the application of a tourniquet, or Esmarch’s elastic ligature, until the seat of the rupture can be laid open by incisions, the clots turned out, and both ends of the artery found and securely tied with prepared cat- gut. The wound should also receive antiseptic treatment. But, in most cases, the timely restraint of the extravasation of blood into the connective tissue of the limb is a matter of paramount importance; for, if this etfusion be not soon suppressed, the patient may perish directly from loss of blood, as hap- pened in two instances related above. The inner and middle coats of the femoral artery are sometimes lacerated by a blow upon the thigh, whereupon a femoral aneurism ensues from dila- tation of the external tunic. Mr. Home has reported the following case which was under the care of Mr. Birch, at St. Thomas’s Hospital:— John Lewis, a negro, received a blow on the anterior part of his right thigh. About a month afterward he perceived a small tumor, which increased ; his own expression was that he could feel it thump, thump. The tumor appears to have rapidly enlarged. 1 British Medical Journal, November 22, 1873, p. 603. 2 Ibid., July 30, 1870, p. 116. LACERATED WOUNDS AND RUPTURES OF ARTERIES. 597 He therefore came to London, and entered the hospital, Oct. 26. On examination Mr. Birch found a large pulsating tumor in the femoral region, extending upward to within less than two inches of Poupart’s ligament, and occupying two-thirds of the thigh ; it was without doubt a femoral aneurism. On Nov. 3, Mr. Birch tied the femoral artery half-an-inch below the profunda; pulsation in the tumor immediately ceased. Gangrene of the sac, however, supervened. On Nov. 14, the tumor burst, and dis- charged serum and grumous blood ; the patient died, in the evening, from septicaemia and secondary hemorrhage. Autopsy. The integuments at the middle of the tumor were mortified. The blood contained in the tumor was very putrid. Water injected by the external iliac artery escaped freely from the wound of operation, at the ligature, where the artery appeared to have been opened by ulceration. The laceration of the inner and middle coats from the blow had occurred twp and one-half inches below the origin of the profunda. The arterial tunics did not exhibit atheroma or calcification, or any structural degeneration. “ The opening where the artery passed out of the aneurismal sac was nearly three inches below the part where it entered.”1 The sac of this aneurism appears to have consisted of the external tunic of the artery, widely dilated, and strengthened externally by adherent lamina?, of connective tissue. Another interesting example seems to have been taken from Clarke;— A man, aged 48, entering hurriedly a badly lighted chamber, struck his left groin with great force against the corner of a table. Ten days afterward, a small tumor, of the size of a pigeon’s egg, and at first taken for an enlarged lymphatic gland, appeared at the point contused. This tumor, in three nights, acquired an enormous size; and it pulsated so strongly as to raise the bed-clothes. The tumor sloughed, and burst open, but without hemorrhage. The patient was in the way of cure, when he succumbed to pneumonia. The artery had been torn across.2 In this case the aneurismal swelling, which was formed at first by the gradual expansion or dilatation of the external tunic of the femoral artery at the point where its inner and middle coats had been ruptured by striking against the corner of a table, suddenly gave way without apparent cause; and, in conse- quence, an enormous swelling, or a so-called diffuse aneurism, soon appeared, from the extravasation of blood into the connective tissue of the thigh; this in turn suppurated and was opened by ulceration or sloughing, but without the occurrence of hemorrhage; the man,however, ultimately died of pysemic pneumonia. External Circumflex.—The following case, in which the external circumflex artery of the right thigh was ruptured, was under Dupuytren’s care at the Hotel-Dieu; it will prove, from its resemblance to the last in several par- ticulars, of much interest in this connection:— A man, aged 46, a cook, in running round a table in the kitchen, struck the outer and upper part of his right thigh against an angle of the table. Pain, at the moment of injury, was very acute ; twelve days afterward, a swellingof the thigh suddenly rose up (in the space of ten minutes). Leeches and resolvent cataplasms were applied. Subse- quently the swelling lessened or increased according to his exact observance of quietude or the reverse. A physician, deceived by the absence of pulsation, made an incision therein two inches long; red blood and coagula were discharged. The wound was im- mediately closed, and the patient entered the Hotel-Dieu on November 30. The right thigh presented a tumor which occupied its external and anterior region. The skin over it was rather leaden-hued ; there was irregular fluctuation in it, and com- plete absence of pulsation. The femoral artery and the dorsalis pedis beat normally. Dupuytren announced that the swelling had resulted from the rupture of small vessels, caused by the blow received on the thigh. Diet and resolvents were prescribed. A 1 The London Medical Journal, 1786, p. 391. 2 Nouveau Dictionnaire de Med. et de Chirurg. pratiques, t. x. p. 471. Paris, 1872. 598 INJURIES OF BLOODVESSELS. compressor, however, was kept ready to suppress any hemorrhage that might supervene. December 4, towards evening, two cupfuls of red blood flowed out ; the compressor was placed on the femoral artery, and arrested the hemorrhage ; five days later it was removed; pus mixed with blood and containing clots was discharged from the wound. December 19, some spoonfuls of blood escaped ; there was also mild delirium. Decem- ber 22, death occurred.1 At the autopsy, a vast cavity containing extravasated blood was found. The external circumflex artery had been ruptured.1 Rupture of the Popliteal Artery.—This vessel, notwithstanding its sheltered position in the flexure of the knee, not unfrequently sustains a traumatic lesion in the shape of rupture. In the following example the popliteal artery was partially, and the popliteal vein completely, torn across, without external wound:— A healthy young man, aged 19, while riding on the front seat of an omnibus, was struck on his left knee by the top of a cart drawn by a runaway horse, which drove his knee backward with great force. On admission to hospital, soon afterward, there was much contusion of the knee observed, with swelling in the popliteal space, but no sign of fracture nor of dislocation. The swelling increased, and the patient complained of loss of sensation in his leg; the temperature of the leg also fell, and pulsation could barely be felt in the posterior tibial artery. On auscultation a low clicking sound was heard in the course of the popliteal artery. The diagnosis was a probable rupture of that artery. Primary amputation above the knee was resorted to, and the patient ultimately did-well. On examination, there was found extensive effusion of blood into the areolar tissue of the amputated member ; the popliteal vein was completely severed ; and the inner and middle coats of the popliteal artery were torn through and separated from the external coat, which remained undivided.2 The injury of the knee-joint which complicated the case, and the gangrene of the leg which was strongly threatened, necessitated the performance of amputation. However, if that operation could have been avoided, and the limb saved, a popliteal aneurism would, doubtless, have resulted from this lesion of the artery; and I believe that a similar lesion of the inner and mid- dle coats of this artery, caused by violent stretchings as well as by blows, not unfrequently gives rise to popliteal aneurism, especially when that affection occurs in young persons who have neither atheroma nor calcification in the walls of any bloodvessel. The following.case illustrates this point:— On March 25, 1869, I was called to a young man, aged about 21, of healthy paren- tage, healthy constitution, and good habits, on account of a popliteal aneurism which had returned several months after being apparently cured by ligature of the superficial femoral artery. The origin of the aneurism could be attributed to nothing but a severe strain, which had probably ruptured the inner and middle coats of the popliteal artery. Flexion treatment had been employed in the summer of 1868, but without benefit; in the autumn, ligature of the femoral had been performed with apparently an excellent result. Early in March, however, the disease had returned ; the tumor had increased rapidly. On the 25th, when I was called, it was considerably more than half as large as my fist, and the pain was intense ; all the signs peculiar to aneurism were present. Notwithstanding confinement to bed, etc., the tumor continued to increase with great rapidity. His home did not permit of operative treatment, and as the speedy employment of operative measures was imperative, on account of the great size and rapid growth of the swelling, I had him sent to St. Luke’s Hospital, on April 12, just nineteen days after I first saw him. There, compression of the femoral artery, both digital and instrumental, was faithfully tried, but without success. The aneurism then appeared almost ready to burst; and, as a last expedient, amputation was performed. He did well for some time; but pyaemia supervened, and, on May 9, caused his death. 1 Nouveau Dictionnaire de Med. et de Chirurg. pratiques, t. x. pp. 467, 468. 2 British Medical Journal, August 28, 1875, p. 259. LACERATED WOUNDS AND RUPTURES OF ARTERIES. 599 A case of popliteal aneurism, operated on by Mr. James Earle, at St. Bartholomew’s Hospital, was also caused by a strain:— John Smith, aged about 50; lie said that about six months before, he had fallen from a scaffold, and that his leg had been caught between the rounds of a ladder, which broke his fall; that he immediately felt pain in the upper part of his leg; that soon afterward it began to swell, and that the swelling had gradually increased to its present size. On examination there appeared a large hard swelling under the heads of the gastrocnemii muscles, reaching up to the bend of the leg. Pulsation was plainly felt in it, and there was no doubt of its being an aneurism. The tumor was now increasing very fast. January 28,1792, Mr. Earle tied the artery a short distance above the tumor, on Anel’s plan; the ligature came away on the fifteenth day, and the man made a good recovery. The case was communicated by Mr. Earle to Home, who published it in the London Medical Gazette. I believe that the violent stretching to which the popliteal artery had been subjected in this case ruptured its inner and middle coats, and thus caused the development of an aneurism. Rupture of the Anterior Tibial Artery.—In the following example, this vessel was burst open by a blow from a spade, without any corresponding breach of the integuments:— A laboring man had noticed a slight swelling on his ankle, which gave him no pain, until he struck it a severe blow with a spade one day while at work. Afterward the swelling gradually and continuously enlarged. An explorative incision gave issue only to blood. On operating for the removal of this swelling, it was found to be caused by a wound of the anterior tibial artery, which communicated with an old bursal cyst.1 By severe blows and by violent strains the posterior tibial artery may be ruptured, just as readily as the anterior tibial, the popliteal, or the femoral; and the treatment should generally consist of bringing into view, by suitable incisions, etc., the ends of the ruptured artery, and securely tying both of them with ligatures of prepared catgut, unless there be some complication present which necessitates amputation. Rupture of the Brachial Artery.—Malgaigne relates the following case:— M. Michaux received at the hospital of Louvain a lad of ten years, who had dislo- cated his elbow backward and outward. There was considerable swelling, but the radial pulse still continued to beat. On the next day reduction was attempted, with assistants. On the third day it was again unsuccessfully attempted; and, in conse- quence, the elbow became greatly swollen, the radial and ulnar arteries ceased to beat, and the hand lost all color and sensibility. Gangrene ensued; and, six days after the last attempt, M. Michaux performed amputation which saved the patient’s life. Examination of the amputated limb showed a rupture of the brachial artery and median nerve.2 The case of a lad, aged 18, who had compound dislocation of the elbow and rupture of the brachial artery, but still recovered, is reported in the Lancet of August 8, 1874. The articular surface of the lower end of the humerus protruded through a lacerated wound at the front and inner part of the forearm. The brachial artery was found to be torn across. The case progressed favorably without interruption. At the end of eight weeks the patient was sent into the country with the wound healed, and the elbow ancliylosed at a convenient angle. In the museum of St. Bartholomew’s Hospital-, Series XIII. 88, there is part of a brachial artery which was torn straight across by external violence. The patient, aged 69, fell with his arm stretched out. At first he seemed little injured ; but pulsa- tion was lost in the radial and ulnar arteries. In a few hours the arm became enor* mously swollen and livid, and amputation near the shoulder was performed.* 1 British Medical Journal, January 11, 1873, p. 43. 2 Traite des Fractures, etc.,t. ii. p. 153. 3 St. Bartholomew’s Hospital Reports, vol. ii. p. 107. 600 INJURIES OF BLOODVESSELS. Pelletan reports the case of Nicolas Pochard, a young soldier, who, from practising the manual of arms with the zeal of a young soldier, acquired an aneurism of the left brachial artery, which was caused by blows or contusions received from the lock of his gun, that were very often repeated until the tunics of the artery gave way.1 Rupture of the Axillary Artery.—Many examples of this lesion, without any corresponding breach of the integuments, have been placed on record. This accident is very serious, for more than two-thirds of the reported cases have proved fatal. Moreover, it has been produced in many different ways, the most important of which I shall briefly refer to or describe. Pelletan relates the case of Gabriel Longpre, a journeyman mason, aged about 40, whose axillary artery gave way so that an aneurism formed, in consequence of the violent stretchings to which he subjected it in suspending himself, with all the weight of his body, by the hands, from the pegs of his scaffoldings, from time to time, in order to alleviate the pains of rheumatism.2 This case proved fatal. Mott reports the case of Wm. Haines, aged 28, whom he found, on examination, to have an aneurism of the right axillary artery, as large as a goose’s egg, with the follow- ing history: “ About seven weeks before, he received a violent strain while carrying a canoe on hand-bars across the arms, which was followed by an extensive discoloration of the skin of the right arm, extending to the chest, and attended with considerable pain. Three weeks subsequent to the accident he observed a small swelling, about the size of a pigeon’s egg, under the right arm, which had rapidly increased.” Mott tied the subclavian artery above the clavicle. The man made an excellent recovery.3 In the museum of the Royal College of Surgeons, Series XXV. 1695, there is an axillary aneurism which was caused by rupture of the axillary artery, from the falling of a man on ice with his arm extended.4 Inspector-General Smart, R. N., has called attention to the fact that the axillary artery may be so much injured by the sudden and violent wrench of the shoulder which gunners sustain when explosions occur while in the act of loading cannon, that gan- grene of the limb ensues from the occlusion of that vessel. He has also reported three cases in point.5 They all occurred from explosions while in the act of ramming home, by which the rammer was expelled, and the arm employed in loading was violently extended. In such cases the artery is injured by the forcible extension of the arm, without puncture or laceration of the integuments. The injury sustained by the artery often consists of rupturing its inner and middle coats, which then recurve and close the lumen of the artery, where- upon gangrene soon results. Dr. Smart points out that when gangrene appears in such cases, amputation near the shoulder, performed without delay, is the only expedient that can save the patient. Similar cases of injury of the axillary artery from strains and blows, with- out any external wound, have been mentioned by Aston Ivey, Le Gros Clark, Liston, Syme, and Gibbs. Such cases with many interesting examples of various accidents belonging to the same category have been collected and arranged in two tables, by Eug. Boeckel, in the “Nouveau Dictionnaire de Med- ecine et de Chirurgie Pratiques,” in the Article Axillaires (vaisseaux), t. iv. pp. 365-9, and 370-74. Paris, 1866. In the following example, the axillary artery was ruptured by passive movements made for the relief of false anchylosis :— A woman, aged 40-45, of rather feeble health, had her left shoulder-joint completely stiffened by rheumatic inflammation. On January 10, 1858, about half an hour ' Clinique Chirurgicale, t. ii. pp. 14, 15. 2 Op. cit., t. ii. pp. 49, 50. 8 American Journal of the Medical Sciences, vol. vii. 1830, pp. 309-11. 4 St. Bartholomew’s Hospital Reports, vol. ii. p. 107. 8 British Medical Journal, September 23, 1871, pp. 342, 343. LACERATED WOUNDS AND RUPTURES OF ARTERIES. 601 after some unusual efforts in the way of passive motion, there came great swelling in and about the axilla, which increased and extended by degrees about the shoulder and upper half of the arm. On January 19, Sir James Paget saw her. She looked pale, feeble, and reduced by the pain. The whole axilla was distended as much as the fixed position of the shoulder would allow, with a tense, firm swelling, raising up in front the pectoralis major, and still more prominently behind the teres major and latissimus dorsi. Pulsation was distinctly felt in every part of this swelling. A rough, blowing sound was heard all over it, and for a little distance above and below. No pulsation was discernible in the brachial artery or its branches. Pressure on the main trunk above the aneurism abolished the pulsation and bruit. Complete rest, diminished food, and anodynes were recommended, and the policy of delay was continued until April 23, when the increased size of the tumor and other symptoms made an operation impera- tive. Sir James Paget opened the tumor, under chloroform, by cutting just behind and parallel to the pectoralis major the whole length of the axilla, and by making a second cut at right angles with this, commencing at its middle, through the pectoralis major muscle, straight upward, its whole width. Raising the angular flaps of the JL shaped wound of operation, the surface of the great mass of the clot was exposed. Two small arteries that were cut were tied. The clots were scooped out and an oval-shaped aper- ture one-fourth of an inch long by one-tenth of an inch wide was found in the posterior wall of the axillary artery. Above and below it the vessel appeared sound. Ligatures were applied above and below the aperture, and the vessel itself was divided between them. The loss of blood during the operation was under six ounces. The cavity of this aneurism was the anatomical axilla exactly filled and distended. The patient made a good recovery.1 I have taken space to give all the steps of this important operation, and almost any surgeon who is about to undertake its performance will con- cede the value of Sir James Paget’s method, and probably wish for greater fulness of detail. Dislocation of the arm at the shoulder-joint is sometimes attended by rup- ture of the axillary artery, without any external wound. In other words, the same force that displaces the head of the humerus, rends the accom- panying artery also, as happened in the following instance, related by Dr. II. Adams:—2 John Smith, aged 50, was thrown down by a runaway horse. About ten minutes afterward he was brought to the Jervis Street Hospital “ in a cold perspiration, pallid, and apparently on the verge of syncope.” The left humerus was found to be dislo- cated into the axilla. The artery accompanying it was also ruptured ; blood was extravasated into the axilla, and there was corresponding tumefaction or diffused aneurism; no pulse in radial and ulnar arteries. Dr. Adams easily reduced the dislo- cation, which he proceeded to do at once, while the man was still prostrated by the “ shock,” and by the concealed hemorrhage. Ten days later, Mr. O’Reilly tied the subclavian artery. The man recovered and lived many years. Nelaton states that, although rupture of the axillary artery in consequence of dislocation of the shoulder is very rare, he has observed a remarkable ex- ample, attending a displacement below the glenoid cavity. The two inner tunics of this vessel were torn to a very small extent; a false aneurism resulted, that grew rapidly, and obliged him, three months later, to resort to ligation of the subclavian artery, which he practised above the clavicle; but the disorder had already made so alarming a progress that, notwithstanding the ligation, the aneurismal cyst burst open, and entailed a sad termination from secondary hemorrhage.3 Elsewhere, I find it stated that the patient was a woman, advanced in years; that the aneurism communicated with the cavity of the joint; and that the reduction was easily effected. From the last-mentioned circumstance, Nelaton probably inferred that the laceration 1 St. Bartholomew’s Hosp. Reports, vol. ii. pp. 103-106. 2 Cyclopaedia of Anatomy and Physiology, article “ Shoulder-joint,” pp. 616, 617. 3 Elemens de Pathologie Chirurgicale, t. ii. p. 368. 602 INJURIES OF BLOODVESSELS. of the artery occurred in connection with the displacement of the caput humeri, just as it did in Dr. Adams’s case, related above. Professor A. Berard has observed in connection with a dislocation of the humerus under the coracoid process, a rupture of the two inner tunics of the axillary artery, extending through its whole circumference; the external tunic was stretched out as a slender tube. This lesion was attended by obli- teration of the vessel, and gangrene of several fingers, and, finally, by the death of the patient. The absence of pulsation in the radial and ulnar arteries made M. Berard suspect a lesion of the axillary artery.1 In this case, doubt- less the ruptured inner and middle coats recurved, so as to close the channel of the artery. Moreover, Malgaigne has shown that rupture of the axillary artery has occurred in connection with most of the common forms of dislocation at the shoulder. In some cases, however, where dislocation of the humerus has been thought to be present, the axillary artery has been found torn by the splinters or frag- ments attending a fracture of the humerus, there being no dislocation what- ever of that bone. The following examples in point have occurred in the practice of two very eminent surgeons:— A man fell and injured his shoulder. The surgeon who first saw him said there was a dislocation, and tried to reduce it. Being not quite satisfied with the result, for the head of the humerus still appeared to project in front more than it ought to do, he sent for Mr. Stanley, who thought it might be a case of partial dislocation forward (much spoken of at the time by Mr. Abernethy). Accordingly, they bound the arm tightly across the chest, with the hand resting on the opposite shoulder. Calling a few days after- ward, Mr. Stanley’s attention was aroused by the fact that there was no pulse at the wrist of the injured arm. The bandage was immediately removed, but without restora- tion of the pulse. Many years later, the man died, and Mr. Stanley carefully examined the part. He found that there had been a fracture through the anatomical neck of the humerus, wdth obliteration of the axillary artery opposite thereto.2 Mr. Callender, in commenting on this case, fancies that the inner and middle coats of the artery only had given way, as in Berard’s case, which I have just presented—where, however, the obliteration of the artery was followed by death from gangrene; and his view of the case is probably the correct one. Mr. Skey3 met with the next example: A woman, aged 55, slipped in walking, and fell violently to the ground, with her arm in an extended position. A day or two afterward she was seen by a surgeon, who detected and reduced, it was said, a disloca- tion of the shoulder. Three or four weeks after that, she began to complain of a swell- ing in the armpit, which appears to have slowly increased. Two months later, some blood escaped. Then she was sent to St. Bartholomew’s Hospital and admitted under Mr. Skey’s care, three months subsequent to the fall. After careful consideration, the swelling wTas laid freely open, the blood turned out, and the axillary artery tied above and below the aperture in its walls. Subsequently, the patient died; and, on autopsy, the humerus was found obliquely fractured in its upper third ; the wound of the artery had been caused by a pointed piece of detached bone. There had been no dislocation. The procedures for reducing dislocations of the shoulder-joint, especially for reducing those which have existed some considerable time, are quite liable to tear the walls of the axillary artery, and many examples of this accident have been placed on record. In some of them its occurrence has speedily been followed by death from shock and hemorrhage, as it wTas in the following case that was treated by Professor Gibson :— A man, aged 50, presented himself with a luxation of the right arm, of two months’ standing. Three weeks after the accident, it was said, four strong men had pulled on 1 Elemens de Pathologie Chirurgicale, t. ii. pp. 368, 369. 2 St. Bartholomew’s Hospital, vol. ii. pp. 102, 103. 3 Ibid., p. 102. LACERATED WOUNDS AND RUPTURES OF ARTERIES. 603 the arm without effect. Five weeks subsequently he was bled to the amount of twenty- four ounces, under Gibson’s direction, and attempts at reduction were made, first with pulleys, then with five or six assistants ; but, the patient becoming faint, these efforts were discontinued. Already a considerable axillary swelling was apparent, when, after two slight rotary movements, the head of the humerus suddenly slipped into its place. But the artery having been torn across, the swelling rapidly increased, the patient became blanched, and died some hours after the operation. On autopsy, the axillary artery was found torn directly across and separated from its connections, and there was a great quantity of coagulum in the axilla.1 Delpech’s case of tlie mayor of dirties belongs to the same category: While lie was reducing a luxation of the arm, in this case, the extension was made by six assistants; at the moment of reduction, the patient turned pale, lost consciousness, and did not recover it; he was dead. The cause of death was rupture of the axillary artery, according to M. Riga!, who was one of the six assistants, and mentioned the fact to Malgaigne.2 The axillary region is capacious, its connective tissue very loose, and, therefore, when the axillary artery is opened subcutaneously, blood may be effused with great rapidity, and in great quantity; and this concealed hemorrhage may, if disregarded, and if the patient be kept in an upright posture, readily prove fatal. Professor Lister has had a case wliere concealed hemorrhage of this sort occurred, and the accident proved quickly fatal:— A man, aged 58, had dislocation of the shoulder, of seven or eight weeks’ standing. Reduction was attempted by manipulation, and subsequently by pulleys, no undue force being exerted by either method. During the attempt a sharp crack was heard ; a swelling appeared on the dorsal and posterior part of the scapula, which ultimately reached the size of an adult’s head ; it was due to a rupture of the axillary artery, with extravasation of blood into the surrounding structures. Without hesitation, Professor Lister cut down on the spot, and searched for the ruptured vessel. An aper- ture was found in the posterior part of the axillary artery, and a ligature was applied on each side of it. The patient rallied, but died about three hours afterwards. Necroscopy showed that the humerus had a small spiculum of bone attached to its shaft, which was the immediate cause of the rupture. The artery itself was very atheromatous.3 A tumor of this description, as large as a mart’s head, would require for its production the loss to the circulation of an immense quantity of blood, enough to produce unaided in most cases anmmic exhaustion of a fatal nature. Verduc4 saw in a reduction of the humerus at the shoulder, the axillary artery torn, and, in consequence, an aneurism which speedily proved fatal. Petit.5 witnessed a similar accident. Platner6 cites a case of rupture of the axillary artery and vein, in consequence of violent extension; which, doubt- less, proved speedily fatal. Sir A. Cooper mentions a case of dislocation at the shoulder-joint, in which reduction was easily effected, but a false aneu- rism formed ; and, the sac bursting, a fatal hemorrhage ensued.7 The artery was found diseased and rigid. Mr. Rivington records the case of a man, aged 71, who died in consequence of hemorrhage from a traumatic aneurism of the axillary artery, that resulted from the reduction of a dislocated humerus.8 The aneurism burst. The sad result in each of these eight cases shows how great the danger of death from hemorrhage really is when the axillary artery chances to be torn 1 Institutes and Practice of Surgery, vol. i. pp. 325-9. 2 Traite des Fractures, etc., t. ii. p. 152. 3 Medical Times and Gazette, February 1, 1873. 4 Malgaigne, Traite des Fractures, etc., t. ii. p. 151. 5 Ibid., p. 151. 7 On Dislocations and Fractures of the Joints, p. 371. 8 Brit. Med. Journal, April 20, 1872. * Ibid. 604 INJURIES OF BLOODVESSELS. in efforts for reducing dislocated shoulders; and, inasmuch as death may speedily follow the rupture from sub-tegumentary hemorrhage, as well as remotely from bursting of the aneurismal pouch, and external hemorrhage, the first indication in the treatment of these cases is plainly to restrain the flow of blood in the torn vessel by compressing digitally the subclavian artery against the first rib, as soon as the axillary swelling begins to appear, and by continuing the compression until the place of rupture can be exposed to view by incisions, and till the artery itself can be secured with catgut ligatures above and below the point at which it has given way. This accident is also liable to be followed by gangrene. For example, Pro- fessor Gibson has reported the following case:— A man, aged 35, with a dislocation of the left humerus of nine or ten weeks’ stand- ing, for which four attempts at reduction had been made, was the patient. Severe operative measures were employed, and, after an hour and three-quarters, the bone snapped into the glenoid cavity. At 8 o’clock next morning, an axillary swelling with characteristic pulsation was observed. The swelling increased, and at 3 P. M. next day, fifty-four hours after the reduction, the subclavian artery was tied, and the tumor ceased to pulsate. The limb, however, became gangrenous, and, on the sixth day after the operation, the man died.1 The inner and middle coats of the artery were found torn across and separated for half an inch, and the external coat was dilated into an aneurismal sac, dating probably from the luxation itself, or from the previous attempts at reduction ; during the last attempt the sac was torn open from behind, and an enor- mous effusion of blood entered the joint through the torn capsule. The rim of the glenoid cavity was fractured anteriorly. In the British Medical Journal, May 18,1872, is recorded the case of a man, aged 38, who dislocated his humerus and had it reduced, lie was then ad- mitted into the Northampton Infirmary. Gangrene of the arm ensued, and the man died. Fracture of the coracoid process, chipping of the head of the humerus, and rupture of the axillary artery, were found. Flaubert has reported the following case which occurred in the practice of M. Leudet:— A sailor, aged 57, was admitted to the hospital at Rouen, with a dislocation of the arm forward, of eleven days’ standing. Extension was made by eight intelligent pupils, and, on the second attempt, the reduction was effected. But, just before relax- ing the extension, the patient became pallid, his radial pulse ceased to beat, and an enormous swelling rose up under the great pectoral muscle. There was intense pain with pulsation in the tumor, and the whole arm became cold and livid. Gangrene little by little took possession of the limb. On the fourteenth day the aneurism burst in two places, and, an hour afterward, the patient died. The axillary artery was found torn completely across a little above the origin of the scapular. The pectoralis major and the coracoid portion of the biceps muscles were also extensively lacerated. The rim of the glenoid cavity, too, was broken.2 This accident is sometimes attended by death from exhaustion. For ex- ample, Mr. De Morgan, in a clinical lecture,3 relates the case of a man, aged 54, who came under his care a fortnight after the reduction of a dislocation of the shoulder, under chloroform, with the heel in the axilla. Extravasa- tion of blood into the axilla occurred, and increased. The man’s strength failed, and he got rigors. Mr. De Morgan laid open the swelling, turned out the clots, etc.; but the man continued to sink. At the necroscopy it was impossible to detect the source of the bleeding. Anaemic exhaustion arising from loss of blood in the form of a concealed hemorrhage, however, is one of the most important causes of the deaths which result from this lesion. 1 Am. Journ. of tlie Medical Sciences, pp. 136-141. 2 Malgaigne, op. cit,, t. ii. p. 153. * British Medical Journal, January 6, 1872. 605 The axillary artery may possibly be tom across in striving to reduce dislo- cations of the shoulder, in such manner that the bleeding may spontaneously cease, that the extravasated blood may undergo absorption, and that a cure may thus ensue, without operative interference. I believe that this fortu- nate occurrence is exemplified by the history of the following case:— Professor H. B. Sands1 was called to a lady, aged 86, seven or eight weeks after her right shoulder had been dislocated downward. Soon afterward it had been reduced. About ten days later, however, the dislocation was reproduced, and it remained in that state until Professor Sands’s visit. The patient was etherized, and a very moderate effort was made at reduction. While arranging for a second attempt, five or six minutes subsequently, Dr. Sands thought he perceived a swelling in the axilla. He removed the sheet; it was very apparent that a bloodvessel had given way; there was a quite rapid in- crease of the swelling in the axillary region, and it was very soon as large as the head of a child at term. There was no pulsation in the radial, ulnar, or brachial artery. No- thing in the way of treatment was done, except to place the arm by the side and apply a bandage; but within half an hour the skin of the axilla had begun to show discolora- tion, and within a few hours the discoloration was very marked, and extended up to th& shoulder. The patient was excessively prostrated by the accident, and at one time it seemed not improbable that she would die from syncope. Hypodermic injections of brandy were given, and brandy by the mouth as soon as it could be swallowed, but she remained in a very low condition for some time, especially at night. In the course of the next day after the accident, the extravasation gave signs of its presence quite distinctly, upon the side of the chest; and afterwards it could readily be seen on the side of the trunk as- low as the pelvis. The discoloration behind covered nearly the entire scapular region. There was neither fluctuation nor murmur over the extravasation. There had been gradual improvement, and although pulsation had not returned in any of the arteries,, the limb itself presented no unfavorable appearance. The patient made no special complaint, excepting a very uncomfortable tingling, at times along the distribution of the ulnar nerve. Professor Sands thought that no vessel except the axillary artery was ruptured, was surprised that the rupture should occur from the use of so little force, and was gratified at an unexpected recovery from so dangerous an accident. The rapidity and copiousness with which the hlood was effused in this case indicate that some large vessel was opened; the disappearance or cessation of the pulse in the radial, ulnar, and brachial arteries, together with the site of the tumefaction itself, shows that the axillary artery was the vessel ruptured. And, were the axillary artery completely torn across in this case, it was quite within the range of possibility for the ragged ends to become permanently closed by the contraction and retraction of the torn tunics of the artery, sup- plemented by the formation of a conical plug from eoagulum in each end thereof, which would become organized. The natural haemostasis in such cases is, no doubt, aided considerably by fastening the arm to the trunk with a broad roller. The swellings appearing suddenly in the axilla during attempts to reduce old dislocations of the shoulder-joint, which the Trench surgeons formerly called tumeurs aeriennes, and which usually ended in recovery without opera- tion, were not unfrequently due to rupture of the axillary artery. The fol- lowing example of tumeur aerienne occurred in the practice of Desault:— A man, aged 60, came with a dislocation of a month and a half’s standing. The reduction was scarcely achieved when a tumor was suddenly seen to rise up under the great pectoral muscle, and extend itself towards the armpit, occupying finally its whole extent. The pulse on the affected side became scarcely perceptible, and the man fell into a syncope. Desault himself at first feared that the axillary artery was ruptured. Methodical pressure was applied to the swelling by means of compresses and a bandage, which, at the same time, kept the arm fixed against the trunk. That niglit, acute pain LACERATED WOUNDS AND RUPTURES OF ARTERIES. 1 Medical Record, January 10, 1880* 606 INJURIES OF BLOODVESSELS. about the shoulder and the tumor came on ; next day, high fever also appeared ; on the third day they left. The swelling likewise abated, and, by the fifteenth day, had entirely disappeared. There still remained, however, a very extensive ecchymosis ; hut its resolution was complete on the twenty-seventh day.1 Considerable light is thrown upon the real nature of the lesion which existed in this case by what happened in a precisely similar case related by Pelletan,2 the tradition of which had been preserved at the IIotel-Dieu for almost twenty years. Whilst violent efforts to reduce a dislocation of the humerus, of four months’ standing, were being made, a painful tearing occurred, and a large-sized tumor rose up. This tumor was declared to be emphysematous. It was opened by an incision; and the patient died of hemorrhage. Some of the eye-witnesses informed Pelletan that there was a rupture of the axillary artery with extravasation of blood. Had the incision not been made, the patient would probably have recovered. Malgaigne relates another case which ended in recovery, without opera- tion :— A carman, aged 44, dislocated his humerus forward under the clavicle, and after suffering numerous unsuccessful attempts to reduce it, came to Malgaigne, who, on the sixty-eighth day, also attempted its reduction, and success seemed assured when he saw the subclavian hollow suddenly elevated by a tumefaction which almost visibly overran the axilla and part of the shoulder. Percussion gave a dull sound. Auscultation revealed nothing. The radial pulse continued to beat. The attempt at reduction, how- ever, was at once abandoned, in order to avert the danger. The arm was immovably fixed against the side, and the tumor was covered with ice. Some hours later, the growth of the swelling seemed to be arrested. Soon afterwards, an enormous ecchy- mosis appeared. On the ninth day absorption had begun ; and, on the twenty-second day, the tumor and the ecchymosis had vanished.3 Malgaigne thought that, inasmuch as the radial pulse was not affected, the axillary artery was not opened; but this circumstance only shows that the canal of the axillary artery was not obstructed. Recovery in such cases takes place without the obliteration of the canal. In one case, analogous to the above, Scarpa observed that the wounded edges of the artery had adhered, and that a mere line of cicatrization was discoverable when the artery was slit open. The coagulum, shut out in this manner from the canal of the ves- sel, formed a tumor which was attached to the outside of the artery.4 Hodg- son, also, remarks that “ an aneurism arising from a punctured artery some- times becomes tilled with lamellated coagulum, which seals up the orifice through which the sac communicated with the artery, and the cure of the disease is accomplished without the canal of the artery being obliterated ; the coagulum is absorbed, the sac contracts, and the orifice in the artery is per- manently closed ;”5 and, in support of this view, he cites observations recorded by Saviard, Petit, Foubert, Scarpa, and Jones. It is obvious that when a rupture of the axillary artery is cured by Nature in either of these two ways the radial pulse may remain unaffected throughout. Symptoms and Diagnosis of Rapture of Axillary Artery.—The phenomena which indicate that the axillary artery is ruptured, are those that arise from a rapid and copious effusion of blood into the loose connective tissue of the armpit, namely, a swelling appearing suddenly in some part of the axillary region, increasing quickly to a great size, so as to fully occupy that locality, and attended soon by discoloration of the integuments with infiltrated blood; the general signs of hemorrhage are often present, for instance, pallor of coun- 1 (Euvres Chirurgicales, t. i. pp. 379, 380. 2 Clinique Chirurgicale, t. ii. p. 95. 4 Hodgson, Diseases of Arteries, pp. 489 , 490. 3 Op. cit., t. ii. p. 150. 6 Ibid., pp. 488, 489. LACERATED WOUNDS AND RUPTURES OF ARTERIES. 607 tv nance and lips, weak, rapid, or scarcely perceptible pulse, and great debility with marked faintness, or even complete syncope. The characteristic symp- toms of aneurism, however, are very frequently absent, as the examples of this accident, which have already been presented, fairly show; for in many of them there was neither pulsation in the tumor, nor aneurismal thrill, nor .aneurismal bruit, nor even circumscribed tumefaction. When the aperture in the artery is very small, or when the laceration does not at first extend through all the coats of the artery, the swelling may come on very slowly or very irregularly; and this circumstance, together with the absence of the symptoms which characterize aneurismal tumors, has led surgeons of deserved eminence into errors of diagnosis that have been attended with disastrous consequences. The following case, reported by Mr. Callender, illustrates in a useful manner the symptomatology and some of the difficulties which may attend the diagnosis of this accident:— A gardener, aged 61, dislocated his left shoulder-joint by a fall. The luxation was redueed ; but, from employing passive movements too soon, it recurred. At the begin- ning of the seventh week, Mr. Callender again reduced it, under chloroform, by cir- cumduction, “ with the exercise of very slight force.” Immediately afterward, “ a swelling, rapidly lifting itself and projecting the pectoral muscle,” attracted his atten- tion. It did not pulsate, and the radial artery beat naturally. He eiToneously thought the main artery was not injured ; “ so the arm was confined by a bandage and the patient was removed to his bed.” “ The swelling having attained considerable size ceased to grow larger, and, as the man recovered from chloroform, there was no com- plaint of local pain.” “ The following morning, the patient’s general condition was good.” “ The swelling beneath the pectoral muscle had become more diffused,” “ so that it extended around and behind the shoulder.” “ There was considerable ecchy- mosis,” “as low as the buttock,” “ and the entire arm was (edematous.” “ No change occurred, save that the ecchymosis began to clear up,” and the oedema of the arm was rapidly subsiding, until the fourth day. “ Then, after straining at stool, he complained of pain about the shoulder, and it was evident that blood had been freshly effused.” “ The radial and ulnar arteries continued to beat normally.” During the next thirty- eight days, the tumor “ did not materially increase in size. But now it again enlarged itself.” “As before, no pulsation existed in the swelling, nor was any bruit detected, carefully as it was naturally sought for.” The confinement to bed and the local mis- chief were beginning to tell on the patient; it was decided to operate, about six wreeks after the reduction of the luxation. An incision was made along the outer border of the pectoralis major, and was intersected by another, at its middle, extending inward through the whole thickness of the muscle, as high as the clavicle. When the great cavity thus opened was cleared of blood, some clots were seen projecting from behind the pectoralis minor. On removing them with a finger, a gush of arterial blood immediately follow ed. This bleeding was readily checked by compressing digitally the subclavian artery as it came over the first rib, and the distal portion in the low'er part of the opened cavity. The pectoralis minor was then cut through, and it wras seen that the bleeding came from a small, roundish aperture in the upper wall of the artery, and by pressing on this spot all hemorrhage w'as arrested. The vessel was next more completely exposed, and a ligature was passed around it on the distal side of the aperture, and then tied. A second ligature was placed on the vessel, about one inch above the first, and the artery itself was cut across midway between them. The wrnlls of the vessel wrere considerably thickened. The principal veins and nerves w7ere uninjured. For four days the patient did well. On the fifth day, the arm became gangrenous. On the afternoon of the seventh day, he died suddenly with symptoms of pulmonary embolism.”1 Had a correct diagnosis been made at the outset of this case, and had a plan of treatment consisting of adequately compressing the subclavian artery upon the first rib, and likewise the tumor itself, and confining the arm to the chest 1 St. Bartholomew’s Hospital Reports, vol. ii. pp. 96-1.00. 608 INJURIES OF BLOODVESSELS. by means of a broad roller, been judiciously carried out from the beginning, it is not improbable that the issue of the case would have been favorable. The following example will serve to illustrate still further the symptoma- tology of this accident, and the errors of diagnosis which may attend it:— A woman, aged 66, sustained a dislocation of the shoulder, which, at first unrecog- nized, was reduced at the end of six weeks by a “ bone-setter,” who made extension by the elbow and wrist, with the aid of four strong men. The arm remained engorged, and two or three months after the accident the patient entered the Hotel-Dieu. Twelve days after admission, she received from another patient a blow on the elbow, which deter- mined the appearance of a tumor in the axilla, of the size of an almond ; and a pupil, who examined her at this time, found the radial pulse already absent. Six or eight days later, the swelling having increased, Dupuytren mistook it for an abscess; he thrust a bistoury into it, saw a jet of arterial blood escape, and, on making a better examination detected an obscure thrill in the tumor. He proposed to ligate the sub- clavian, a bold idea for the period (1810), but Pelletan would not allow it to be exe- cuted. Valsalva’s plan of treatment was essayed ; an eschar formed on the tumor, a hemorrhage completed the patient’s exhaustion, and she died eight days after the punc- ture, and fourteen days after the appearance of the aneurismal tumor. On autopsy, the outer coat of the axillary artery was found dilated, through a space two inches long, to a diameter of one inch, where widest. This dilatation presented on its posterior, exter- nal aspect, an aperture which opened into the cavity of a very much larger swelling, equalling at least the size of a new-born infant’s head, and having cellular tissue only for its wall. Above the dilatation, the artery was dry and hard ; below, its canal was completely obliterated.1 It is probable that the employment of violent extension, in this case, was attended with rupture of the inner and middle coats of the axillary artery,, and followed by dilatation of the outer coat into an aneurismal pouch; that the blow on the elbow made a small rent in this pouch, and led to an effusion of blood into the connective tissue of the armpit, which Dupuytren punctured because he thought it to be an abscess. Exploration of the tumor with the grooved needle, or even a critical examination of the tumor by ordinary means, would have prevented this sad mistake. The sudden formation of a large swelling in the armpit, in consequence of a lesion of the axillary vessels resulting from a blow, or from a strain of the shoulder, or from violent extension of the arm, or from dislocation of the arm at the shoulder-joint, or from efforts to reduce this form of disloca- tion, is but seldom due to anything beside a rupture of the axillary artery. When such a swelling pulsates and presents the thrill and bruit of an aneurism, there is, of course, no difficulty whatever in determining its true character. But this is not often the case. Generally such swellings, have neither pulsation, nor thrill, nor bruit. When, however, pulsation ceases in the radial, ulnar, and brachial arteries, simultaneously with the injury and the appearance of the axillary swelling, it is indicated with sufficient clearness that the continuity of the axillary artery as a canal or tube has been destroyed by the accident, or that the lumen of the vessel has been filled up by the lesion. When pulsation continues in the arteries of the forearm and arm, notwithstanding the tumefaction in the axilla, we must bring to our aid, in order to determine the nature of the tumefaction, the situation and extent of the subcutaneous eccliymosis, the gravity of the general signs of hemorrhage, the shape of, and degree of tension in, the axillary swelling itself, and a recollection of the fact that there are but three or four cases of uncomplicated rupture of the axillary vein on record, and that it is an accident of extremely rare occurrence. Moreover, when such a swelling is 1 Pelletan, Clinique Cliirurgicale, t. ii. p. 83 ; Dupuytren, Legons Orales, 2me 6d. t. iii. p. 12. LACERATED WOUNDS AND RUPTURES OF ARTERIES. 609 due to rupture of the axillary vein, it is likely to he much less tense and rounded than when it is due to rupture of the axillary artery. The con- tinuance of the radial pulse when the axillary artery is torn open, denotes that its coats are perforated by a small aperture, that its canal remains open, and that possibly a cure may be effected by compressing the main artery on the cardiac side of the swelling, and by binding, at the same time, the arm to the trunk with a broad roller. Treatment.—Sir Charles Bell relates that, at the infirmary of Newcastle, strong efforts to reduce a dislocation of the shoulder ruptured, at the same time, the muscles and the axillary artery, so that it was necessary to resort to immediate amputation.1 The operation failed to save the patient. Syme, however, has amputated in three cases where the axillary artery had sus- tained a rupture, with success in each instance; and in cases where gangrene follows 'this accident, amputation in the upper third of the arm, or at the shoulder-joint, is almost our sole expedient. Warren tied the subclavian artery successfully in the following instance:— A man, aged 30, dislocated his shoulder whilst drunk. The reduction was immedi- ately effected with the operator’s boot in the axilla. A tumor formed in the armpit; forty-three days afterward it broke open, and two hemorrhages ensued. The sub- clavian artery was then tied in the third part of its course, and the life of the patient was saved.'2 In the cases operated on by Mott and O’Reilly, which I have already presented, ligature of the subclavian artery was also followed by recovery. But in another case that was operated on by Nelaton, also presented above, ligature of the subclavian artery in the third part of its course was followed by bursting open of the aneurismal pouch, and by death from secondary hemorrhage. Furthermore, Panas has reported a case of axillary aneurism which supervened fifteen days after reducing a dislocation of the left shoulder. He tied the subclavian artery, external to the scaleni, but, three months after- wards, the patient died from suppuration of the aneurismal sac. The autopsy showed that the rupture had involved mainly the inner and middle tunics of the artery, and that it had occurred near the origin of the subscapular.3 These cases of elaton and Panas clearly show that ruptures of the axillary artery, when treated by ligation of the subclavian in the third part of its course, are very liable to be followed by bursting open of the axillary swelling, and by death from secondary hemorrhage or from suppuration of the aneurismal cavity. Blackman tied the axillary artery, in the first part of its course, without benefit, in the following case :—• A physician, aged 50, presented himself with a dislocation of the shoulder down- ward and inward, of sixteen weeks’ duration, one unsuccessful attempt at reduction having been made ten weeks after the accident. Chloroform and ether (mixed) having been administered, the arm was adducted, rotated, abducted, and elevated; these manipulations having been continued about ten minutes, tumefaction appeared in the pectoral region, which in a few minutes attained considerable size, and it was then found that the radial and ulnar arteries had ceased to pulsate. Rupture of the axillary artery was diagnosed. The axillary itself was then tied in the upper part of its course, but the patient died on the twelfth day from secondary hemorrhage, occurring at the seat of ligation.4 The untoward result in this case shows very clearly, I think, how badly adapted the operation of Anel is for affording relief in all similar cases. 1 Malgaigne, Traitfi des Fractures, etc., t. ii. p. 151. * American Journal of the Medical Sciences, 1846, vol. xi« p. 539. 3 Nouveau Dictionnaire de M6decine et de Chirurgie pratiques, t. xiii. pp. 492, 493. Paris, 1870. * Hamilton, Fractures and Dislocations, p. 657. 610 INJURIES OF BLOODVESSELS. Sir James Paget, in a case of rupture of the axillary artery which I have already presented, laid the tumor freely open hy a j_-shaped incision, scooped out the clots, found an oval-shaped aperture in the posterior wall of the artery, ligated the artery on each side of the aperture, and divided the vessel itself midway between the two ligatures. The loss of blood attending the operation was less than six ounces. The patient made a good recovery. By the same procedure, which is in substance the “ old operation,” Syme also treated with success two cases belonging to the same category. In such cases this method of operating should generally be preferred, because it is much less liable to be followed by secondary hemorrhage and suppuration of the sac than ligation of the subclavian artery in the third part of its course, or ligation of the axillary artery itself in the first part of its course. In per- forming the “old operation,” the distal ligature should generally be applied before the proximal, because the flow of blood from the distal portion of the •artery is apt to give the surgeon much more trouble than the hemorrhage from the proximal portion. The surgeon may, indeed, be strongly tempted to tie the subclavian artery in the third part of its course, on account of the comparative ease with which this operation can be performed, instead of cutting down upon the seat of the rupture, and tying the artery above and below it; hut if he listen to this prompting of indolence, he may live to .sorely regret his failure to employ the more difficult procedure. Compression of the main artery on the cardiac side of the lesion has not, I believe, received that degree of attention in cases where the axillary artery is ruptured without external wound, and blood is being poured in great quantity into the loose connective tissue of the armpit, which its importance as a haemostatic measure really demands. In the foregoing pages I have briefly presented thirty-four cases in which there was a rupture of the axil- lary artery. Twenty-six of them ended in death, and only eight in recovery; and in four of these successful cases, no treatment whatever was enjployed, excepting compression, with fixation of the arm to the side of the trunk by means of a bandage, and quietude; and in one instance the application of ice. When, therefore, the surgeon has the misfortune to witness the occurrence of this accident, he should immediately proceed to compress the subclavian artery against the first rib, for by so doing he will restrict the extravasation to a moderate amount, and may even effect a permanent cure. By this means he can at least prevent the concealed hemorrhage from going so far as to produce a fatal syncope in a short time, or anaemic exhaustion and death therefrom in the course, of a few days. In most instances of extravasation from rupture of ihe axillary artery, as soon as the diagnosis becomes clear, the best course for the surgeon to pursue is, while continuing the pressure on the subclavian artery, to cut down upon and expose the axillary artery where it is lacerated, and to place a carbolized catgut ligature around it on each side of the lacera- tion, finally dividing the vessel itself midway between the two ligatures. But when the surgeon is not called to the case until a great extravasation has already occurred, and the armpit is hugely distended with effused blood, the patient at the same time being cold, pallid, and almost pulseless from shock and hemorrhage, vigorous pressure should instantly be applied to the subcla- vian artery, and continued unceasingly, in order to prevent the further effu- sion of blood, until such time as the patient may have reacted sufficiently to allow the performance of the operation. Whenever a great extravasation of blood has occurred in consequence of this lesion, no operative procedure ex- cept the old one, or amputation at the shoulder, should be employed; and generally in such cases the cure should be attempted by compression supple- mented by the “old operation.” And, inasmuch as this operation is not .always easy of performance, the surgeon will probably succeed best by thor- oughly and faithfully compressing the main trunk on the cardiac side of the lesion, keeping the arm at the same time fastened to the chest by a broad roller, unless he possesses more than ordinary ability for operating on blood- vessels, and has the aid of at least one assistant, who is almost as competent as himself for such undertakings. When, however, the laceration being hut slight and restricted to the inner and middle coats of the axillary artery, the aneurismal tumor is developed but slowly, and has not yet attained a very considerable size—while it is also quite circumscribed, and has a genuine sac or a well-defined wall consisting of the external tunic of the artery, strengthened outwardly by laminae of condensed connective tissue—it may be expedient to tie the subclavian artery in the third part of its course on the plan of Hunter, as was practised by Mott with success in a case which I have already presented. But in all cases where the tumefaction is very great, or is caused by extravasation of blood into the connective tissue of the armpit, the only plan of ligation ad- missible is the “old operation,” whereby the clots are all taken out, and the artery itself is secured on each side of the laceration, and also divided mid- way between the two ligatures; for when this procedure is employed in such cases, the liability to death from secondary hemorrhage, or from suppuration of the sac, becomes very much less than it would be were Hunter’s or Anel’s operation performed. Furthermore, the surgeon should never make haste to use the knife so much as to ignore the diagnostic signs of this lesion; and in their absence he should place his main dependence on compression. Before quitting this subject it will be useful for me to point out the prin- cipal methods by which compression may be successfully applied to the sub- clavian artery for the cure of axillary aneurism ; and I cannot do this more clearly and tersely than by presenting a few examples in point:— A man, aged 71, under the care of Mr. Erichsen, in whom the aneurismal tumor had been noticed only one month, had compression applied for twenty-five hours —digital compression for eleven hours and mechanical for fourteen. The treatment ex- tended from June 23 to August 12, and resulted in cure.1 Mr. Cooper Forster also records a case. Pressure (digital and with a key) was ap- plied to the subclavian, at intervals, for three days, with some benefit; and then, under •chloroform, with a key above the clavicle, for five and a half hours, with complete suc- cess. It was, however, continued three hours longer.2 M. Verneuil3 had under his care a man suffering from an aneurism in the left axilla, having a diameter of about three and a half inches. First the arm was carried back- ward, pronated, and adducted, and fastened in this position to the thorax, but the patient could not bear this position of the limb any considerable length of time. Then digital compression of the subclavian artery (above the clavicle) was continued for twenty-four hours, but had to be abandoned, as the assistants became fatigued. A thick plaster of gypsum was now laid in the supra-clavicular region, and digital com- pression was made through it until the plaster had become hardened. From the model of the part thus obtained, a leaden cast, weighing six and a half pounds, was made, and it was used for effecting compression of the subclavian, its potency being increased by means of a handle. The patient ultimately attached to the handle three bands, which were fastened to the bed in various directions, and kept the mass of lead in place. This plan succeeded perfectly, when the weight was increased to about eleven pounds. By this means the subclavian artery was compressed during six or seven hours daily for about ten weeks, at the end of which time the size of the swelling had become reduced by nearly one-half, and the pulsations had almost ceased. The patient LACERATED WOUNDS AND RUPTURES OF ARTERIES. 611 1 Lancet, November 15,1873. 2 Guy’s Hospital Reports, 3d S. vol. xviii. p. 61. 3 Gazette Hebdomadaire, No. 12, 1873. 612 INJURIES OF BLOODVESSELS. was now dismissed from the hospital, but continued to apply the compression at home during several hours daily for ten months. Several years later he reported that the cure was complete ; the place of the aneurism was occupied by a hard mass of the size of a nut, which did not impair the usefulness of the arm. Generally, compression, applied in some of the ways mentioned above, should be faithfully tried before resorting to operative procedures with the knife, for the cure of traumatic aneurism of the axilla. In cases where the “ old operation” is practised, a drainage tube, deeply inserted, should be left in the wound. In such cases, also, antiseptic dress- ings are of great value, and, therefore, should be exclusively employed. When the torn artery has been ligated above and below the rent in its tunics, by this method, should secondary hemorrhage ensue, the wound of operation must be promptly reopened, the bleeding point sought for and found, and tied anew with carbolized catgut. Amputation near the shoulder, performed without delay, is the only expe- dient that can save the patient in cases where gangrene attacks the limb in consequence of an occlusion of the axillary artery resulting from rupture of its inner and middle coats, as happened in the cases reported by Professor A. Berard, and Inspector-General Smart, R. 1ST., which I have already pre- sented. In such cases, the gangrene usually appears first in the fingers. Wrhen the other arteries of similar magnitude that belong to the extremi- ties, both lower and upper, are ruptured without external wound, the treat- ment should be conducted on the same general plan, for the underlying prin- ciples remain unchanged. Lacerations of the Main Arteries of the Extremities Caused by Frac- ture of the Long Bones.—This accident has often been met with in the leg, and numerous examples of it have been reported. Dupuytren says that, from 1806 to 1825, he witnessed as many as seven cases of diffuse aneu- rism caused by fractures of the leg. He also says: “ It may be that practi- tioners have overlooked this serious complication of fractures and gunshot wounds, because they have regarded it as beyond the ordinary resources of art to cureand he adds that, “ in such cases, the universal recommendation has been to amputate.” But this mode of treatment has been attended with a great fatality. For example, Pelletan amputated the thigh in three cases belonging to this category, and lost two of his patients by death. J. L. Petit, in a fracture of the leg without external wound, saw the artery which passes between the two bones (doubtless the anterior tibial) laid open by the sharp edge of the broken tibia. The whole leg and foot became greatly swelled and ecchymosed; the part also became cold as well as dis- colored, and appeared gangrenous. He laid open the leg by an incision about six inches in length, extending above and below the fracture, and, discovering the open vessel, arrested the hemorrhage without displacing the bones. The case was then treated as an ordinary compound fracture, with success. This innovation was a great improvement. Boyer also recommended this plan of treatment, which consists essentially in cutting down upon the lacerated artery and tying its bleeding extremities. Dupuytren, in 1809, tied the femoral artery at the middle of the thigh, in a woman, aged 62, for the cure of a diffuse aneurism resulting from a simple fracture involving both bones of the leg, at the junction of the middle and inferior thirds. The fracture was oblique; there was also great swelling and tension of the surrounding soft parts. On attempting the reduction, Dupuy- tren felt in the calf of the leg strong pulsation, distinct to the eye as well as to the touch, and synchronous with the heart’s action; disappearing, too, on compressing the femoral artery, and returning on the withdrawal of"the com- LACERATED WOUNDS AND RUPTURES OF ARTERIES. 613 pression. The vessel lacerated was, in all probability, the posterior tibial artery. The application of the ligature immediately suppressed all further pulsation in the tumor. On the sixth day the bulk of the tumor was already lessened by one-third. The woman perfectly recovered. Delpech, in 1815, acting on this precedent, ligated the femoral artery toward the upper part of the thigh, in the case of a postillion, aged 30, who had sustained a simple comminuted fracture of both bones of the leg near the centre, from the pass- age over it of the wheel of a loaded cart. The leg was discolored, and exces- sively distended from tumefaction. The tumefaction itself pulsated distinctly, especially at the calf; the pulsations were synchronous with those of the heart, and were controlled by pressure on the femoral artery. The patient made a good recovery. Dupuytren, in 1818, in a case of compound fracture, employed the same method that had been successfully employed in these two cases of simple fracture of the leg. An officer was shot through the upper part of his right leg by a pistol-ball. It passed from before backward and inward, traversing the interosseous space, and injuring both bones. Severe hemorrhage from both apertures immediately ensued; it was arrested by compresses. The leg swelled and became acutely painful; and afterward alarmingly benumbed. There was no external hemorrhage until the thirteenth day ; but, meanwhile, blood was extravasated so as to form a diffuse aneurism which increased day by day in size, and exhibited pulsations which were synchronous with those of the heart, and immediately ceased on compressing the femoral artery. The hemorrhage which occurred on the thirteenth day was repeated at intervals, and greatly reduced the patient. At this time Dupuytren was called in, and found that the foot and leg were tumid, purple, cold, and benumbed; that there was a tense tumor at the upper part of the leg, which expanded and contracted with each beat of the heart; that this swelling was surmounted by two apertures, one in front, the other behind, made by the entrance and exit of the ball; and that these apertures had, for the last few hours, been closed by plugs of coagulated blood, which each pul- sation threatened to dislodge. Fortified by his previous success, he tied the femoral artery at the middle of the thigh. Before tightening the ligature, he ascertained that pressure on the exposed artery arrested pulsation in the tumor. In three months the patient perfectly recovered.1 Verneuil, in 1859, reported a case of diffuse aneurism from simple fracture of the leg, in which a new and much simpler plan of treatment was equally successful. The patient, being on horseback, struck his leg against a carriage- shaft, and broke it, but the fracture was masked during fifteen days by the swelling. The swollen region, however, was the seat of pulsations, syn- chronous with those of the femoral artery, and disappearing on compressing that vessel; the presence of a murmur or bruit was always doubtful. The arteria dorsalis pedis remained unaffected. Compression (intermittent) of the femoral artery upon the pubis was made by the patient himself; afterward, bags of shot were applied over the course of the femoral artery, and the cure became complete. Thus Verneuil avoided both amputation and ligation with perfect success. Azam has published a case of diffuse aneurism, with pulsa- tion and murmur, that was caused by simple fracture of the leg at its inferior part, in which a cure was obtained by compressing the femoral artery at the pubis. The patient himself, by means of a watch-glass, compressed the artery from six to eight hours daily. Two months after the accident, the callus was solid and the cure complete.2 Valette (de Lyon) has reported two analo- gous cases in which a cure was also obtained by compressing the femoral 1 Lecterns Orales, t. ii. pp. 521 et seq. Paris, 1839. 2 Nouveau Dictionnaire de Medecine et de Chirurgie pratiques, t. xix. p. 550. Paris, 1874. 614 INJURIES OF BLOODVESSELS. artery. In one of them, the fracture was complicated with an external wound of the leg, and with severe primary hemorrhage, which, however, was suppressed by pressure combined with the local use of the perchloride of iron. On the twentieth day the hemorrhage reappeared ; the same means were again employed, but they failed to control it. Finally, Valette stopped the bleed- ing by digital compression of the femoral artery; and compression thus applied was continued during about ten days, by four journeymen locksmiths, comrades of the patient, who relieved each other every four hours. The wounded man completely recovered. In the other instance, compression of the femoral artery also succeeded, but the success was perhaps less striking, because the hemorrhage was less severe; nevertheless, the result was highly encouraging for the future employment of compression.1 Symptoms of Arterial Laceration due to Fracture.—In cases of simple frac- ture, the occurrence of this accident is denoted by the following signs: tume- faction tense in character, discolored by subcutaneous ecchymosis, increasing rapidly, and pulsating synchronously with the heart; the pulsations them- selves ceasing on compressing the main artery on the cardiac side of the swelling, and returning on withdrawing the compression; and the tenseness of the swelling growing markedly less under compression of the main artery, to return again when the compression is discontinued. The peculiar thrills and murmurs which are found in spontaneous aneurisms may also be present in diffuse aneurisms from fracture. But the thrill is often, and the murmur sometimes, absent in such cases. For instance, in Verneuil’s case, related above, the presence of a murmur was always dubious. When the arterial wound is very small or very oblique, neither distinct pulsations, nor arieur- ismal thrills, nor aneurismal bruits are to be found, but only an impulsion, synchronous with the contraction of the heart, is imparted to or discernible by the hand. In an example presented by Dupuytren, a sort of tremulous movement, increasing and diminishing alternately, was perceptible in the swelling, but no distinct pulsation. This tremulous movement, however, ceased when the popliteal artery was compressed; and, at the same time, the swelling was observed to become less tense, and to diminish a little in volume. The tremulous movement, and the tension, and the volume of the swelling, too, were restored when the pressure was removed from the artery. The diagnosis was, therefore, not doubtful. Moreover, in certain patients an aneurismal bruit has been recognized in the swelling, when pul- sation, or impulsion, or tremulous movements have been wholly wanting in it. The symptoms of diffuse aneurism may not appear until several days after the fracture, because the artery remains unopened until that time. In one of Pelletan’s cases, they did not appear until the seventy-fifth day. In such cases the artery is, for the most part, penetrated by ulceration from pressure exerted by the fragments. When the fracture is compound and the hemorrhage is external, the blood is bright red, but it rarely issues in jets. As syncope approaches, the bleed- ing can generally be stopped by local applications, but after some days it returns as strongly as ever; it may do.so again and again, and, if they be not properly treated, these successive hemorrhages must end by carrying off the patient. One of Valette’s cases, related above, illustrates this point; so also does one of Dupuytren’s examples. Fr. Poncet2 presents in a tabular form twenty-one cases of diffuse aneurism resulting from fracture of the leg, that occurred in the practice of Kibes, Desault, Dupuytren, Delpech, Mirault, Lisfranc, Guthrie, Travers, and others, 1 Ibid., t. xix. p. 585. Paris, 1874. 2 Nouveau Dictionnaire de Medecine et de Cliirurgie pratiques, t. xv. p. 497. Paris, 1872. LACERATED WOUNDS AND RUPTURES OF ARTERIES. 615 in which either ligation or compression was resorted to. No mention, how- ever, is made therein of those instances of this accident, although they are quite numerous, which have been treated by amputation of the thigh, or have been allowed to run their course without surgical interference, and which have terminated fatally by hemorrhage or by gangren€. The following is a brief summary of the tabulated cases d— Ligature of the femoral artery has furnished Cukes. . 5 Deaths. 1 Ligature of the tibial above the tumor .... . 3 2 Ligature of the peroneal ....... . 2 — Compression applied in the wound ..... . — 2 Compression applied to the main artery above . 3 — Add the cases of Verneuil and Yalette .... . 3 — 16 5 To these, Azam’s case, related above, in which a cure was obtained by compressing the femoral artery at the pubis, is to be added, which gives in all seven examples of this formidable lesion that have been cured by indirect compression, without any accident, and without any failure. Ligature of the femoral artery at or above the middle of the thigh has furnished fi ve recoveries, and one death. The most dangerous plans of treatment are, beyond doubt, compression applied in the wound, and ligature of the injured artery imme- diately above the tumor; and, therefore, these should generally be considered as inapplicable to, and not permissible for, this lesion. Appreciation of Methods.—There are four distinct surgical procedures which may at times be required in treating the lacerations of arteries which are caused by fractures of the leg. (1) Indirect compression, that is, com- pression of the parent vessel, or arterial trunk, on the cardiac side of the lace- ration, at some considerable distance from it. (2) Ligature of the lacerated artery itself, on each side of the laceration. (3) Ligature of the superficial femoral artery, at or above the middle of the thigh. (4) Amputation. (1) Compression of the femoral artery at the pubis, from its innocuousness, and the remarkable success which has attended its use, is far preferable to every other plan of treatment; and the surgeon should always make faithful trial of it, when practicable, before proceeding to operate with the knife. It is always advisable to make digital compression in such cases, if possible; but this plan of treatment requires the co-operation of at least several intelli- gent assistants ; these are not always at hand, and in the country especially the surgeon may ofttimes be unable to find them. lie should then, if he can, resort to the use of instruments for compressing the femoral artery, such as I have already described on pages 521 et seq. But, after all, there will be cases in which, either from want of the means to make compression, or from failure of the compression itself, recourse must be had to other procedures. (2) The “ old operation,” that is, the ligation of the torn artery itself in the wound, above and below the rent in its tunic, although J. L. Petit, performed it with success, is not admissible in cases of simple fracture, because it would convert them into compound fractures. There is no pretext under which a surgeon can justify himself in voluntarily converting a subcutaneous into an open fracture. But in cases where the fracture is already compound, and the hemorrhage is external, wrhen compression of the femoral artery at the pubis is impracticable or ineffectual, it is often, perhaps generally, advisable to lay open the swelling, by enlarging the original wound, if necessary, in order to 1 There are also a good many instances of this accident on record in which the “ old operation’* was performed, or recovery spontaneously occurred, that are not mentioned or embraced in Poncet’s table. 616 INJURIES OF BLOODVESSELS. find the lacerated artery and secure it with ligatures of carbolized catgut applied on each side of the aperture in its walls. The external wound should then be closed and treated antiseptically. (3) Ligation of the superficial femoral artery, at or above the middle of the thigh, as originally recommended and practised by Dupuytren, is the opera- tion which must be performed in cases of diffuse aneurism resulting from fractures of the leg that are simple or unattended with external wounds, whenever compression of the femoral artery is impracticable or proves inef- fectual. (4) Amputation at the knee should be performed, without delay, as soon as gangrene appears in the toes or foot belonging to a limb where this accident has occurred; and there is but one circumstance besides gangrene which makes this operation admissible for the lesion in question, and that circum- stance is the failure of all other plans of treatment. The surgeon should, generally, when this accident has occurred, be in no great hurry to operate with the knife, unless there is external hemorrhage not amenable to compression, or unless gangrene makes its appearance; and then he cannot perform the operation of ligation on the one hand, or ampu- tation on the other, too speedily. Concerning the application of compression to the femoral artery for this lesion, the surgeon should never, in an excess of zeal or anxiety, ignore the fact that it need not suspend the circulation entirely, need not even act con- tinuously, in order to effect a cure. In several of the cases presented above, where the success was most striking, the compression was intermittingly applied, and in two instances it was made by the patients themselves. Thus the surgeon may, without risk, substitute for the intolerable torture of the old modes of compression, a treatment which, in ordinary cases, is harmless, and which, in a few, is absolutely painless. But the occurrence of diffuse traumatic aneurism in consequence of fracture is not restricted to the leg, although it is met with in that region much oftener than elsewhere. Fractures of the thigh, likewise, are not unfre- quently complicated by lacerations of large arteries, and by the appearance of sanguineous tumefactions communicating with the canals of the torn vessels, which, in default of a more appropriate name, are called diffuse traumatic aneurisms. Giirlt1 presents a long statistical table, containing twenty-five examples of this accident that occurred in the thigh, leg, and arm; four of them were observed in the thigh, tweMy in the leg, and one in the arm. The four thigh cases were reported by Bransby Cooper, by Lyon of Glasgow, by Trugen of Posen, and by Guthrie. Three of these patients died and only one recovered. The excessive mortality sufficiently attests the gravity of the lesion. The following case occurred at the Middlesex Hospital, under the care of Mr. Moore:— In a man, aged 35, having simple fracture of the femur, there was an extensive swelling of the thigh, together with an arterial bruit in some vessel—not the femoral artery—which could be felt below the seat of injury.2 The symptoms of an arterial wound in this case, viz., the bruit and swelling, disappeared under the influence of the absolute rest of limb and general quietude of body which the fracture necessitated, that is, without any special treatment, and the fracture itself united in three months. It is probable that in the examples of this accident met with in the thigh, the branches of the femoral artery are the seat of the lesion much oftener than the parent vessel. 1 Handbuch der Lehre von den Knoclienbriichen, Bd. i. S. 526-537. 2 Holmes’s System of Surgery, second ed., vol. iii. pp. 519, 520. LACERATED WOUXDS AMD RUPTURES OF ARTERIES. 617 The arm case contained in Gurlt’s statistical table was reported by Perus- sault, and the patient recovered. There was crushing (zerschmetterung) of the external condyle of the right humerus, of the olecranon, of the radius, and of the ulna. The following arm case was under Mr. Moore’s care at the Middlesex Hospital, and is of special value in this connection, because it illus- trates the subject much better than many words of abstract description:— A woman, aged 42, injured her right arm by falling down stairs at night, and pre- sented herself next day. The whole hand and forearm, and part of the upper arm, were tensely swollen and covered with bullae of various, but principally of small size. Serum mixed with blood tilled the bullae. Fracture of the olecranon was easily made out, but no other osseous lesion could be detected. On the following day the swelling was larger, and the vesications more extensive. There was an aneurismal pulsation in front of the elbow, strong and expanding, but deeply seated. The impulse extended half-way up the inner side of the arm, and more than half-way down the whole palmar surface of the forearm. A distinct bruit was heard with the stethoscope in front of the elbow. The two arteries at the wrist beat so forward and so forcibly, and appeared so much larger than those of the other side, as to give the idea that they had been raised up by extravasated blood, and that the pulsation was communicated to the distended sheaths of the vessels. The skin on the hand was dusky from congestion; and when the color was expelled by pressure, it returned very slowly, showing the embarrassed condition of the circulation. The limb was everywhere warm, however, and there was no sign of impending gangrene. At the consultations various opinions were expressed as to the appropriate treatment; but it was agreed that some large artery, possibly the brachial, was wounded. It was ultimately decided to watch the case. In the evening, the swelling was found not to have increased, and the hand was certainly less tense. A rounded swelling was found near the armpit, in the neighborhood of the brachial artery, which appeared to be the end of the clot of extravasated blood. On the following day (the third from the accident) pulsation had ceased in all other parts, and was perceptible only in front of the elbow, over a space about as large as a half-crown, and not strong. Next day the aneurismal pulsation disappeared, and the swelling afterward gradually subsided. When the subsidence was sufficient, fracture of the lower end of the humerus was detected. The case did well.1 This case shows that lacerations of healthy arteries, when uncomplicated with external wounds, sometimes show a re- markably strong tendency to recovery. Mr. De Morgan, in a clinical lecture at the Middlesex Hospital, also says: “ We have had, within the last few years, two or three cases of simple fracture where there was a large and rapid effusion of blood beneath the skin, and marked aneurismal pulsation; in which, however, arrest of the hemorrhage ensued spontaneously, and complete absorption took place, although it was clear that a large artery had been torn through.”2 Diffuse traumatic aneurisms, resulting from fractures, when they occur in the thigh or arm, should be treated on exactly the same principles as when they occur in the leg, a thorough discussion of which accidents has just been pre- sented. I must, however, add that examples of this accident occurring in the leg, too, sometimes recover without any special treatment of the arterial lesion. Such a case was under the care of Mr. Mitchell Henry, at the Middle- sex Hospital. The posterior tibial artery was wounded, in a boy who had simple fracture of the leg. The diagnosis rested on the absence of pulsation in that artery and the presence of bruit in the swelling, together with a pecu- liar restlessness of the limb. The fracture healed slowly (in about two months), and these symptoms gradually subsided, but the pulse did not return in the affected artery.3 In such cases it is sometimes said that the arterial wound heals spontaneously ; it must not be forgotten, however, that but few 1 Ibid., pp. 519, 520. 2 British Medical Journal, January 6, 1872. 3 Holmes, System of Surgery, 2d ed. vol. iii. pp. 519, 520. 618 INJURIES OF BLOODVESSELS. things which the surgeon may do can promote the closure of the torn artery and the absorption of the extravasated blood, more effectually than the fixed position, absolute quietude, and equable support of the injured part, with general quietude of the whole body, which the fracture and its dressings en- force. Compression, digital or instrumental, of the main artery, should always be thoroughly tried in the thigh and arm, as well as in the cases of this acci- dent occurring in the leg, before resorting to the “ old operation,” or to liga- tion of the main artery on Hunter’s plan. There is good ground for hope that almost all arteries of the extremities, both lower and upper, when wounded in cases of simple fracture, will heal when the fixed position and quietude, just mentioned, are supplemented by adequate compression of the parent vessel. The appearance of gangrene in such cases necessitates the immediate performance of amputation. But traumatic aneurisms resulting from fractures are not confined to the regions of the leg, thigh, and arm; they are also found in any part of the body where an artery lies sufficiently near the bone to be pierced or torn by its broken fragments. Mr. Busk and Mr. Curling have each placed on record a case in which a traumatic aneurism formed upon the ophthalmic artery in consequence of fracture of the base of the skull. In both cases the carotid artery was tied, and in both with complete success.1 Gunshot Wounds of Arteries. The large arteries of the extremities are, to a considerable extent, protected from gunshot perforations, by the strength of the fibrous sheaths which in- vest them, by the toughness and extensibility of their own tunics, and by the readiness with which they can slip aside from the track of a gunshot missile, owing to the fact that they are elastic tubes, and that their contents are liquid. By these means, doubtless, the large bloodvessels often escape lacerations from bullets; and in this way we can account for the fact that such arteries as the femoral, the carotid, and the brachial are found to be practically uninjured, although lying exactly in what appears to be the track of the missile. The late civil war furnished numerous examples. “ A num- ber of drawings at the Army Medical Museum, exhibiting the course of balls directly in the track of the great bloodvessels of the neck or of the limbs,, illustrate the fact, so well known to military surgeons, of the great resiliency of the large arteries.”2 The surgical historian of the British Army in the Crimean War justly observes:— “ The amount of this resiliency of the large arteries of a limb is much greater than is usually supposed. Thus, in a soldier of the 50th Regiment, a fragment of shell passed through the ham, between the artery and the bone, without injuring either,, although it was much too large to have done so without displacing the vessel. The man afterwards died of diarrhoea. In the 9th Regiment a similar case occurred, but in it a portion of the bone was scooped out by the missile, and the man recovered. In the 47th Regiment, a large piece of shell passed through the upper third of the thigh,, between the artery and the bone, but injured neither, and recovery took place.”3 Notwithstanding this wonderful resiliency of the arteries of the neck and extremities, which oftentimes enables them to escape all serious injury even when they appear to lie exactly in the track of wounds made by gunshot missiles, it not unfrequently happens that they sustain solutions of continuity 1 Medico-Chirurgical Transactions, vols. xxii, xxxvii. 2 Circular No. 6, S. Gr. 0., p. 39. 3 Surgical History of the Crimean War, vol. ii. p. 340. GUNSHOT WOUNDS OF ARTERIES. 619 from the impact of such missiles. Experience has shown that these arteries may be wounded in such a way as to have their calibres directly opened by musket, ride, carbine, and pistol-balls, by case-shot, and by fragments of shells. It seems, however, to be necessary for the accomplishment of such a result, that the missile should be moving with great velocity at the moment when it strikes the artery. Hence it happens that bullets are much less likely to penetrate the arteries after they have passed through the compact structure of the long bones of the extremities, than they are before making such a passage through osseous tissue. If the velocity of the missile has been con- siderably lessened ere it impinges against the artery, it may only bruise its tunics j1 but, in so doing, it may cause as much damage to the patient as it would have done by opening its calibre. The solutions of continuity or breaches, produced in the walls of blood- vessels by gunshot missiles, are essentially contused and lacerated in their nature, and usually present some of the features which belong to each of those classes of injury. They can, therefore, be most conveniently considered in this place, that is, immediately after the contused and lacerated wounds of arteries have been discussed. The breaches in the walls of bloodvessels which gunshot projectiles occa- sion may be separated into two important groups:— 1st. Partial or incomplete division of the vessel, considered as a tube for the transmission of blood. 2d. Complete division of the same. We find, on studying attentively the details of this subject, that each of these groups presents peculiarities in respect to phenomena and consequences, of so much importance in both a scientific and practical point of view as to demand for each a separate consideration. Examples of gunshot injury in which the wound of an artery constitutes the sole or even the principal primary lesion are not of frequent occurrence in surgical practice, and are not often met with by surgeons even on battle-fields, although arterial wounds very often present themselves as complications, it is said, of gunshot fractures and other important injuries. On this point the late Dr. Otis, the distinguished historiographer of our civil war, remarks:— “ The number of cases reported under this head is extremely small. In the cam- paign of the Army of the Potomac, from the Rapidan to the James, in May, June, and July, 1864, of a total of 36,508 gunshot wounds, only twenty-seven belonged to this category. The cases of compound fracture complicated with injuries of the large vessels, the cases in which limbs are carried away by solid shot or shell, and the cases in which all the tissues of the limb are disorganized by contusion from a large projectile, and the vitality of the arteries is destroyed, are all returned under other heads. Those only are included in which the canal of a large vessel is primarily opened, and in which this is the principal accident. Such cases are to be sought for among the dead on the battle-field, rather than in the field hospitals.”2 Again, in almost all the cases where an artery of considerable magnitude has been opened by a gunshot missile, which are brought to the surgeon for treatment on the field of battle, the injured vessel is found to be situated in the extremities, in the neck, or in the head, but most frequently in the extremities. Gunshot wounds of the great arteries of the abdomen and the thorax fail to come under the notice of military surgeons, not because these vessels escape all injury, but because, whenever they are opened, death usually very speedily ensues. I am fully convinced from personal observation, that these vessels are frequently wounded in battle; that such injury is, for the 1 See Contused Wounds of Arteries. 2 Circular No. 6, S. Gr. 0., pp. 38, 39. 620 INJURIES OF BLOODVESSELS. most part, very quickly followed by death from hemorrhage; and that this form of gunshot lesion should be ranked as one of the principal causes of sudden death in warfare. The subjects of this form of gunshot injury almost always perish from hemorrhage before they can be taken up from the field, and hence they are generally reported on the company-rolls as killed. Partial or Incomplete Division of Arteries by Gunshot Missiles.— This lesion presents itself in two principal forms. In one of them a side of the arterial tube has been carried aw7ay ; in the other, the vessel has been perforated through and through by the missile. The former occurs much oftener than the latter. The former is met with in vessels presenting much variety in respect to size; the latter only in large ones. But the consequences of the arterial wound are quite similar in both instances. The following abstract, and the woodcut which accompanies it (Fig. 427), afford a most excellent example and illustration of the partial division of a large artery by a cylindro-conoidal bullet:— A soldier, aged 19,1 was accidentally wounded, January 11, 1866. The missile, a conoidal musket-ball, entered his right side, just below the cartilages of the false ribs, passed upward, and fractured the eighth rib ; it then emerged from the chest, and, the axilla, traversed the arm, and passed out at the top of the shoulder, without Fig. 427. Guashot wound of the right axillary artery ; pieces of cloth, driven in by the ball, moderated the bleeding. (Spec. 2674, Sect. I., A. M. M.) injuring the humerus. He was taken to the post-hospital, in a state of syncope, unable to speak and almost pulseless. His extremities were cold, and he was said to have lost a bucketful of blood. Powerful stimulants were immediately administered. The hemorrhage did not return until the 20th, when he lost about fifteen ounces. It was stopped by compression. It again recurred on the 21st, and he lost about twenty ounces. On the 22d, although the prostration from loss of blood was extreme, it was deemed expedient to tie the axillary artery, which was accordingly done with a single ligature; but he survived the operation only a few minutes. During the operation several fragments of cloth were extracted, and also two pieces of the axillary artery. On the extraction of the cloth, hemorrhage, per saltum, commenced, but it was easily controlled by compressing the subclavian above the clavicle, with a door-key. Ne- croscopy—A large semicircular piece, embracing about half the calibre of the vessel, was cleanly cut out by the ball from the side of the axillary artery, about one inch below its origin ; brachial plexus uninjured. The fragments of cloth and flesh which were extracted during the operation had doubtless been driven into the artery, and their dislodgment by accident or by suppuration brought on the secondary bleeding. Such a wound of the axillary artery usually causes death from primary hemorrhage in about five minutes. The accompanying woodcut (Fig. 427) represents the specimen, which is preserved in the Army Medical Museum. The wound was inflicted, whilst the man was lying in his tent, by a com- rade who was handling a loaded musket. The missile was therefore moving with great velocity, and it cut cleanly out a large semicircular piece from the side of the axillary artery, embracing about one-lialf its calibre. Generally, when large arteries are laid open by gunshot missiles, the wounds are inflicted at short range by small-arm projectiles, the missiles moving with great velocity at the moment of impact; especially when such arteries as the 1 Med. and Surg. History of the War of the Rebellion, First Surg Vol., p. 553. GUNSHOT WOUNDS OF ARTERIES. 621 femoral, the carotids, the axillary, and the brachial, are involved. But wounds, inflicted at long range by the same class of projectiles, may be attended with contusion of these arteries; or, from their resiliency, they may escape all appreciable injury. An important fact connected with this case, wherein the main artery of the upper extremity was cut half-way across by a cylindro-conoidal ball,, only one inch below where it is called subclavian, is that the bits of cloth carried into the wound by the ball, and the occurrence of syncope, stopped the primary hemorrhage. Another important fact is, that the bleeding was restrained for nine days, that is, until the bits of cloth, pieces of flesh, and occluding clots had become loosened and detached by suppuration. The following abstract and woodcut (Fig. 428) present us with another- instance and illustration of the incomplete division of a large artery by a cylindro-conoidal missile:— A corporal, aged 22,1 was wounded May 3, 1863, by a conoidal musket-ball, which entered the nose and escaped near the right ear, having shattered the right superior maxilla in its course. Slight hemorrhage began on the 9th, but it yielded to compression. It recurred, however, several times with great profuseness ; the patient became frantic with alarm, and prevented all attempts at compression, etc.; and died, rather suddenly, from hemorrhage, on the 11th—eight days after the casualty. The specimen is represented in the accompanying woodcut (Fig. 428), which shows the terminal portion of the common carotid, the first portion of the in- ternal carotid, and the external carotid from its origin up to and beyond the site of the gunshot lesion of its walls. In this case the primary hemorrhage, which doubt- less was severe, ceased on the approach of syncope; for the bruised and lacerated tissues surrounding the track of the ball afforded a good lodgment for a coagulum to plug the wound, and thus stop the outflow of blood. The hemorrhage was restrained until the sixth day, when the bruised and lacerated tissues, or the slough, surrounding the hole made by the ball, began to get loose, preparatory to- their discharge by ulceration. The following abstract and woodcut (Fig. 429) also illustrate in a useful manner the partial division of a large artery by a gunshot projectile:— Fig. 428. Shot-wound of the external; carotid, near the origin of the- internal maxillary artery. (Spec. 2222, Sect. I., A. M. M.) A soldier,1 aged 25, on July 3, 1863, received a gunshot wound of the neck and face.. On the 9th, secondary hemorrhage from the external carotid artery, to the extent of twelve ounces, occurred. On the 10th, the common carotid was ligated, three-quarters- of an inch below the bifurcation. The hemorrhage did not return ; but, on the 13th,. the patient died. The specimen is represented in the annexed woodcut, which shows well the lesion of the external carotid, the ligature in position on the terminal portion of the common carotid, etc. (Fig. 429.) As in the last case, so in this, the hemorrhage was restrained by the coagu- lum that plugged the wound until the sixth day, when the slough began to separate. But the secondary bleeding which then occurred was arrested by tying the common carotid artery, and did not return. The patient, however,, died three days after the operation, probably from anaemic exhaustion caused 1 Med. and Surg. History of the War of the Rebellion, First Surg. Vol., p. 396 ; also, Catalogue of Army Medical Museum, p. 455. 2 Med. and Surg. History of the War of the Rebellion, First Surg. Vol., p. 420. 622 by the losses of blood which had occurred before the operation. An example of this form of injury that oc- curred in the lower extremity, will be useful: Colonel Roderick Matheson, commanding the 32d Xew York Volunteers, was wounded in the battle of Crampton Gap, Maryland, September 14, 1862, the ball passing through his right leg, and fracturing the fibula in its course. Cold water dressings were applied. Six days after the casu- alty, a slight discharge of dark-colored blood occurred, and two days afterwards was repeated; the whole amount of both hemorrhages did not exceed four fluidounces. Yo further bleeding appeared until the seventeenth day, when about a pint escaped, not enough, however, to cause syncope. Xext day, under chloroform, the coagu- lum wTas removed, when considerable hemorrhage followed, coming, as was soon ascertained, from the posterior t.ibial artery. It was then decided to enlarge the wound and tie the artery in it, which was accordingly done. On exposing the artery, one side of it was found to have been car- ried awTay, to the extent of nearly one inch; a ligature was placed around it, both above and below the aperture, a few pieces of bone were re- moved from the fractured fibula, and the patient was placed in bed. Symptoms of great prostra- tion being present, every possible effort was made to rally him, but without avail. He lived but a few hours after the operation.1 For two or three months before the casualty the patient had suffered from army-diarrhoea, in consequence of which he was much enfeebled; too much, in fact, to survive the loss of blood and the shock of the operation. The partial division of large arteries by gunshot missiles, as these cases show, is very dangerous to life. The aperture in the tunics of the injured vessel gapes widely open from contraction of the arterial fibres, but lessening of the vessel’s calibre at the place of injury from contraction of the arterial fibres does not occur; retraction of the injured portion into the arterial sheath cannot take place; an internal coagulum, or a clot within the mouth of the wounded vessel, cannot be formed; and the external coagulum adheres so loosely to the mouth of the wounded vessel that sooner or later it becomes displaced, and then either a traumatic aneurism will form, or a hemorrhage wTill burst forth externally, and the patient will lose his life unless surgical aid is seasonably obtained. INJURIES OF BLOODVESSELS, Fig. 429. Shot-wound of the external carotid artery, and ligation of common carotid. (Spec. 3969, Sect. I., A. M. M.) The perforation of arteries from side to side, which constitutes the only remaining form of the partial division of arteries that may be caused by gunshot projectiles, is not often met with in the extremities; nevertheless, Professor Alfred C. Post has reported a good example :— Henry Schatt, aged 30, wounded March 25,1865, was admitted into Mount Pleasant Hospital April 2, with a gunshot wound of the left thigh. A conoidal ball had passed through the popliteal space from without inward, injuring the popliteal artery. On 1 American Medical Times, Feb. 28, 1863, p. 101. GUNSHOT WOUNDS OF ARTERIES. 623 the day of his admission, the thigh was amputated by the circular method, under ether and chloroform (mixed). Very little blood was lost. There was good reaction. The toes of the amputated limb were bluish ; the foot was cold, and covered with bluish :and purple spots. The entire leg was greatly swollen; the superficial veins engorged. Small veins on the inner surface of the thigh were somewhat discolored ; the integu- ment presented a yellowish color. The pulse of the patient, at the time of the opera- tion, was small, sharp, and frequent. The face was pale, and the tongue coated. The popliteal artery was found to have been perforated by the ball, and to be nearly sur- rounded by a large traumatic aneurism. The tissues of the posterior part of the leg wrere infiltrated with blood down to its middle third. The popliteal vein was not injured. There was a slight fracture of the inner part of the head of the tibia. After the operation the edges of the wound were approximated with strips of adhesive plaster, and cold-water dressings were applied. On May 31 the patient was recovering, and it is believed that he ultimately got entirely well.1 The symptoms in this case denoted that gangrene of the foot and leg was about to occur, and the performance of amputation was therefore indispens- able. Moreover, gunshot wounds involving the popliteal artery are exceed- ingly apt to be followed by gangrene of the foot- and leg; and the cause of this liability will be shown in the sequel. The following, likewise, is a good example of the gunshot perforation of a large artery:—• The Army Medical Museum1 possesses an example of perforation, from before back- ward, of the right primitive iliac artery, by a pistol-ball. (See Fig. 311, supra, page 200.) The patient lived twelve minutes after the reception of the wound, so that, had a competent surgeon been at hand, and had the abdominal aorta and left primitive iliac artery been firmly compressed against the spine immediately after the casualty, so as to stay the hemorrhage for the time being, it would have been possible to tie the vessel above and below the wound with success. When a large artery is notched or perforated by a gunshot missile, the single orifice that is caused by the notching, or the double orifice that is caused by the perforation of its walls, as the case may be, never heals spon- taneously, for reasons which have just been presented; and if the track of the missile through the parts that surround the artery is in such a condition as to allow unrestrained communication between the orifice in the vessel and the exterior of the body, or the interior of one of its great cavities, such as the cavity of the abdomen or that of the thorax, the patient soon perishes from hemorrhage, unless efficient surgical aid is very promptly afforded. In cases where the arterial orifice happens to be primarily closed by bits of clothing, or by the torn and disintegrated tissues themselves, or by blood-clots, the hemorrhage may thus be restrained until the separation of the disintegrated tissues as a slough begins, when the hemorrhage that has been suppressed for some days will reappear, and the patient will perish from the loss of blood, unless surgical assistance be near at hand. But when from closure of the external wound by pressure, or from closure of the track of the ball by the sliding past each other of muscular planes and fasciae, which sometimes occurs on altering the position of the injured part, the external hemorrhage ceases, but, at the same time, the internal does not cease, the blood continues to issue from the aperture in the wounded artery with each contraction of the heart, and, finding no vent, accumulates in the surrounding connective tissue, thus forming a diffuse traumatic aneurism which may prove fatal by bursting and bleeding, or by causing gangrene, as ■occurred in Prof. Post’s case above quoted. 1 U. S. Sanitary Commission Surgical Memoirs, pp. 47, 48. New York, 1870. 8 Med. and Surg. Hist, of the War of the Rebellion, Second Surg. Vol., pp. 323, 324. 624 INJURIES OF BLOODVESSELS. Treatment of Partially-divided Arteries.—Arteries when opened or partly divided by gunshot missiles must always be secured in the wound, if pos- sible, by two ligatures, one being placed above and the other below the aperture in the arterial tunics. The artery should also be completely divided between the two ligatures. In the following case this operation was per- formed on the femoral artery, with a most excellent result:— Corporal H. C., Co. I., 114th Colored Troops, aged 29, was accidentally wounded at Fort McIntosh, Texas, December 18, 1866, by a conoidal pistol-ball, which entered two inches below Poupart’s ligament, and, passing inward, downward, and backward, emerged from the inner part of the thigh three inches below the level of the point where it entered, injuring the superficial femoral artery half an inch below the pro- funda. When brought to the hospital, he was very faint from excessive loss of blood. Four hours after the accident the wound of entrance was enlarged by incision, the patient being under ether; a tourniquet was applied, and the femoral artery ligated above and below the seat of injury. The wound of exit was then enlarged to favor drainage. On Dec. 31 the patient was doing well. On Feb. 28, 1867, he returned to duty, cured.1 Arterial wounds attended with brisk hemorrhage must always have digital compression instantaneously applied either in the wound itself, or upon the proximal portion of the wounded artery, or upon the parent trunk, by methods already described, in such a way as to suppress the bleeding until ligatures can be placed around the injured artery, as just directed. In cases where large arteries like the common carotid, the common femoral, the axil- lary, etc., are laid freely open by gunshot missiles, compression of the open mouth of the injured vessel, directly and instantaneously effected, with one or more fingers inserted into the wound and kept there until a surgeon can be brought and ligatures applied, affords the only means of saving the patient. In such cases, a delay of but one or two minutes in applying the pressure may be attended with the loss of so much blood as to prove fatal, either immediately by syncope, or after some days by anaemic exhaustion. When the operation of tying the injured artery in the wound with two threads is not practicable, the injured artery itself, or its parent trunk, must be secured by ligating it with carbolized catgut, on the cardiac side of the wound, but as near to it as possible. Under such circumstances, Anel’s plan of operating should generally be preferred to that, of Hunter; for instance, in a case where the tongue is wounded, the lingual artery should be tied instead of the carotid; or, if the wound involve the external carotid, that artery should be ligated instead of the common carotid, etc. Anaemic ex- haustion resulting from hemorrhage should, in uncomplicated cases, be treated by transfusion. In those cases of gunshot arterial lesion where, after the hemorrhage has ceased externally, it continues internally in the shape of an extravasation into the connective tissue, that is, in those cases where a diffuse traumatic aneurism forms, the surgical treatment should, in general, be pre- cisely the same as if the external bleeding had continued; for, in both in- stances, the lesion to be treated is the same, namely, the arterial wound. When gangrene ensues, our sole expedient is amputation ; and this operation should be performed without delay, that is, before the system at large becomes septicsemic in consequence of the passage into it of putrid blood and serum from the gangrenous part. These three operative procedures, namely, ligation in the wound, ligation on Anel’s and Hunter’s plan, and amputation, should never be held in abey- ance, as expedients of last resort, while other things are being tried ; but, on 1 Circular No. 3, S. GL O., Washington, August 17, 1871. GUNSHOT WOUNDS OF ARTERIES. 625 the contrary, each of them should be promptly performed by the surgeon whenever it is indicated as the best means at his command for saving life. The treatment of gunshot wounds of arteries, when complicated with gun- shot fractures, will be considered hereafter. Concerning the employment of styptics, as, for instance, the persulphate and the perchloride of iron, etc., as haemostatic agents in hemorrhages from gunshot wounds of arteries, some mention should here be made. In the first place, in the instances where large arteries are opened by musket-balls, etc., they are entirely inadequate to meet the requirements of the case. When the hemorrhage proceeds from small arteries, such styptics, even when aided by local compression and cold, are often worse than useless. Thirteen fatal cases of bleeding from the minor branches of arteries in the upper extremity are reported in the Medical and Surgical History of the late Civil War.1 In a number of these cases the application of styptics contributed much to the fatal issue. To imperfect or inadequate ligation several of these deaths must also be directly charged. For example, four cases of ligation of the radial artery in gunshot wounds unattended by fracture terminated fatally:—“ It is no- ticeable that in these four fatal cases proximal ligatures only were applied.”2 All the cases in which the radial artery was secured with distal as well as with proximal ligatures ended in recovery. Of five patients in whom the ulnar artery was tied above and below the lesion, for hemorrhage in gunshot wounds, all recovered but one, and he died of pygemia. In three instances where the ulnar artery was tied on the proximal side only of the lesion, “ two of the three patients died, one having undergone consecutive amputation; the third recovered, after consecutive ligation of the brachial.”3 The surgeon should never forget that, “ when the injury is inflicted on an artery near the extre- mity of a limb, it is indispensable to employ the double ligature, on account of the multiplied communications by anastomosing branches.” (Dupuytren.) Thus experience shows that hemorrhage from wounded arteries should not be treated by applying styptics when it is practicable to ligate them; and that a distal as well as a proximal ligature should be placed around the wounded vessel. Complete Division of Arteries by Gunshot Missiles.—Small arteries are severed in almost every case of gunshot wound; yet this accident but seldom causes troublesome hemorrhage, or any other bad consequence. The bleeding from these small vessels, when they have been completely divided by gunshot projectiles, spontaneously ceases in a short time, as a rule, and does not recur. Large arteries, too, have sometimes been found severed in the wounds made by small-arms, but not often; much less often than they are found notched or perforated, that is, incompletely divided in such wounds. For the severance of arterial trunks, and of large arteries in general, by rifle or pistol balls, it is especially needful that the missile should be moving with very great velocity at the moment of impact. The same missile proceeding in exactly the same track, but with less velocity, might only notch the artery; moving with still less celerity, it might only bruise the arterial tunics; and, if moving more slowly still, it might leave no trace of arterial injury. The late Dr. Otis justly calls attention to this point. He remarks :4 “ The reader will observe here, as elsewhere, the very large proportion of gunshot wounds of arteries in accidents, assassinations, and suicides, in comparison with those 1 Second Surg. Vol., p. 460. 8 Ibid., p. 452. 2 Ibid., pp. 452, 453. 4 Circular No. 3, S. Gr. 0., p. 55. 626 INJURIES OF BLOODVESSELS. received in battle. In other words, that the great arterial trunks are often divided at very close range by the small projectiles, but very rarely at long range.” The velocity of these projectiles is, of course, very much greater at short, than it is at long range. I shall illustrate the principal facts pertain- ing to the division of arteries by small-arm missiles, by presenting a number of well-authenticated examples. In the tirst three cases the carotid artery was involved:— Private James B. Morrissey, Co. B. 34th United States Infantry, was shot through the neck, at Grenada, Mississippi, March 28, 1868. The missile entered two and one- dialf inches below the lobe of the left ear, and emerged on the right side of the nape one inch and a half from the spinous processes. The carotid artery was severed, and death was almost instantaneous.1 Private George Robinson, Co. D, 40th U. S. Infantry, was shot on August 26, 1868, by the officer of the guard, for mutinous conduct at the United States Army post, Goldsborough, N. C., with a Colt’s navy revolver, in the neck, the ball severing the carotid •artery. Death from hemorrhage resulted almost immediately, September 13, 1868.2 Major John A. Thompson, 7th U. S. Cavalry, was wounded by a pistol-ball while engaged in suppressing an affray between a party of soldiers and desperadoes, near Fort Mason, Texas, on November 14, 1867. The missile struck the right malar bone, and emerged below the left ear, severing the left carotid artery. He was taken to the post hospital, and died the next day, from hemorrhage.3 In the following instance the subclavian artery was divided:— Private James Smith, Co. I, 38th U. S. Infantry, was shot, by the accidental discharge of a Springfield musket (calibre 50), in the hands of a comrade, while standing in the door of the company quarters. The ball entered the right shoulder from behind, and, passing through the scapula, divided the subclavian vessels and fractured the clavicle. Death was almost immediate.4 In the next three examples the external iliac artery was severed:— Private John Gerhardt, Co. K, 2d U. S. Infantry, aged 22, received, on January 0, 1869, accidentally, a gunshot wound of the groin. He was immediately admitted to the regimental hospital, and died one hour afterward of hemorrhage, from the external iliac artery, which was divided in the wound.5 Private Winny Abbott, Co. K, 25th U. S. Infantry, committed suicide at Jackson Barracks, New Orleans, August 8, 1869, by shooting himself with his own musket. The ball entered the abdomen two inches above the pubis, and one inch to the left of the linea alba, passing through the rectus abdominis muscle, cutting off the bowel, severing the external iliac artery, and escaping posteriorly through the os innominatum. He expired immediately after receiving the wound.6 Corporal R. A., Co. E, 38th U. S. Infantry, aged 35, was admitted to the post hospital at Fort Hays, Kansas, October 21, 1867, in an intoxicated condition, with a gunshot wound of the abdomen; pulse small and feeble, skin cold; was very restless, and vomited several times. Death resulted at two o’clock next morning. Autopsy— Thirty-six ounces of fluid tinged with blood, a quantity of coagulated blood, and some fecal matter were found in the abdominal cavity. The ball had wounded the small intestines in two places, passed through the sigmoid flexure of the colon, severed the external iliac artery completely, and the vein partially, etc., and lodged in the gluteal muscles.7 In the next two cases the femoral artery and vein were divided:— Henry C. Clinton, artificer, Co. C, 2d Infantry, was shot in a street-brawl at Louis- ville, Ky., October 19, 1868, through the right thigh, by a round pistol-ball, which ' Ibid., p. 21. 4 Ibid., p. 23. * Ibid., p. 22. 5 Ibid., p. 55. 6 Ibid., p. 55. 3 Ibid., p. 23. 7 Ibid., p. 55. 627 GUNSHOT WOUNDS OF ARTERIES. passed obliquely through from behind, severing the femoral artery and vein at the point where the artery passes through the adductor magnus. Death occurred in a fewr minutes from hemorrhage.1 Private William Neff, Troop B, 9th Cavalry, was admitted to hospital at Fort Stockton, Texas, in a moribund condition, having bled almost to death from a gunshot wound of both thighs. A tourniquet was put over each femoral artery. The patient’s condition precluded an operation for ligating the injured vessels. The autopsy showed the femoral artery and vein to be severed.2 Thus, I have briefly presented nine cases in which large arteries were com- pletely divided by ride or pistol-balls. Eight of them perished from the primary hemorrhage. In some, death was almost instantaneous ; in others, it occurred in some minutes; and in a few at the end of some hours; but, in almost all, death occurred in a very short time. Digital compression ap- plied in the wound immediately after the casualty, and continued until the ends of the severed artery can be securely tied, affords almost the only means of saving such patients. But one of these nine cases survived the primary hemorrhage. He lived until the eighteenth day, when secondary hemorrhage supervened, and car- ried him off almost immediately. In the following example, also, death ensued from secondary hemorrhage:— James Brown, 3d Tennessee Mounted Infantry, was shot through the right thigh, just below Poupart’s ligament, obliquely from before backward, at the battle of Chicka- mauga ; the wound involved the track of the femoral artery, but not the bone. The man was taken to the field hospital; no pulsation could be felt below the wound, and it is there- fore believed that the common femoral artery was divided; there was then no bleeding of consequence, so the case was left to nature, and the patient did well for six days, when hemorrhage suddenly supervened while he was at stool. Liquor ferri persulph. was immediately injected into the wound, and compression applied, but without suc- cess. The external iliac artery was then ligatured, under chloroform, by Sir A. Cooper’s method. But the patient never rallied from the loss of blood ; he gradually sank, and died from anaemic exhaustion on the seventeenth day after the operation.3 For secondary hemorrhage in such cases, digital compression, applied without delay in the wound, and kept up until the ends of the severed artery are secured with ligatures, is the proceeding which must be employed, for it is about the only one that can rescue the patient. Gangrene has often been observed in patients who had survived the shock and the primary bleeding incident to the division of large arteries by small- arm projectiles, and I shall present several examples in point:— Private C. Gross, Co. K, 6th Pa. Cavalry, wounded May 30, 1864. A mini6- ball passed through both thighs at the middle, from left to right, dividing also the left femoral artery, but without injuring the bone. Patient lay in the woods for twenty-four hours; hemorrhage occurred several times, which he partially controlled by making pressure with his fingers. May 31 he was discovered, and taken to the field hospital, where the severed artery was cut down upon, and both ends tied. June 4, he was admitted to Stanton Hospital, under my care; countenance pallid ; pulse weak ; limb very much swelled, oedematous, and presenting dark patches of extra- vasated blood around the groin. On the 5th secondary bleeding occurred to moderate extent, and was arrested by ferri persulph., etc. It recurred, and was arrested by digital compression. On the 8th his foot became gangrenous, and the gangrene spread upward. On the 9th he died. Autopsy—Limb very much swollen; muscles exten- sively infiltrated with pus from groin to knee; femoral artery severed about its middle; both ends tied, but the distal ligature had slipped off; femoral vein also found liga- 1 Ibid., p. 78. 2 Ibid., p. 85. 3 U. S. Sanitary Commission, Surgical Memoirs, vol. i. p. 51. New York, 1870. 628 INJURIES OF BLOODVESSELS. tured with a separate thread. All the viscera were normal.1 The gangrene appeared on the tenth day after the casualty. Dr. J. C. Baylor, of Norfolk, Va., has reported another example: J. W. Dinguid, wounded by a minie-ball on June 1, 1864. Femoral artery severed in its lower third ; no consecutive hemorrhage ; died on the loth, fourteen days after the injury. Autopsy —Gangrene of foot had commenced ; wound in thigh a sloughy mass ;. no effort at repair.2 In both of these cases the gangrene was late in making its appearance: in the first on the tenth, and in the last about the thirteenth day after the casualty. Both patients appear to have been sunk into so low a state from anaemic exhaustion that amputation was not admissible when gangrene- set in. In the next four examples the severance of the popliteal artery was followed by gangrene in three instances:— Private James H. Butcher, 2d N. Y. Heavy Artillery, aged 24, was admitted to Stanton Hospital, under my care, June 4, 1864, from the field, having been wounded on May 31 by a conical musket-ball which passed through his left knee from before backward, and involved the track of the popliteal artery. Being very low, and the leg already gangrenous, he was placed on supporting treatment lo prepare him for successful amputation, if possible. June 5—Foot and leg greatly swelled, dark-brown in color, and emitted an offensive, gangrenous odor. Thigh much swollen and hot; also extensively ecchymosed, and the swelling extends up to the groin. No line of separation yet appears. Countenance pale and anxious, pulse frequent and weak ; general debility great. He was perfectly clear-minded, and expressed a strong desire to have the gangrenous limb removed. I accordingly at once, under ether, amputated it high up in the upper third of the thigh by the flap method ; femur sawed off three-fourths of an inch belowT the trochanter minor. The shock of the operation was very great; reaction established with difficulty, and not complete until the next day. Dissection of the amputated member showed that the popliteal artery was completely divided by the bullet, just above its termination in the anterior and posterior tibials. June 6—He is feeble, pale, and anaemic. June 7—Condition unchanged; pulse about 90, and weak, notwithstanding that he receives all possible support from nutrients, tonics, and stimulants. June 8—No improvement; stump sloughy. He sank and died at 11 P. M. He also had obstinate- vomiting with hiccough on the last day. The hemorrhage in this man’s case ceased spontaneously. It must, how- ever, have been considerable, for it left him in a state of anaemic exhaustion from which he never recovered. Ilis death, too, was hastened by septicaemia; or by the fact that his system was contaminated with the decomposing fluids which readily passed into it from the gangrenous leg, as no line of separation formed between the dead and the living tissues. Private Sam. C. McCreary, 100th Penna. Vols., aged 24, was wounded at Chantilly,. Sept. 1,1862, by a ball which passed through the right popliteal space, having entered about three inches above the insertion of the biceps flexor cruris, passed immediately behind the femur, and emerged through the inner hamstring muscles, chipping out a small piece of the inner condyle, and dividing of course the popliteal artery. He lost a great deal of blood on the field, but the hemorrhage ceased of itself.' On the fourth day afterward, he entered hospital at Alexandria, Va., in a very feeble condition and pre- senting an ensanguinated appearance; no pulsation in either tibial artery, and the leg itself cold. Gangrene followed, beginning at the toes. On Sept. 13, the limb was- amputated four inches above the knee, under chloroform, by the flap method. For nearly three weeks after the operation, the patient’s life was almost beyond hope ; there was almost total anorexia, and large bed-sores formed about the sacrum. Under stimu- 1 Ibid., pp. 53, 54, 57. 2 American Journal Med. Sciences-, 1865, p. 254. GUNSHOT WOUNDS OF ARTERIES. 629 lants, tonics, and nutrients, however, the patient slowly recovered, and on Dec. 4 left the hospital with his father, the stump being nearly healed.1 The above is the almost exact prototype of a case of wound of the popliteal artery, which occurred at the battle of Chickamauga, with similar treatment and results.3 Private W. D. Thompson, Company E, 5th Cavalry, aged 40; gunshot wound (minie) of left knee-joint, ball entering outer portion of popliteal space, traversing inner condyle, and emerging at inner side of joint; popliteal artery completely divided; no consecutive hemorrhage; no effort at repair in the wound. Wounded May 5, died May 18, thirteen days after the casualty. Case reported by Dr. J. C. Baylor, of Norfolk, Va.3 Thus, I have briefly presented four cases in which the popliteal artery was severed by minie-balls. In all of them the hemorrhage ceased spontaneously; but in each the loss of blood appears to have been great, and to have caused anfemic exhaustion. In three of them gangrene of the foot and leg occurred in consequence of the arterial wound. In the remaining case, if gangrene did not appear, the fatal issue was probably due to anaemic exhaustion. Ampu- tation of the thigh saved two of the three patients attacked with gangrene. But why is gangrene so apt to follow the severance of the popliteal artery by small-arm projectiles? The anatomical structure of the parts furnishes a good reason. When the popliteal artery has been divided in a gunshot wound, the foot and leg must derive their supply’ of nutrient blood through the collateral channels, which are the several articular branches at the knee, and they are so small as to afford, at best, but very scanty facilities for estab- lishing a collateral circulation. But, in cases of gunshot wounds involving the popliteal space and parts bordering thereon, the inflammatory swelling, which always attends such wounds in this region, diminishes still further the supply of nutrient blood to the foot and leg by compressing the collateral channels at the knee; at least, the compression exerted by this inflammatory swelling is very liable to prevent the collateral channels at the knee from un- dergoing that development or expansion of calibre which is requisite in order to furnish such a supply of nutrient blood to the foot and leg as will preserve their vitality after the popliteal artery is severed. Gunshot wounds dividing the popliteal artery must therefore be classed among the most troublesome as well as among the most dangerous wounds in surgery. In order to achieve a suc- cessful treatment of such cases, the indications are twofold : First, the primary bleeding must be arrested at the outset, so that the occurrence of exhaustion from the loss of blood, or anaemic exhaustion of a fatal character, may be prevented, by the employment either of digital compression, or of Esmarch’s elastic ligature. Secondly, the leg should be amputated at the knee-joint, during the primary period, before the patient becomes worn out by his suf- ferings, and before gangrene of the leg, with its attendant septicaemia, has occurred. I shall next relate two cases in which the posterior tibial artery was severed by cylindro-conoidal musket-balls. In one of them there also was fracture of the fibula; in the other the bone was uninjured. In both, however, the arterial wound was the principal lesion. In both traumatic gangrene occurred. In both, likewise, the primary hemorrhage ceased spontaneously. Private Conrad Kogel, Co. D, loth U. S. Heavy Artillery, aged 39, was admitted to Stanton Hospital, under my care, June 4, 1864, having been wounded at Mechanics- ville, May 30, by a minie-ball, which passed nearly transversely through the calf of his right leg, from without inward, and somewhat upward. When admitted, his leg 1 U. S. Sanitary Commission Surgical Memoirs, vol. i. pp. 57, 58. New York, 1870. 3 Ibid., p. 58. 3 American Journ. Med. Sciences, 1865, p. 254. 630 INJURIES OF BLOODVESSELS. was very much swelled and inflamed up to the knee. No tibial pulse could be felt at the ankle. lie had much constitutional disturbance, and was very restless. The ice- dressing was applied to his leg ; nutrients and tonics were administered. June 6—Leg still more swelled, and beginning to mortify in spots; constitutional state worse, and there is irritative fever of a low type. Amputation being the only resource left, it was without delay performed at the lower third of the thigh, under ether, by the circular method. The shock was moderate, and the patient reacted promptly. Examination of the amputated member showed the posterior tibial artery divided by the bullet. The operation afforded much relief until June 10, when the flaps began to slough. He then sank into a so-called typhoid condition. June 15 (evening)—He had a pyaemic chillr after which he sweat profusely. June 16—He had two rigors, and the sweats con- tinued. His countenance had become sallow, and he was delirious. In the evening he died. The autopsy revealed the lesions belonging to gangrenous osteo-myelitis and pyaemia, a description of which want of space excludes. Lieutenant-Colonel W. G. Delaney, a prisoner of war, was admitted to Stanton Hospital, under my care, September 25, 1863, having been wounded on the 23d by a conical musket-ball, which entered his left leg on the outer side, about two inches below the head of the fibula, fractured that bone with comminution, and emerged, after crossing the track of the posterior tibial artery a short distance below its origin. The casualty was attended with considerable hemorrhage, but this ceased spontaneously, and did not return. When admitted, the patient had considerable fever of an irritative type, some oedematous swelling of the leg, and no pulsation in the posterior tibial artery at the ankle. The swelling of the leg increased, and gangrene ensued, but the patient’s general condition was so bad as not to warrant the performance of amputation. On Oct. 2 he died. The autopsy showed the posterior tibial artery to have been completely divided by the bullet, about one inch below its origin at the bifurcation of the popliteal; there was fracture of the fibula with considerable comminution. No line of separation had been formed. Wounds inflicted by cylindro-conoidal musket-balls which sever the pos- terior tibial artery in the upper third of the leg, are often, perhaps generally, attended with consecutive gangrene. The reason is twofold: flrst, the divi- sion of the artery cuts off' the supply of blood which is needed by certain parts of the limb. Secondly, the inflammatory swelling attending such wounds is always great, especially when the arterial wound is complicated with fracture. This swelling involves the tissues which are covered or bound down by the deep fascia of the leg, as well as those external to it. As this fascia is very strong, and cannot give way, the inflammatory tumefac- tion beneath it compresses the anastomosing branches to such extent, and with such force, that a collateral circulation cannot be established, and thus the parts below perish from want of nutrient blood. Wounds such as these demand that amputation at the knee-joint shall be performed either primarily,, or as soon as gangrene presents itself in the toes or foot. If the operation be delayed after the appearance of gangrene, the risk of septicaemia will be correspondingly increased. In the following example, the axillary artery was divided by a cylindro conoidal musket-ball; the hemorrhage was not troublesome, but gangrene cfl the hand, forearm, and arm ensued, and destroyed the patient:— Private T. H. Hudson, a prisoner of war, aged 21, was admitted to Stanton Hospital, under my care, May 18, 1864, having received two wounds from minie- balls at Spottsylvania, Va., on the 11th. One of them entered his left shoulder from behind, and escaped in front a little way below the having crossed the course of the axillary artery. The other penetrated his right hip near the sacrum, and emerged in front near the right groin. The hemorrhage was not troublesome from either wound. On admission, the patient’s condition was good, and his wounds looked wTell. It was observed that there was no brachial nor radial pulse on the left side, and it was supposed that the left axillary artery had been severed. May 22—The wounds GUNSHOT WOUNDS OF ARTERIES. 631 appear to be doing well, but the left hand, forearm, and lower part of arm have become much swollen and dark in color. No pulsation in brachial, radial, and ulnar arteries. May 28—The gangrene is still progressing, and the mortified tissues of the forearm are exulcerating. June 1—The gangrene is limited at middle of arm. The gunshot wounds look well, but still the patient is obviously failing; he is emaciated; appetite poor; tongue dry ; some diarrhoea. He continued to sink, and on June 6 he died. At the autopsy, the axillary artery was found completely divided by the bullet, and its two ends retracted or separated two inches from each other. Both ends were securely plugged up. The axillary vein and the brachial plexus of nerves were not wounded. Although this patient’s general condition was so had that amputation did not seem justifiable at any time after gangrene appeared, still, on reviewing the case now, I am inclined to think that the operation might have somewhat improved his chance of recovery, especially if it had been performed in the upper part of the arm as soon as the gangrene presented itself in the hand. This plan of treatment I now recommend, and shall hereafter follow, namely, that, when gangrene occurs in consequence of division or obstruction of the axillary artery, amputation is to be practised in the upper third of the arm as soon as the hand is attacked. The hemorrhage not unfrequently ceases spontaneously in cases where the axillary artery is divided in wounds made by musket, carbine, or pistol- balls. I shall relate another example which came under my own observation, in speaking of traumatic aneurism. The elder Larrey reported the case of General Dulong, who was wounded in the right axilla by a small-arm projectile. Although there was scarcely any hemorrhage, there was good reason to believe that the axillary artery had been divided. Dr. James M. Holloway1 records a case in which a minie-ball passed through the left axilla from behind forward, crossing the track of the axillary artery. The bleeding ceased spontaneously, although there is good reason to believe that the artery was severed. That which was found on autopsy to have occurred in Hudson’s case, related above, shows how the natural haemostasis may succeed in such cases. The tunics at each end of the divided artery retract, recurve, and contract, whereby the orifices become much smaller, and a secure lodgment is afforded for the occluding plugs of clotted blood. “M. Verneuil communicated to the Surgical Society of Paris five cases of injuries of large arteries by balls and pieces of shell, in which hemorrhage was arrested spontaneously. The performance of primary amputation allowed the state of the vessels to be examined. The arterial coats were divided throughout on the same level as if they had been cut by a knife, and clots extended for some way above the divided ends of the vessels. In two of the cases the posterior tibiae! and the popliteal were the injured vessels.”2 In the following example the brachial artery was severed in a wound made by a musket-ball. The primary bleeding was so slight as to escape mention. Eighteen days afterward secondary hemorrhage supervened, and was perma- nently arrested by securing both ends of the severed artery with ligatures. Private W. J. Beverley, Co. C, 17th Maine Vols., aged 27, was admitted to Stanton Hospital May 23, 1864, on account of secondary hemorrhage from a gunshot wound of his right arm, with which he had been attacked in the streets of Washington while on his way homeward on furlough. On May 5, at the battle of the Wilderness, a musket- ball had penetrated his right arm just above the flexure of the elbow, and, passing behind the biceps muscle, had escaped on the inner side of the arm, without injuring the bone or causing much loss of blood. The secondary hemorrhage was arrested by pressure applied to the seat of injury. On the evening of the 24th, however, it returned. The brachial artery was then cut down upon at the seat of injury, and found completely 1 American Journal of the Medical Sciences, October, 1865, pp. 352, 353. 2 Graz. Mid., Juillet 22, 1871, and New Syd. Soc. Biennial Retrospect, 1871, 1872, pp. 263, 264. 632 INJURIES OF BLOODVESSELS. divided by the projectile. Both ends of the vessel were securely ligatured, and the hemorrhage did not recur. May 26—A slight recurrent pulse can be felt in the radial artery. June 1G—The wound of operation has healed, hut purulent matter has exten- sively burrowed among the muscles of the forearm, necessitating an incision about six inches long to relieve the burrowing. Pyaemia supervened, and, on July 2, the patient died of pysemic pneumonia. The autopsy showed visceral abscesses in the lungs, liver, etc. Two additional cases in which the brachial artery was divided in wounds made by musket-balls, are recorded in the U. S. Sanitary Commission’s Surgical Memoirs, vol. i. In one of them the missile struck the left arm near the junction of the upper and middle thirds, severed the artery, and shattered the humerus for four inches; for a moment or two the bleeding was profuse, but it ceased spontaneously. The arm was amputated, two inches below the head of the humerus, four hours after the casualty. The patient recovered. In the other case, the ball passed through the anterior and inner aspect of the right arm, and directly across the course of the brachial artery. When brought to the field hospital there was no pulsation at the wrist; sensation and motion were impaired. There had been no hemorrhage excepting slight capillary oozing. No pulsa- tion was detected by passing a finger into the wound. The shock was very great, with tendency to syncope. No secondary bleeding occurred, and the patient got well without giving much trouble.1 In neither of these three cases of complete division of the brachial artery by musket-balls was the primary hemorrhage excessive. It was suppressed in each instance, also, with great promptitude, by the processes of nature. Arteries of medium calibre, that is, belonging to the next subdivision after the brachial, very often, perhaps generally, cease spontaneously to bleed when completely divided in wounds made by musket-balls, etc., as happened with the internal epigastric arteries in the following instance:— A prisoner of war was shot by the guard while attempting to escape. The bullet went into one inguinal region and emerged from the other, cutting through the entire abdominal wall, from side to side, about half an inch above the pubis. It severed the epigastric artery on either side (the ends were visible), and produced a gaping wound about eight inches in length, plainly exposing the pelvic viscera. There appears to have been no bleeding. Three weeks afterward the patient was returned from the hos- pital, convalescent, to the military prison.2 But the bleeding does not always cease spontaneously in such cases, as the following example shows:— Private A. Y., Co. D, 23d Infantry, received a severe gunshot wound of the wrist- joint, in a skirmish with Indians, April 29, 1868. The radial artery, being lacerated, was ligated above and below the seat of injury, and water dressings were applied to the wound. In July, 1868, the patient returned to duty.3 The observations presented above show that gunshot wounds dividing large arteries are not only very dangerous, but also destroy life in certain deter- minate ways, the principal of which are primary hemorrhage, secondary hemorrhage, and consecutive gangrene. Gangrene ensues after such wounds much oftener than many suppose; I have presented eight examples of it, five of which passed under my own observation, and have seen several other examples of which unfortunately I did not take notes. As this subject (traumatic gangrene) possesses much importance in this connection, I have taken some pains to collate Guthrie’s experience concern- ing gangrene following gunshot wounds of bloodvessels. It appears that he saw seven cases belonging to this category in military practice. In three of 1 Op. cit., pp. 69, 70. 2 Med. and Surg. History of the War, Second Surg. Vol., p. 175. 8 Circular No. 3, S. Gr. 0., pp. 237, 238. GUNSHOT WOUNDS OF ARTERIES. 633 them the popliteal artery was involved. In two of these three cases it was found, on dissection, that there was complete division of the artery; in the other case it was surmised that there was complete division of the artery, but no autopsy was made. In the remaining four cases it was believed that the femoral artery was wounded by a musket-ball in every instance; but it was not known that the artery was completely divided in any of them. Of these .seven cases observed by Guthrie, then it appears that, as far as known, the vessel was completely divided in but two instances, both pertaining to the popliteal artery. Amputation was resorted to in two instances, but without avail. Every one of these seven cases proved fatal.1 Guthrie also stated that he had seen, in London, three cases of gangrene following wounds of the femoral and popliteal arteries; in two the popliteal, and in one the femoral was the injured vessel. All proved fatal from the extension of the gangrene.2 The principal cause of the great fatality which attends traumatic gangrene, is the fact that a line of demarcation, or separation of the dead from the living tissues, is but seldom formed in such cases. This circumstance is also noticed by Guthrie. The consequence is, that the veins which proceed from the gangrenous part toward the trunk, not being closed or obliterated as they would be if a line of separation were formed, convey the decomposing blood and other putrescent liquids from the gangrenous part, and pour them into the current of the general circulation. Thus, systemic poisoning of a septic character, or septicaemia, is produced, and the patient’s life is destroyed; and the earlier the date may be when the gangrenous part is removed from the •body by amputating it, the less will be the degree of the septicaemia. Symptoms of Complete Arterial Division.—The symptoms which indicate that a large artery that lies in or crosses the track of a gunshot wound is •completely divided, are, brisk hemorrhage, and the disappearance of pulsation in the injured vessel and its branches below or beyond the wound. In cases where there is such absence of pulsation, but no hemorrhage, there may be some doubt as to whether the lesion consists of complete division of the artery, or complete obstruction of its canal from recurvation of its severed inner and middle coats or from plugging with coagulum. But such an occlusion from plugging, without division of the external tunic of the artery, is a very rare occurrence in the history of wounds made by small-arm missiles, however frequently it may be met with in cases where arteries are stretched or bruised; and it should be estimated accordingly. Treatment.—When a large artery is completely divided in a gunshot wound, the first indication is to suppress the primary bleeding, without delay, by digi- tal compression, and to restrain it in this manner until the ends can be found and secured by a carbolized catgut ligature applied to each of them. The method in which digital compression can be most effectually employed in such cases, consists hi placing both index fingers, or a thumb, in the wound, and applying them directly to the ends of the bleeding vessel. In this way the hemorrhage can be arrested with promptitude, with certainty, and with but little effort; for only a slight degree of pressure is required to arrest the flow ot blood, if applied directly to the bleeding orifice of the artery. I say again that, in this way, the hemorrhage from gunshot wounds involving the arteries of the neck, armpit, and extremities, may readily be controlled by any person of ordinary intelligence, until surgical assistance can be obtained, and the injured vessel can be properly ligated. Moreover, the compression, 1 Diseases and Injuries of Arteries, pp. 235-243. 2 Ibid., p. 245. 634 INJURIES OF BLOODVESSELS. to be of much use in such cases, must be promptly applied; otherwise, so much blood will be lost as to prove fatal by anaemic exhaustion, if not by syncope. Both ends of the severed artery must be tied with carbolized cat- gut. The following example will usefully illustrate the subject of ligating the smaller arteries which may be severed in gunshot wounds:— Private W. Jess, Troop M, 7th Cavalry, received Nov. 21, 1868, a gunshot wound of right forearm at the middle. The ball passed between the radius and the ulna without fracturing either. No hemorrhage occurred until the fifth day ; afterward, hemorrhage occurred about every twenty-four hours, generally at night, from a few ounces to a pint at a time. When the dressings were removed the hemorrhage would cease; an opera- tion was consequently delayed from day to day, in the hope that it would be unnecessary. The arm began to swell, became painful, tense, and glossy, and from above the elbow to the shoulder was swollen and oedematous. On Dec. o, a deep incision, four inches long, was made lengthwise at the wound. A large quantity of clotted blood was thrown out from between the muscles, which had been dissected up by it in every direction. The interosseous artery was found severed, and both ends of it were tied. The pain was immediately relieved, and the swelling rapidly disappeared. No bad symptoms oc- curred, and the patient was returned to duty in January, 1869.1 The second indication in the treatment of cases where large arteries are divided in gunshot wounds, is to anticipate and prevent the occurrence of secondary hemorrhage. Should the ends of the severed artery be sought for and tied, in such cases, when they are not bleeding? Secondary hemorrhage when it occurs in such cases is almost always fatal; and, inasmuch as the best method of preventing secondary hemorrhage from wounded arteries consists in properly tying them, I do not doubt that, in most cases where large arteries are divided in gunshot wounds, their ends should, if practicable, be brought into view by making the necessary incisions, and carbolized catgut liga- tures should be applied to both the proximal and the distal ends, although they are not bleeding at the time. Had this been done in three of the cases presented above, where secondary hemorrhage occurred and death ensued, namely, that of George Robinson, whose carotid artery was divided, that of James Brown, whose femoral artery was severed, and that of W. J. Beverley, whose brachial artery was cut across, there is good reason to believe that all of them wo I'd d have been saved. Furthermore, I hold that, in every case of gunshot injury where there is reason to believe that large arterial trunks have been damaged, even when they are not divided, a careful search should be made; and should it prove that such is the case, they should be tied with antiseptic ligatures, whether bleeding or not, to render them secure against the effects of reaction and the occurrence of secondary hemorrhage. These proceedings, and the taking care to tie the ligatures in such a way that they cannot slip oft* from the ends of the artery, constitute the chief surgical means of fulfilling the second indication. The third indication in the treatment of such cases consists in anticipating the occurrence and obviating the effects of gangrene. Whenever the femoral, popliteal, or posterior tibial artery in the upper third of the leg is severed in a gunshot wound, there is much greater risk of the occurrence of gangrene than of secondary hemorrhage; and gangrene is more fatal than even secondary hemorrhage in such cases. For out of eighteen cases of gangrene caused by gunshot wounds of arteries, related or referred to above, all ended fatally save one, and in this the patient was saved by amputation. The great danger of this form of gangrene is because of the very great liability to the occurrence of septicaemia from the non-formation of a demarcating line, as I have just shown 1 Circular No. 3, S. GL 0., p. 238. 635 GUNSHOT WOUNDS OF ARTERIES. above. The only way to obviate the deadly consequences of such a gangrene, and notably the septicaemia, is to remove the mortifying part by amputating the limb at the summit of the region deprived of nutrient blood by the arte- rial wound ; and, the earlier the operation is performed, the less the degree of septicaemia, and the greater the hope of a successful issue. Hence, as soon as the toes become gangrenous in consequence of a severance of the posterior tibial or the popliteal artery, the leg should be amputated at the knee-joint;, or, if in consequence of a severance of the femoral artery, the thigh should be amputated above the seat of the arterial lesion. In the upper extremity, as soon as the fingers mortify in. consequence of a gunshot severance of the axillary artery, the arm should be amputated at the shoulder-joint or within two or three inches thereof. It is a still better practice, however, to remove by primary amputation the parts in which we know from experience that gan- grene will almost certainly ensue; for instance, in cases of gunshot severance of the popliteal artery, or of the posterior tibial in its upper third, especially if the bone be also implicated, primary amputation ought generally to be per- formed. Under a policy of delay in such cases, gangrene almost always ensues. Primary amputation, by anticipating and averting the occurrence of gangrene and septicaemia, gives the patient the best possible chance to re- cover. When gunshot severance of the femoral artery is complicated with gunshot fracture of the thigh bone, I believe it is always best to amputate without delay, because gangrene is almost certain to ensue if the limb be not cut off, and because amputation in the primary period is much more likely to prove successful in such cases than amputation performed in the inflammatory period, or after the appearance of gangrene. When gunshot severance of the posterior tibial artery is complicated with gunshot fracture of both bones of the leg, I believe it is generally preferable to employ primary amputation, especially in military practice in the field. In civil life, however, where the circumstances are usually much more favorable for conducting the after- treatment, it may be advisable to attempt to save the leg when the commi- nution is not extensive, and the laceration of the soft parts not great, and especially if only one bone be broken. In such a case, occurring under cir- cumstances favorable for treatment, it may be advisable to tie both ends of the artery in the wound, and-then to treat the case as a gunshot fracture,, with antiseptic dressings. When gunshot severance of the brachial artery is attended by gunshot fracture of the humerus, the chances of treating the case successfully, with- out amputation, are generally much greater than in corresponding lesions of the lower extremity. When the broken humerus is but little comminuted, the soft parts surrounding it but little torn, and the accompanying nerves uninjured, it is generally advisable to tie both ends of the artery, and at- tempt to save the arm. But when the comminution is extensive, and the laceration of the soft parts great, the brachial artery also being severed, primary amputation should be performed. In gunshot fractures of the fore- arm associated with corresponding wounds of arteries, however, it is but seldom necessary to amputate, unless the elbow-joint be implicated; in such a case it is generally advisable to amputate without delay. Again, when a gunshot wound of the femoral or popliteal artery is attended with a corresponding lesion of the vein and nerve, although the bone be unin- jured, primary amputation should always be performed. Antiseptic dressings should always be employed, and thorough drainage of the wound should be secured by using Chassaignac’s drainage-tubes, etc.,, in all cases where arteries are involved in gunshot lesions. 636 INJURIES OF BLOODVESSELS. The inapplicability of styptics, such as thq persulphate and the perchloride of iron, etc., to the treatment of hemorrhage from gunshot wounds of arte- ries, has already been pointed out. (See page 625.) Incised Wounds of Arteries. The incised wounds of arteries are inflicted with knives of various sizes and shapes, with sharpened swords or sabres, and with many of the edge- tools used in the mechanic arts. A sharp cutting instrument cleaves the tissues with the least possible disturbance of their histological elements, and leaves the opposing surfaces of the section or wound smooth, even, or level, and in the best possible condition for speedy and perfect reparation. But the same ■circumstances favor the outflow of blood; for the smoothly divided vessels present no such mechanical obstacles to hemorrhage, at their open mouths, as are seen in most other wounds. The incised wounds of arteries are inflicted in accidents, with design, and in war. "When arteries are invaded by cutting instruments, the lesion consists either of a complete division of the arterial tube, or of a partial division, or of a divi- sion of the sheath and the external tunic only, or of a mere puncture of all the arterial tunics. But the punctured wounds of arteries are often caused by instruments other than cutting ones, and therefore this form of injury constitutes a separate class, which we have already attentively considered. The incised wounds of arteries are more prone to bleed than the contused, or the lacerated, or the gunshot wounds, for reasons just stated above. The hemorrhage but seldom, if ever, ceases spontaneously when large arteries are severed by sharp-edged instruments, unless death is at hand, and there is no longer any blood to flow away. But the bleeding from the contused, and the lacerated, and the gunshot severance of arteries, having a similar size, not unfrequently stops of itself, as we have already shown. Incised wounds of arteries are characterized as a class by excessive hemorrhage; and they are more liable as a class to produce death by primary bleeding than any other form of vascular injury. When a small artery is but partially divided by a cutting instrument, it is always more diflicult to stanch the hemorrhage than it is when the same vessel is completely divided. Thus, in abstracting blood from the temporal artery (arteriotomy), when it becomes necessary to stop the bleeding, the first thing to be done is to completely divide the artery at the place where it has been opened, and then a moderate amount of pressure applied for a short time at the place of division will generally suffice to permanently suppress the bleeding. But, if the division of the artery be not made complete in such a case, if pressure be applied for the purpose of arresting the outflow of blood while the arterial tube is only partly divided, then it generally follows that either a traumatic aneurism is formed in the wound, or secondary hemor- rhages successively ensue, which may place the patient’s life in great peril, even where an artery as small as the anterior branch of the temporal is the vessel involved in the lesion. In cases of incised wounds in general, where the hemorrhage from small arteries that are but partially divided gives trouble, the first thing to be done for suppressing it is to complete the division of the bleeding vessels. Thus we perceive that the treatment of the incised wounds of arteries must be conducted on principles somewhat different from those which obtain in treating the contused, the lacerated, and the gunshot ■wounds of arteries. The two following examples usefully illustrate what takes place when a INCISED WOUNDS OF ARTERIES. 637 large artery is completely divided in an incised wound, and the case is left to Xature:— William Barren, a sailmaker, aged about 32, was stabbed in the throat, and in other places, in an affray, on Saturday night, December 11 ; he bled very profusely from the throat-wound, and expired in about twenty minutes from the hemorrhage. Autopsy, at the Fourth Ward Station-house, December 13, by the author, at twelve M Face, lips, gums, and surface of whole body pale and exsanguinated. On left side of neck was found an incised wound, two and a half inches in length, commencing anterior to the ear, and extending forward and somewhat obliquely downward, just beneath and nearly parallel to the body of the lower jaw ; its lips were drawn together and held by one suture; the lips of the wound were somewhat irregular in shape; the track of the wound extended almost transversely across and nearly through the throat, severing, in its course, the anterior third of the sterno-mastoid muscle, the left external carotid artery near its origin, and the accompanying vein ; it also passed through the muscles at the root of the tongue, cutting off the epiglottis at its base ; it divided the great cornu of the hyoid bone on the right side, and terminated near the anterior margin of the right sterno-mastoid muscle. Some clotted blood was found in the larynx below the rima glottidis. The stomach contained a few ounces of a substance resembling coffee-grounds. Internal organs generally exsanguinated, but otherwise sound. The ends of the severed external carotid artery were somewhat contracted, but still permeable, and not plugged up with coagulated blood. The wound in the neighbor- hood of the vessel contained clotted blood. (The parts of the record not pertinent are omitted.) John Heavy, middle-aged, was cut in the upper and inner part of his right arm with a knife, and died from the hemorrhage in fifteen or twenty minutes—in not less than fifteen nor more than twenty minutes—on the night of May 3. Autopsy by the author, at the Fourth Ward Station-house, on May 4, at 4 P. M Cadaver large and muscular; face, lips, and surface of body generally very pale, and presenting a waxen appearance. There was an incised wound of the integuments on the antero-internal part of the right arm, just below the fold of the armpit, one inch and a quarter in length, and extending obliquely across the arm. It was about two inches in depth, and involved the brachial artery, which had been severed transversely near its origin. The ends of the divided 'vessel were partially contracted, but not plugged up with coagulated blood. The wound of the soft parts exterior to the vessel was filled with clotted blood. The lungs, liver, spleen, and internal organs in general, contained much less than the normal quantity of blood; heart large and fatty, with some blood in its right cavities. (Some immaterial points are omitted.) In neither of these cases was any effort of importance made to suppress the bleeding. The largeness and smoothness of the gash in the integuments and other parts exterior to the artery, allowed the blood to escape unobstruct- edly from the arterial lesion, in both instances. Careful inquiry was also made by the author, for the purpose of ascertaining how long each man lived after he was stabbed. As both cases were thoroughly investigated by the coroner, unusual facilities were afforded for pursuing this inquiry. The wit- nesses agreed in testifying that in the external carotid case the man expired in about twenty minutes, and in the brachial artery case in fifteen or twenty minutes—in not less than fifteen nor more than twenty minutes—after the gash was made. In both instances the ends of the severed arteries were somewhat contracted, but they were still open, and not filled or plugged with coagulated blood. In each instance, however, the gash in the soft parts exterior to the vessel was filled with clotted blood. In such cases, as the pulsations of the artery become weaker and the coagulability of the blood increases, the external wound becomes filled with a coagulum, in the middle of which a channel remains open, through which the blood continues to trickle until the clot becomes stronger than the current of the blood, that is, 638 INJURIES OF BLOODVESSELS. until the clot coheres with more force than the impulse which the blood receives from the almost empty artery; but when the hemorrhage thus ceases, death is usually very near. How can such arterial wounds be successfully treated ? In cases where either of the carotids is involved, pressure must be applied, without delay, by both index lingers or a thumb, in the wound, to the ends of the orifice in the wounded artery, until it can be securely tied with carbolized catgut, above and below the lesion. (Consult also on this point the case of a miller, stabbed in the neck with a pocket-knife, who was successfully treated on this plan, p. 561; and the remarks on the treatment of punctured wounds of arteries on p. 567.) In cases where the brachial artery is opened by an incised wound, the bleeding must be promptly suppressed by digital com- pression, or by an extemporaneous tourniquet, or by Esmarch’s elastic liga- ture, until the artery can be tied above and below the wound. In the fol- lowing instance this was done with tourniquets extemporized with pocket handkerchiefs:— An insubordinate soldier, aged 26, while in liquor, resisted arrest and attempted to use violence, whereupon one of the provost guards stabbed him with his sword in the upper part of the left arm, the wound corresponding to the lower third of the coraco- bracliialis muscle. Profuse hemorrhage followed, and was arrested by the corporal of the guard, who applied a handkerchief tightly above and another below the wound. This was so cleverly done that the patient lost no blood until the dressing had been removed two horn’s subsequently, Sept. 20, 1861, when he was conveyed to the hospital for treatment. On careful examination, the brachial artery was found wounded; without further delay an incision was made as for ligature of the ai’tery, and the vessel secured above and below the wound, and the portion between the two wounds cut out. The venae comites were also tied because they were wounded. With the exception of con- sidei’able oedema of the hand, forearm, and arm, which was controlled by bandages, the case pi'ogressed well. On Oct. 16, the patient was returned to duty, entirely well.1 In this case, the first or proximal ligature having been applied, the wound was carefully sponged, and red blood was distinctly seen jetting out of the mouth of the vessel from below, and that with considerable'force, showing that the application of a ligature to the artery above the wound only would have been an insufficient and an incomplete operation. The arterial wound consisted of a gash which extended about half way across the artery, in a nearly transverse direction, and was situated about one inch below the origin of the artery. The weapon penetrated the limb in an oblique direction. The incision of the skin was about, one inch long. On loosening the extemporized tourniquet, the hemorrhage did not recur; the wound was filled with coagu- lated blood; but it was found that there was no radial, nor ulnar, nor bra- chial pulse. The nature of the injury, therefore, could not be mistaken. But the ocular demonstration of regurgitating distal hemorrhage was, per- haps, the most interesting part of the case. The history just related affords a capital illustration of what the treatment should be in cases where the main artery of an extremity is opened by an incised wound, namely, the arrest of hemorrhage, without any delay, by applying digital compression in the wound, or a tourniquet, or an elastic ligature above and below the wound temporarily, that is, until surgical aid can be obtained, and the artery tied properly above and below the gash in its coats. In the following example, although the compression was con- tinued for eighteen days, the operation for applying ligatures had to be per- formed in order to obtain a cure:— 1 Med. and Surg. Hist, of the War, Second Snrg. Vol., p. 436. 639 A man, aged 36, accidentally stabbed himself with a pocket-knife toward the inner side and a little below the middle of the left thigh. There was a profuse escape of arterial blood, and he fainted. He was treated by compression for eighteen days, and brought to hospital on March 8. There was found some swelling surrounding an aperture in the skin an inch long, rounded in form, and situated as above stated. The tumor w'as hard, and did not pulsate. On the 12th, sharp hemorrhage suddenly occurred to the extent of an ounce or two. On the 16th, a pulsating tumor having formed at the seat of injury during the past two days, the artery was cut down upon by enlarging the wound, and tied, under chloroform. A large quantity of firmly laminated fibrin was turned out. The artery was compressed on the pubis by a finger during the ope- ration. But little blood was lost, and recovery, though somewhat tardy, followed.1 One or two additional examples, briefly narrated, will impart more infor- mation concerning the treatment of this most formidable lesion of the femo- ral artery than a lengthy disquisition:— Private George Hastings, Co. K, 37th Infantry, was admitted to hospital July 30, 1868, having been accidentally stabbed the same day, in the upper part of the thigh, with a long, narrow, exceedingly sharp hunting-knife, which, passing by the superficial femoral artery, partially divided the 'profunda femoris below the origin of the external circumflex. The hemorrhage was excessive. Some few moments only elapsed after the accident before complete syncope ensued. Pressure on the common femoral arrested the hemorrhage, but the prostration w7as so extreme as to prohibit operative interference at the time, and stimulants and nutriments wrere administered. At 10 o’clock P. M., hemorrhage again occurring, now from the lower or distal extremity of the artery, the wound was enlarged and the arteria profunda secured with ligatures above and below the lesion. The patient was kept for several days under the influence of morphia. Slight pressure continued on the common femoral, although not sufficient at any time to greatly impede the circulation in the limb. At no time after the operation was the cir- culation arrested. On the nineteenth day the upper ligature was removed, but the lower one did not come away until the thirty-fourth day. The patient recovered completely, and was returned to duty in the following October, between two and three months after the casualty.2 The following case, in which the employment of compression to temporarily restrain the first bleeding from an incised wound of the femoral artery, appears to have been neglected, has peculiar interest in this connection:— A man, aged 53, was admitted to hospital on November 11, pulseless and faint from the loss of blood. There was a small wound, two inches below Poupart’s liga- ment, in his left thigh, over the femoral artery, caused by a knife that had accidentally slipped. The bleeding, which evidently had been great, had ceased. He w'as placed in bed ; and, as reaction came on, a pulsating swelling was revealed beneath the wound. Nov. 14—Tumor larger, and pulsation more marked. The tumor was laid open with a view to ligature the artery above and below' the aperture in it. A large, gaping w'ound was found in the femoral artery. Much difficulty was experienced in applying the proximal ligature, on account of a large branch given off from the artery beneath the wound, which proved to be the profunda. After applying the proximal and distal liga- tures and letting up the pressure, a fierce gush of blood from regurgitation through the profunda followed. This artery also was tied, and the hemorrhage ceased. The patient sank gradually, and died on the 21st, from exhaustion due to the loss of blood.3 The observations on punctured wounds of the femoral artery, and their treatment, at page 573, should also be consulted in this connection. Incised wounds of the popliteal artery are not frequent occurrences; still, Deschamps has related a case:— Etienne Repasses, a servant, aged 41, was admitted to hospital, on May 9, for a •stab in the ham, inflicted with the point of a sabre, which completely divided the pop- INCISED WOUNDS OF ARTERIES. 1 British Medical Journal, August 3, 1872, p. 126. 3 British Medical Journal, Feb. 13, 1875, p. 211. 2 Circular No. 3, S. G. 0., p. 242. 640 INJURIES OP BLOODVESSELS. liteal artery. A traumatic aneurism formed. On June 20, it was laid freely open by an incision about six inches in length, all the clots were removed, the cavity was thoroughly cleansed, and a ligature was tied around each end of the severed artery about four lines from its extremity. A deep abscess in the leg ensued, which emptied itself into the wound. The patient died on the thirty-eighth day after the opera- tion, apparently from pyasmia.1 The result could have been no worse if the femoral artery had been tied on the plan of Hunter, or even if amputation had been performed- In the following instance, Hunter’s operation was performed : Private David Jones* Company E, 4th Infantry, was wounded at Fort Sully, on March 7, 1866, by a soldier who made a thrust with a large bread-knife, which entered the thigh trans- versely, about three inches above the inner condyle of the femur, and, passing almost through, severed the popliteal artery, vein, and nerve. The hemorrhage was con- trolled by compression, and it was then deemed best not to open the wound and attempt to ligate the artery therein. On the fourth day, some arterial hemorrhage occurring,, it was thought unsafe to delay, and the femoral was tied at the middle third. There had been no warmth nor circulation below the wound since the injury, and at the time of the operation there were strong indications of gangrene. The patient died on the seventh day after the operation, March 16.2 Although the cause of death is not expressly stated in this case, still I think that it may fairly be taken by implication to have been traumatic gangrene. In many cases belonging to this category, where gangrene is likely to ensue, it will be advisable to amputate at the outset—that is, to perform primary amputation. Ho one plan of treatment can be prescribed which will suit all, or even the majority of cases, when the popliteal artery has been opened by an incised wound. In some cases it will be advisable for the sur- geon to expose the artery, and ligature it above and below the seat of injury; in others, to perform Hunter’s operation; and in still others, to amputate the limb. Each case must be judged by itself, and that procedure selected which appears most likely to save the patient’s life. The occurrence of gangrene* however, always necessitates immediate amputation in these cases. Incised wounds of the tibial arteries should, generally, be treated on the same plan as incised wounds of the femoral and brachial arteries, just described. The hemorrhage should be restrained by compression until the injured vessel can be laid bare and tied above and below the cut in its walls. Leisrinck has made, in a case of incised wound involving the anterior tibial artery, a fortunate application of the elastic compression of Esmarch. A man having been wounded in the leg with the point of a knife, there rose up in the course of the anterior tibial artery a bluish-colored and pulsating swelling, of the size of a fist. By employing elastic compression (pp. 524-529), Leisrinck was enabled to readily apply to this traumatic aneurism the ancient method of operating; namely, to freely lay open the sac, completely evacuate its con- tents, and find and tie the artery above and below its open mouth.3 Ho doubt, in many cases where the tibial arteries are wounded, the elastic ligature may, with great advantage, be applied to the leg, both above and below the wound, so as to effectually control the circulation while the injured artery is being ligated on the “ old plan.” Boyer has forcibly illustrated the great superiority of the “ old plan” of treatment in such cases:— A young man received an incised wound involving the posterior tibial artery in the low'er part of his leg, near the internal ankle. In some additional cases, the malleolar and tarsal arteries whichyun over the foot were likewise divided. These patients all died; they might have been saved, if, instead of stuffing the wounds with styptics and lint, the surgeon had cut down upon the arteries and tied them above and below.4 1 Observations on Aneurism, Sydenham Society’s edition, p. 410. a Circular No. 3, S. Gr. 0., pp. 241, 242. 3 Nouveau Dictionnaire de Med. et de Chirurg. pratiques, t. xix. Paris, 1874. 4 Op. cit., vol. i. p. 132, Am. ed. INCISED WOUNDS OP ARTERIES. 641 In the following example the dorsal artery of the foot was ligatured on this plan with a good result:— Private James Lasby, Co. G, 23d Infantry, aged 33, while chopping wood at Fort Colville, on December 15, 1868, cut his right foot with a sharp axe. The flexor ten- dons of the foot, the dorsalis pedis artery, and the metatarsal bone of the great toe were divided, causing a gaping wound four inches in length. He was admitted to the post hospital, where the dorsalis pedis artery was ligated, and the wound closed by inter- rupted suture. The wound failed to unite by first intention, and, on Dec. 20, the ligature was removed. The patient was returned to duty in March, 1869.1 Distal ligatures must be applied to wounded arteries in the foot and leg, as in the hand and arm, in order to guard against the regurgitating hemor- rhage which, in their absence, would result from the remarkably free inoscu- lations of the terminal branches with each other by means of the plantar arches, etc., in the one case, and of the palmar arches, etc., in the other. Hemorrhage from incised wounds of the foot, ankle, and leg, when the wound is recent and the parts are sound, will give the surgeon but little trou- ble provided he treats it on the orthodox plan of bringing the bleeding point distinctly into view, applying a ligature on each side of it, and dividing the artery midway between the ligatures, so that the ends may retract. During the late civil war, three hundred and fifty-seven cases of incised and punctured wounds of the upper extremities were reported. There were four deaths: two from neglected arterial bleeding, one from gangrene, and one from a fever long after the wound had Incised wounds of the brachial artery have already been discussed at sufficient length. The exam- ples of punctured, wounds of the brachial artery and the remarks thereon, given at page 570, should also be examined in this connection. Incised wounds of the shoulder are sometimes attended by a tremendous hemorrhage from lesion of some branch of the axillary or subclavian artery, as happened in the following instance, where the posterior circumflex artery was opened:— Private Thomas Quigley, Co. G, 17th Infantry, aged 21, received, at Sulphur Springs, Texas, on December 24, 1868, an incised wound of the left shoulder, eight inches in length, from the shoulder downward. He was admitted to the post hospital; he had fainted from the loss of blood, and his pulse was almost imperceptible. The wound was explored, and the posterior circumflex artery, which was found injured and bleeding, was securely tied ; the edges of the wound were brought together and held by silk sutures and adhesive plaster. On December 31 the wound was healing rapidly. In February, 1869, the patient was returned to duty.3 This case usefully illustrates the plan of treatment w'hich should be carried out in all cases of hemorrhage from incised wounds of the shoulder and arm where the lesser arteries are involved. The wound must be explored, and the bleeding vessel must be brought into plain view, and securely tied. In this way the very best possible results are obtained. But stuffing such wounds with lint soaked in the persulphate or perchloride of iron has often been attended with disastrous consequences. How should incised wounds of the radial, ulnar, and interosseous arteries be treated ? On this point the brief presentation of a few cases will give the requisite information in a convenient way. When the radial artery is completely divided, properly adjusted compres- sion at the wound will not unfrequently stop the bleeding permanently, as it did in a case reported by Dr. Franz in the Medical and Surgical History of the War.* But this is not always, nor even generally, the best practice, and 1 Circular No. 3, S. G. 0., p. 243. 2 Med. and Surg. Hist., Second Surg. Vol., pp. 436, 437. * Circular No. 3, S. G. 0., p. 243. 4 Second Surg. Vol., p. 436. 642 INJURIES OF BLOODVESSELS. when the wound is inflamed or much swollen, it cannot be employed. Much preferable to it for general use is ligation according to the ancient method, as was practised in the next two examples:— A soldier, aged 24, received, September 22, 1868, an incised wound on the dorsal 'surface of his right hand, severing the radial artery. He was taken to hospital, where both extremities of the artery were ligated. On September 30 the patient was doing well; in October he was returned to duty.1 A cavalry soldier at West Point severed the radial artery by striking his fist through a window-pane May 31, 1868. The wound was enlarged by incision, and both ends of the artery were tied by Dr. E. J. Marsh. Considerable swelling followed; the wound, however, healed with but slight suppuration. On June 9 the ligatures were removed ; the 18th the patient was returned to duty.2 The following case, in which the ancient method of ligation had finally to he practised for an incised wound of the ulnar artery, will serve to show the comparative value of several different plans of treating the consequences of this wound:— A zinc-plate worker, aged 29, was admitted to St. George’s Hospital March 6, under care of Mr. Pick. Twelve days before, a chisel slipped and entered his left wrist over the ulnar artery. Profuse hemorrhage followed; it was controlled at first by a ligature tied tightly round the arm, and subsequently by direct pressure over the wound, which was maintained for two or three days, the wound, on its removal, being found healed. In the course of a few days, however, a swelling appeared, which, on admission to hospital, was found to be oval in shape, of the size of a walnut, and situated on the wrist in the course of the ulnar artery. It was surmounted by a cicatrix. Pulsation and bruit were marked. The forearm was kept forcibly flexed upon the arm for twenty- one hours, without benefit. Two horse-shoe tourniquets were next applied, one on the brachial, the other on the ulnar artery, and were kept on as long as the patient would bear them, and until the limb was very cedematous, but without success. On. April 15, galvano-puncture was applied. On the second day afterward the sac burst, and much bleeding ensued. The sac was then laid open from top to bottom, and a few clots, with some decolorized fibrin, turned out. In the posterior part of the sac the upper and lower orifices were seen. The vessel was then tied above and below, and divided between the two ligatures. The man made a good recovery.3 Had the last operation been performed at the outset, much time, much expense, much trouble, and much suffering would have been saved to patient and surgeon. Let me here say, also, that hemorrhage from incised wounds of the radial, ulnar, and interosseous arteries, or their branches, when the wound is recent and the parts are sound, will give the surgeon but little trouble, provided he treats it on the orthodox plan of bringing the bleeding orifice clearly into view, applying a ligature on each side of it, and dividing the artery midway between the two ligatures, so that the ends may freely retract. But if the surgeon rely on compression and styptics, in such cases, he may cause for himself a great deal of trouble, and for his patient a great deal of suffering, which could readily have been avoided by ligaturing the wounded vessels according to the method just described. In such cases, too, distal ligatures are indispensable in order to prevent the regurgitant bleeding which, in their absence, would ensue from the remarkably free inosculations that exist between the terminal branches by means of the palmar arches, etc. Incised wounds involving the 'palmar arches are not unfrequently met with. They are caused by the sharp-edged tools of industry; also by grasping with, the hands, in self-defence, the razors, knives, and daggers with which assaults .are made. These wounds, when treated at the outset on the orthodox plan • Circular No. 3, S. G. 0., p. 237. 2 Ibid., p. 237. 3 British Medical Journal, June 1, 1872, p. 582. INCISED WOUNDS OF ARTERIES. 643 described above, give but little trouble. But, as tlie late Dr. Otis very justly remarks: “The subjects of such injuries are very unfortunate if they have not the services of a surgeon possessed of the requisite skill and courage to thoroughly explore the wound at the outset.”1 I do not say that such cuts never get well under the use of compresses and bandages; I do say, however, that compression often fails to check the bleeding permanently, and that I have seen several instances of such a failure, in some of which the patients were blanched or exsanguinated, and exhausted, from the frequently recurring hemorrhages. Professors Gross and Agnew advise that the general rule for the treatment of wounded arteries should not be deviated from here; and that in recent punctured or incised wounds of the palmar arches, the wound should be enlarged and both ends of the bleeding vessel tied. But the neglected cases present the real difficulties; and in these, compression, cauterization, acupressure, ligation of the radial or ulnar artery, or both, and ligation of the brachial artery, have all been employed with reported successes and failures. Concerning the neglected cases, Professor Yon Pitha observes: “I saw several cases of exceedingly rebellious bleeding from cuts and stabs of the palm; two of these were brought to me after numerous ineffectual attempts to stop the bleeding, in a profoundly anaemic condition; yet I was never forced to practise ligation, as the bleeding ceased, on removing the coagula, completely and permanently The first thing to be done in such cases is to freely expose the bleeding vessel by enlarging the wound, and to boldly clear away all coagula. The irritation caused by the sponge and by the admission of cool air frequently induces the gaping arterial wound to retract. The wound should not be immediately closed, but should be kept under close observation for some time.”2 Many other surgeons, including the author, have likewise seen, in cases of recurring hemorrhage from wounds of the palm, the bleeding cease completely and permanently on laying bare the open mouth of the bleeding vessel, by enlarging the wound, completing the division of the artery in cases where it was incompletely divided, and at the same time removing all coagula and thoroughly cleansing the wound. The ends of the severed artery, which projected at first from the surface of section, have many times been seen to retract, contract, and become completely closed, so that all future hemorrhage was effectually restrained. The most important points to be considered in treating hemorrhage from wounds of the palm are: (1) To distinctly bring into view the mouth or mouths of the bleeding artery, by enlarging the wound; (2) to complete the division of the artery whenever it is found to be incompletely divided; (3) to remove all clots and foreign sub- stances from the wound, and apply pressure to the ends of the severed artery by means of a finger placed in the wound; and (4) if the ends of the artery do not retract, contract, and become completely occluded with a supplemental internal coagulum, to place a ligature of carbolized catgut, securely, on each of the ends. In all cases, whether they be quite recent, or old and neglected, or badly treated, the bleeding artery must be sought for and found in the wounded palm. (For further information on this and other important points, examine the cases and the discussion of punctured wounds of the palmar arches on p. 571.) The objection that a search for the wounded artery may necessitate more or less mutilation of the palm should not be allowed to have much weight against the possibility of failure, as well as the danger, which, in such cases, attends upon the deligation of the arterial trunks in the forearm and arm. Incised wounds involving the lesser arteries of the head and face should 1 Med. and Surg. Hist, of the War of the Rebellion, Second Surg. Vol., p. 437* 8 Ibid., p. 437, foot note. 644 INJURIES OF BLOODVESSELS. be treated by removing all the coagula and exposing the aperture whence the blood issues distinctly to view, by completing the division of the artery whenever it is not complete, and by applying pressure to the ends of the divided artery with a finger in the wound. The success of this proceeding can be considerably aided by simultaneously compressing the trunk of the common carotid artery against the transverse processes of the vertebrae, on the same side as the wound (see Fig. 346, p. 518), with the thumb of the other hand. If in a short time the bleeding is not stanched by these proceedings, a ligature must be put on each end of the wounded artery. In cases where the ligatures, both proximal and distal, have been applied without previously dividing the artery, the artery should be divided midway between the liga- tures, so that retraction of the ends may take place. The hemorrhage from incised wounds of the neck involving the occipital, vertebral, or superior thyroid artery, should be treated on the same general plan as the hemorrhage from incised wounds of the carotids; the surgeon should explore the wound with an index finger, find the aperture in the vessel, from which he will feel the blood issue with each pulsation, place the tip of his finger on this aperture, enlarge the wound if necessary, apply a ligature on each side of the aperture, and finish by dividing the artery midway be- tween the two ligatures. In the following example, the superior thyroid artery was severed by an incised wound, both ends were ligated, and the bleeding did not recur:— Private J. H., Co. K, 1st Infantry, aged 27, cut liis throat with a razor November 3, 1866. The larynx was opened, and the superior thyroid artery was completely divided. When admitted to the post hospital he was nearly pulseless. Both ends of the divided artery were immediately ligated. The patient did very well, and seemed to improve until the evening of Nov. 5, when he had a choking fit, and died in a few minutes from asphyxia.1 The hemorrhage from incised wounds involving the arteries of other regions, for instance, the armpit, the groin, the thigh, etc., should be con- trolled in the same way by the surgeon. He should explore the wound with a finger, feel for the orifice in the wounded vessel from which a stream of blood issues in jets, cover it with the end of his finger, and keep it so covered until he can enlarge the wound, and tie the artery on each side of the aper- ture. lie should also divide the artery midway between the two ligatures, unless this has already been done. Concerning the intercostal, internal mam- mary, internal epigastric, gluteal, vertebral, and many other different arteries, the reader may consult what has been said concerning them in describing the treatment of punctured wounds of arteries, pp. 567-585. The ligatures to be applied should always be antiseptic, and of animal origin. Both ends should be cut off near the knot; incised wounds should, as a rule, be closed immediately with interrupted sutures or with strips of adhesive plaster. In all wounds involving arteries, antiseptic dressings only should be applied. Transfusion is likely to prove useful in many cases of anaemic exhaustion, when it is due to excessive loss of blood from the incised wounds of arteries, and the possible utility of this procedure should not be overlooked in the after-treatment of such cases. Wounds of Veins. Complaints are justly made that this topic receives scant notice in some works on surgery, although the wounds of veins are of frequent occurrence, 1 Circular No. 3, S. GK 0., p. 236. WOUNDS OF VEINS. 645 and although those which involve the large venous trunks must be classed among the most fatal of all accidents. Almost every conceivable wound is attended with the lesion of some vein, however small or large it may be; and wounds of the internal jugular, subclavian, and axillary veins, or of the com- mon iliac, external iliac, and internal iliac veins, are quite as fatal as wounds of the carotid, the subclavian, the axillary, or the iliac arteries, and perhaps even more so. In estimating the gravity of such lesions, it should also be eonsidered that the walls of veins are thin, and their contractile power very feeble; that their capacity, always great, increases with age, so that, when they are opened by wounds, the loss of blood will be greater in the old and debilitated than in the young and strong, while the conveying capacity of the arteries is correspondingly diminished. The veins are wounded, not only very often, but in various ways: homici- dally, suicidally, accidentally, in surgical operations, and in war. The principal sources of danger in venous wounds are :— 1. Primary hemorrhage. 2. Secondary hemorrhage. 3. Septicaemia. 4. Traumatic phlebitis. 5. The entrance of air into the circulation. Symptoms of Venous AVounds.—A vein is known to be wounded when -dark (or so-called venous) blood flows in a rapid and uniform stream from the seat of injury. Sometimes it will be prudent not to decide hastily, •especially in cases where the blood issues from a deep wound. Generally, however, the question may easily be determined; but in cases of doubt we may get valuable aid by compressing the main vascular trunks on the cardiac side of the wound. If the hemorrhage be restrained by so doing, we are assured that it is arterial; but if it be increased, we are almost equally assured that it is venous. Still, it should be remembered that in the extre- mities the blood which flows from the distal aperture of a wounded artery has a dark color, and flows in a steady stream. The wounds of small Veins are less serious than similar injuries of small arteries, because the blood-pressure is less strong, the blood-stream is less swift and powerful, the heart’s contractions are less felt, and, consequently, there is less risk from hemorrhage in the former than in the latter. Dr. Otis, the distinguished historiographer of our civil war, observes: “ Hemor- rhage of consequence from the lesser veins must be a rare event. In a single instance in the reports, attention is directed to bleeding from a gluteal vein.”1 The small veins, when divided, close spontaneously in a few seconds, or their •closure may be hastened by elevating the wounded part, or by applying cold or other haemostatics. When veins no larger than those of the subcutaneous tissue bleed persistently, it is usually because there is some impediment to the flow of blood toward the heart. In a case of this sort which I saw at the battle of Ball’s Bluff, the impediment was caused by an extemporized tourniquet, which had been placed around the wounded arm of a soldier by a comrade; on removing the constriction and applying a roller to the arm, the bleeding ceased. In prolapsed hemorrhoids, also, the grip of the sphincter ani often causes a large loss of blood in a few minutes, which can be promptly ■suppressed by dilating the muscle and returning the tumors into the rectum. So, too, free bleeding from branches of the portal vein is sometimes caused by certain morbid conditions of the liver which obstruct the flow of blood from that vein; and here the causal indication for treatment is to remove 1 Medical and Surgical History, etc., Second Surgical Volume, p. 338. 646 INJURIES OF BLOODVESSELS. the hepatic disorder. The hemorrhage from small veins, when wounded, seldom gives trouble, and can always be controlled by removing the obstruc- tion which causes it. But when large venous trunks, as, for instance, the innominate, the internal jugular, the subclavian, or the axillary, are divided, death follows in a few minutes from the loss of blood, as the cases to be related will abundantly show. The flow of blood from wounded veins in the neck is remarkably affected by the respiratory movements. During inspiration, when the walls of the thorax are expanded, and when no obstacle is offered to the passage of the blood toward the right side of the heart, the wounded vein remains shrunken or partially collapsed, without shedding a drop of blood ; but in expiration, when the thorax becomes contracted, when the great venous channels at the root of the neck become compressed by the lessened diameter of the thorax, and there is a momentary pause in the downward flow of the stream, the blood wells up in the breach as from a fountain. The wounds of deep veins, even those that are not large, always have a grave importance when the injured vessels are so situated that the blood can flow from their open mouths into one of the great cavities of the body, as, for instance, the cavity of the abdomen, that of the thorax, or that of the cranium; for in this way a fatal hemorrhage may ensue—a hemorrhage, too, over which art has but little control. The wounds of veins, like the wounds of arteries, may, for purposes of study and description, be advantageously classified as follows:— 1. Incised and punctured wounds. 2. Contused wounds. 3. Lacerated wounds and ruptures. 4. Gunshot wounds. In incised, in lacerated, and in gunshot wounds, the vessel, as a tube, may be either partially or completely divided. In punctured wounds the division is, of course, always incomplete; and, in contused wounds the vein is not, as a rule, opened until the bruised portion separates as a slough. When a vein is completely divided, its ends contract, although somewhat less than the ends of a severed artery ; they also retract into the sheath. The natural haemostasis is promoted by these movements, and by the formation of a coagulum around the orifice. But these processes are slow in their op- eration, very feeble, and practically insufficient, at least in the case of large veins. When, therefore, deep veins of large size are divided and cannot be treated, a fatal result rapidly ensues from the hemorrhage. When veins of some magnitude are partially divided, the bleeding often gives much trouble. It does not, however, when the injured vessel is super- ficial, and is located in one of the extremities, because by elevating the limb, and by applying a compress over the wounded part with carefully adjusted pressure by means of adhesive strips or a roller, we can almost always sup- press the bleeding, and then, in three or four days, union by adhesion may fairly be expected. After the hemorrhage is controlled, the wounds of veins, as a rule, heal very quickly. They often unite by the first intention, and heal so perfectly as not to leave any appearance of a scar. The repair of wounds made in veins differs in no essential respect from the same process in arteries. The blood pressure or tension of the circulation in wounded veins, however, is not strong enough to separate the adhesion of the lips or margins while union by the first intention is taking place. Hence, the wounds of veins in one respect heal very differently from the wounds of arteries. While the tubes of the latter are almost invariably obliterated in the human subject, even after punctured wounds, the wounded tunics of a vein can readily be repaired 647 without at all diminishing its calibre. We all know how seldom the canal of a vein has been obliterated by the operation of venesection; and the same disposition to maintain the permeability and lumen of its canal is witnessed after most wounds in which a vein is partially divided. In a case recorded by Guthrie, where the internal jugular was cut into, the cure at the end of eight days was found to be so complete, that the vessel was not only pervious, but without a mark to indicate where the wound had been. The following example shows how injured veins heal when ligatured:— Professor Langenbeck, while removing an epithelial cancer, wounded the internal jugular vein, and tied the cardiac end only, there being no hemorrhage from the distal end. The common carotid artery being involved in the tumor was tied with two threads and divided. When operated on, the man had bronchitis, from which he died on the twelfth day. A necroscopy showed the vein completely healed as if by the first intention, without the slightest trace of redness, thickening of its walls, or formation of a clot. Travers was the first to show that veins, when ligatured or divided, united without any adhesive inflammation. The fact is, the venous tunics when wounded heal more perfectly than almost any other structures in the whole body. The hemorrhage from wounded veins should be restrained, (1) by raising up or elevating the wounded part; (2) by carefully applying pressure by means, of well-adjusted compresses, with adhesive strips or bandages; (3) when these prove inadequate, by applying ligatures, without hesitation, above and below the seat of injury. The ligatures should consist of carbolized catgut, and antiseptic dressings should be applied to the wound. All the measures for restraining hemorrhage from wounded arteries are applicable to wounded veins; and the ligation of veins is as free from special danger as the ligation of arteries. To ligature a large vein in its continuity, the surgeon should pass around it the blunt end of an eyed probe, or a Mott’s aneurism needle, armed with a thread of carbolized catgut, carefully separating the vein from the accompa- nying artery and nerve, but to no greater extent than is absolutely necessary. Incised and Punctured Wounds of Veins.—In every act of venesection a punctured or an incised wound of a vein is made. In most amputations the section of large veins is a matter of necessity. In many of the subcutaneous, operations for tenotomy or myotomy, the lesser veins are punctured or divided. Sometimes, too, the great venous channels are accidentally opened by sur- geons. Wounds of veins thus made generally heal quickly and kindly; and we may well say, therefore, that the incised are the least harmful of all the venous wounds. The incised and punctured forms of venous wounds often occur in the common accidents of life; they are, likewise, frequently made by persons in attempts to destroy their own lives; they are, too, not unfre- quently inflicted with the weapons of war and in warfare; and finally, they are sometimes inflicted by persons while committing, or attempting to com- mit, the crime of murder, and hence they are important in a medico-legal point of view. The following example comes under the last named-head:— Mary Dean, a young mulatto girl, was gashed in the left side of her neck, about lb P. M., June 13, 1880, by Augustus D. Leighton, a jealous lover, with a razor, during an interview, while standing in the street near the basement door of her home. Her aunt, who was looking on from a window above, testified : “ I saw him make a sweep with his hand, and Mary vanished into the basement; it was all over in a moment; I found her in the basement, on the floor, all covered with blood, and dead.” Another eye- WOUNDS OF VEINS. 648 INJURIES OF BLOODVESSELS. witness, testified : “Leighton gave a sweep with his right hand ; Mary staggered into the basement, and pointing three times up towards her apartments, fell over and died, without saying a word.” All the eye-witnesses testified that the blood ran down from her neck in a great stream. At the autopsy, an incised wound, five inches in length and two inches in depth, severing the internal jugular vein but not the carotid artery, was found on the left side of the neck ; and there had evidently been but a single stroke of the razor. It is somewhat remarkable, that, although the internal jugular vein has not unfrequently been opened in incised wounds with a fatal result from the loss of blood, S. W. Gross, on diligent search, could find only four cases on record. This circumstance affords good cause for reporting the above case with some minuteness of detail. Death ensued from the loss of blood in one, or at the utmost, two minutes. Incised wounds dividing the internal jugular vein that have size enough to allow the blood to escape externally without any hindrance, prove fatal quite as speedily as similar wounds of the common carotid artery, if not more so. In accounting for the extreme rapidity with which death ensues, in such cases, the enormous capacity of the internal jugular vein for discharging blood, and its freedom from valves, as well as the anatomical relation which it bears to the great sinuses of the dura mater which empty directly into it, must be considered. Thus, the hemorrhage occurs in a great stream drawn directly from the cranial cavity, whereby cere- bral anaemia of a fatal character is directly produced with the greatest possi- ble celerity. The following example, as far as it goes, confirms these views:—• M. Vallee saw a soldier who had been stabbed in the neck, the right jugular vein being almost completely divided. The edges of the wound were retracted, and the vein was empty. Death was almost instantaneous.1 This example, like the last, vividly illustrates the destructive power of the primary bleeding in such instances. But, in cases where the internal jugular vein is gashed, if the hemorrhage be restrained by timely compression until the vein can be ligatured above and below the lesion, the patient may be saved, as is shown by the result in the following instance :— Mr. John Woodman2 records the case of a woman whose throat was cut with a razor. A longitudinal wound was found in the left internal jugular vein, a wound therefore at right angles to that in the skin. Owing to the hemorrhage necessitating constant compression, much difficulty was experienced in ligaturing the vein, but it was finally tied above and below the wound. The bleeding came from the distal part of the vessel. The result was successful. A case is reported in the Medical and Surgical History of our civil war which admirably illustrates the same point:— Pri vate William McDonald, Co. F, 51st New York Volunteers, received a gunshot fracture of the lower jaV, March 14, 1862. The missile lodged behind the common carotid artery and the internal jugular vein. In cutting down over the ball, in order to extract it, on January 5, 1863, the vein was accidentally wounded. The hemorrhage, however, was inconsiderable, being controlled by pressure, the danger of cutting the vein, and the probability of the accident, having been anticipated and provided for. The ball was extracted with some difficulty. A double ligature was passed around the vein, so as to secure it above and below the aperture. The wound was drawn together by interrupted sutures and adhesive straps. It healed kindly, the ligatures coming away on the ninth day after the operation.3 * Gaz. Medicate, 1837, p. 267; and American Journal of the Medical Sciences, January. 1867, p. 37. 2 British Medical Journal, October 18, 1873. ? Medical and Surgical History, etc., First Surgical Volume, p. 397. WOUNDS OF VEINS. 649 Thus it is clearly shown what should be done when the internal jugular -vein is gashed, whether accidentally by a surgeon in operating on the sur- rounding parts, or designedly by an assassin ; the bleeding must be restrained by compressing the wound, with the fingers if possible, until the vessel is securely tied on each side of the aperture in its walls. The large veins of the extremities when cut open, whether by accident or by design, should be treated on the same plan if compression is inadequate to suppress the bleeding, as was done by the late Dr. George McClellan in the following instance :— In extirpating from a gentleman’s groin a large fibrous tumor, which was wedged Into the external crural ring and the femoral canal, and while detaching it from the Temoral vein, he found the saphena interna involved in the substance of the tumor, just .as it emptied into the trunk vein. He was obliged to divide it there; and afterward failing to restrain a tremendous gush of black blood by pressure, he pursed up the orifice by a spring tenaculum and Liston’s forceps, and had a fine silk thread tied around the margin. This succeeded perfectly in restraining the hemorrhage, and was followed by no inconvenience. He remarks that it was the largest venous orifice he ever saw liga- tured, and that it was large enough to admit one of his ring-fingers.1 Punctured wounds are sometimes accidentally made by surgeons in the Avails of large veins, with the points of their scalpels, while removing tumors. In a case which I saw some years ago, where the internal jugular was punc- tured in this manner while dissecting out a deep-seated tumor of the neck, the margins of the puncture were drawn together and raised up by a Liston’s forceps, and a ligature was tied around them on the side of the vessel—that is, a lateral ligature was applied. This proceeding was successful. Never- theless, it should not be imitated, because of the great risk of secondary hem- orrhage which attends it. For example, it is reported on the authority of Nelaton, that Roux tried lateral ligation of the internal jugular in three cases, but that all of them proved fatal from secondary hemorrhage about the sixteenth day.2 In such cases the primary bleeding should be controlled if possible by compression, and if, after a fair trial, this is found inadequate, the wounded vein must be ligatured above and below the puncture. The Army Medical Museum contains a specimen of punctured wound of a large vein. It consists of “ a wet preparation of the left femoral vein pierced by a darning- needle. Private B. A., ‘A,’ 5th Iowa, 40; a conoidal ball passed through Scarpa’s triangle without directly injuring the bloodvessels, Vicksburg, 19th May; admitted to hospital with wound in a sloughing condition, Memphis, 27th ; hemorrhage checked by compression, 31st of May ; wound opened and needle extracted from the sheath at 2 P. M.; artery ligated for secondary hemorrhage at 8 P. M. ; died at 11 P. M., 1st •June, 1863.” 3 The veins in the extremities are often punctured by the fragments in cases where the long bones are fractured. In such cases, considerable tumefactions not unfrequently arise from the extravasations of venous blood, but, as a rule, they speedily subside under the combined influence of quietude and moderate -compression. The large veins in the neck, etc., are sometimes pierced in a fatal manner, in gunshot wounds, by the splinters of bone that are broken ■ott‘ by musket-balls. For instance, Stromeyer, in 1849, had a case of gunshot fracture of the lower jaw, in which fragments of the bone were driven deep into the throat. The man “ died suddenly on the fourth day, in the presence of his attending physician, a thick stream of dark blood issuing from his 1 Principles and Practice of Surgery, pp. 194, 195. Foot-note. e American Journal of the Medical Sciences, April, 1867, p. 327. 3 See Catalogue, A. M. M., p. 472, Spec. 2020. 650 INJURIES OF BLOODVESSELS. mouth.” The autopsy showed an opening in the internal jugular vein, made by a splinter of bone, which still remained in it.1 As soon as the mechanical obstacle became loosened by suppuration, hemorrhage ensued. Large veins are sometimes punctured by the minute bird-shot or squirrel- shot of sportsmen, as happened in a case already related on page 565, that occurred in the practice of Professor Gross, where the right internal jugular vein was penetrated by a squirrel-shot, and the venous wound healed in a noteworthy manner, without the aid of a hlood-clot or the occurrence of inflammation—healed in fact by the first intention—and the shot itself became encysted, by the same process, in the wall of the vein at a point opposite to the place of entrance. The patient died on the fourteenth day after the accident, from protracted epileptic convulsions, and the autopsy revealed what has just been described.2 The subclavian artery also was punctured. The case is of some importance, because it shows the way in which venous wounds may heal, and that the venous tunics may sustain a severe injury without resenting it. A large vein is sometimes accidentally punctured or transfixed by an artery-needle in performing the Hunterian operation for aneurism. Two fatal examples of this sort, in which the internal jugular was pierced through and through, are presented by Dr. S. W. Gross in a most excellent article on “Wounds of the Internal Jugular Vein.’"3 The transfixion of the vein escaped notice in both instances, and the ligature passing through the vein acted as a seton after the operation. Hence, there ensued ulcerative inflam- mation in the vein-wall, and the train of phenomena usually ascribed to diffuse or suppurative phlebitis, with death from pyaemia. Indeed, it would be hard to plan an experiment more likely to produce such results than the establishment of a seton in this manner in a large venous trunk extending across its channel. There are also on record some fatal cases in which the femoral vein was pierced in like manner, while operating on Hunter’s plan for popliteal aneurism. It is, therefore, of great importance that this mishap should be avoided, and, in case it does occur, that it should immediately he detected. In such cases the ligature must be withdrawn, and reapplied at another point. The bleeding will generally cease on tightening the ligature, this cutting off the blood-supply that otherwise would go to the distal part of the limb, and flow back toward the heart through the punctured vein. Contused Wounds of Yeins.—The tunics of veins, like the tunics of arte- ries, are sometimes bruised by the impact of musket-balls and other missiles in gunshot wounds. When large arteries are contused in this manner, the accompanying veins, likewise, are often found to be contused. For example, in one of Mr. Guthrie’s cases, already mentioned in the section on Contused Wounds of Arteries, the walls of the femoral vein were bruised by a musket- hall as well as the walls of the artery, and the canal of the vein was “ filled by a coagulum, and impassable” at the bruised part. The case of P. Ryan, related in the same section, in which a bullet had grazed, but not opened, the sheath of the femoral vessels, and bruised the femoral artery, affords another illustration. “ The vein, however, was not only also slightly contracted, but its internal surface was inflamed and filled with partially organized lymph,, as far up as the entrance of the deep iliac vein, and downwards for about two inches from the wound. Its course was thus entirely sealed, but nothing like pus could be found in the femoral or iliac veins, nor in the system anywhere.”4 1 American Journal of the Medical Sciences, January, 1867, p. 39. 2 Ibid., January, 1867, pp. 41, 42. 3 Ibid., January, 1867, pp. 31, 32. 4 Surgical History of the Crimean War, vol. ii. p. 343. WOUNDS OF VEINS. 651 In both cases the inflammation was formative in character, and there resulted contraction of the bruised part of the vein, and obliteration of its canal. But the contused wounds of veins which are caused by musket-balls and other like missiles, not unfrequently give rise to secondary hemorrhage. The bruised part of the vein separates as a slough, the canal of the injured vein is opened, and an effusion of blood into the wound, or a hemorrhage, takes place. The Army Medical Museum contains several specimens which illus- trate this accident:— One of them is “a wet preparation of a portion of the right internal jugular vein, after secondary hemorrhage from gunshot. The specimen -shows the point of sloughing, and is occupied by a coagulum two inches below the orifice. Private S. W. S., ‘ B.,’ 1st N. Y. Dragoons, 23 ; ball entered two inches below and to the right of the supe- rior angle of the scapula, passed through the neck and fractured the inferior maxilla. Spottsylvania C. H., Va., 8th May ; admitted to hospital, Alexandria, Va., 24th ; secondary hemorrhage, arrested by persulphate of iron, 27th May, 1864 ; date of death not reported.”1 Another illustration of this accident is “ a wet preparation of the upper portion of the femoral vein, showing the point of sloughing after gunshot. The orifice is nearly opposite the mouth of the profunda.” Private M. H., aged 21, was the patient. He was wounded and admitted to hospital April 1, 1863. Venous hemorrhage occurred on the 10th, 11th, and 13th ; on the 15th he died. In both instances the loss of blood appears to have been the cause of death.2 The following case belongs to the same category:— Private M. A. R., Co. E, 46th Ohio Vols., wounded at Dallas May 27 or 28,1864 ; admitted to hospital on the 28th. A ball entered the right side of the face about the middle of the buccinator muscle, fractured the inferior maxilla, passed downward into the neck on the same side, and, lodging, could not be felt. May 30—He felt well; appetite and pulse good, but he could swallow liquid food only. He continued to do well until June 7 and 8, when he lost a great deal of blood from the wound, and became much reduced thereby. On the 27th there was some hemorrhage at seven A. M., which was arrested by com- pression. At nine o’clock he had a convulsion, and died. At the autopsy, the internal jugular vein was found opened for about four inches, and the tissues on the same or right side of the neck were infiltrated with pus. The missile had also fractured the transverse processes of the third and fourth cervical vertebra, and had passed into the chest. In this case the missile was deflected downward into the neck by striking the lower jaw. Thus, the internal jugular vein was grazed and bruised. Some ten or eleven days after the casualty, and when the slough separated, the internal jugular was opened,, and profuse hemorrhage from the wound took place. The bleeding was suppressed, but after a time it recurred, and the man died, having syncopal convulsions (convulsio syncopalis) due to the loss of blood. Were it desirable, additional examples could readily be adduced. Treatment.—The principal indications to be fulfilled in the management of contused wounds affecting veins are: (1) To prevent the occurrence of ulcera- tive phlebitis and secondary hemorrhage; (2) to prevent the absorption of septic matter and the occurrence of septicaemia or pyaemia. Both of these indications are best accomplished by the use of antiseptic dressings and thorough drainage in such wounds; for, in this way, the retention and putre- faction of purulent matter are avoided, and these two sources of danger are eliminated from the case. Should, however, secondary hemorrhage occur, it must be restrained without delay by compression (digital or otherwise) until the bleeding vein can be laid bare, and securely tied above and below the aperture in its walls with ligatures of carbolized catgut. In cases where 1 Catalogue, A. M. M., p. 470, Specimen 2441. 2 Ibid., p. 471, Specimen 1093 652 INJURIES OF BLOODVESSELS. large venous trunks, such as the internal jugular, or the axillary, or the com- mon femoral, are opened in this manner, promptitude in getting complete control of the hemorrhage is a matter of the first importance; and, there- fore, no time should be lost in experimenting with the persulphate or the perchloride of iron, or other astringent substances. Lacerated Wounds and Ruptures of Veins.—The walls of veins are much thinner and less strong than the walls of arteries; hence, the subcutaneous weiris are much more liable to be ruptured by blows than the corresponding arteries. Contusions of the soft parts are very often attended with the lacer- ation or rupture of underlying veins, giving rise to dark discolorations or ecchymoses, and, sometimes, to large sanguinolent collections, which remain liquid for a long time. These bloody tumefactions, or hcematomata, should never he opened by the surgeon unless they suppurate, that is, terminate in ab- scess, or, having become very chronic, cause annoyance by their bulk. While they are still recent, time and the employment of stimulating lotions, in order to hasten absorption, constitute the proper method of cure. Large veins are sometimes torn completely across in open lacerated wounds:— A case of the kind occurred some years ago in the person of a gentleman, under the late Dr. George McClellan’s care. “ His right groin was caught by a large, blunt, iron hook, in a horse-mill, and he was dragged rapidly round the area by it, until a mon- strous rent was torn across, just below Poupart’s ligament, laying bare the femoral vessels and nerves. The artery was completely denuded, and the vein torn across. A prodigious venous hemorrhage ensued.” The artery was taken up, although it did not bleed at the time. The hemorrhage from the vein was restrained by filling the wound with graduated compresses, and binding them down with a thick bandage. “ The result was, that the enormous wound finally healed, and the gentleman eventually got well, although in the mean while the leg mortified and was amputated just below the knee.”1 Dr. McClellan’s remarks on this case are so pertinent that I will quote them : “ Now it is an interesting point to decide whether the ligature around the main artery, which I supposed to be unnecessary and would have opposed, had I been consulted respecting it before the operation, was the cause of the mortification, or whether, as was inferred by some, it was not rather calculated to prevent that unfortunate occurrence. The lat- ter class of my friends considered that the destruction of the great vein at the groin would have caused too great a congestion of venous blood in the parts below, unless the corresponding artery had also been obstructed by the ligature. But other veins, as well &s arteries, might have become dilated in the meanwhile, as indeed they must have done to some extent, because the vitality of the whole knee and parts above was pi’eserved.” The recovery of the patient, in this case, shows that the ligation of the ar- tery was good practice; without such a ligation of the femoral artery, the bleeding from the severed femoral vein would not have been controlled by compression applied in the wound. The restraining effect of tying the femo- ral artery upon hemorrhage from the femoral vein is well shown by one of Professor Agnew’s operations for popliteal aneurism, wherein he wounded the femoral vein in passing the thread around the artery; “ the venous hemor- rhage, which for a time was profuse, immediately ceased on tightening the ligature, and did not afterward return.”2 It is not difficult to conceive how ligaturing the main artery of a limb aids in suppressing hemorrhage from the corresponding vein, for it greatly reduces the supply of blood to be returned by the wounded vein, and arrests the vis a tergo impulse which otherwise would be imparted by the arterial contractions to the circula- 1 Op. cit., p. 171. Foot-note. 2 Op. cit., vol. i., p. 516. WOUNDS OF VEINS. 653 tion in the wounded vein. The femoral artery was ligatured, in the ease related above, about the year 1842, almost twenty years in advance of the famous advice of Langenbeck to the same effect, for suppressing hemorrhage from wounds involving large veins. The axillary vein, in rare instances, has been ruptured during attempts to reduce old dislocations of the shoulder-joint:— Froriep reported the first case : A scrofulous subject, aged 26, was found, twenty day& after the accident, to have sustained a dislocation of the shoulder. At a second attempt at replacement, two distinct sounds were heard, and the dislocation became reduced; but, at the same moment, an axillaiy swelling appeared. The swelling rapidly increased. The patient fainted twice, vomited, went to stool, and expired one hour and a half after the reduction. The axillary cavity was found full of blood, and the axillary vein broken almost entirely across. Its coats were very weak above and below the rupture.1 A second case belonging to the same category happened to Flaubert, in 1827. Some- years ago, the late Mr. Price2 was reducing, at the Great Northern Hospital, an old dislocation at the shoulder of an aged female, when the axillary vein, as was subse- quently ascertained, was torn across, the patient dying on the following day. The artery was not ruptured. This made the third case. In 1863, a, fourth case occurred to Hailey. In 1873, Professor Agnew observed and recorded a* fifth case. A woman,, aged 60, had a dislocated right shoulder of six weeks’ standing. Steady and persevering extension was exerted for several minutes while an assistant’s hand was held in the axilla to guide the head of the bone toward the glenoid cavity. A swelling suddenly appeared in the right pectoral region, distending in an instant the entire breast, ren- dering it exceedingly prominent, and forming a firm but fluctuating tumor. The patient instantly became cold and collapsed; respiration ceased, and the pulse could not be felt. The subclavian artery was compressed, the tongue drawn forward, and cold douches, ammonia, artificial respiration, etc., tried. The patient rallied, and on relaxing the pressure it was found that the radial pulse on that side was just as strong as on the other. The tumor was not tense and distended, and did not seem filling with any force. Com- presses were firmly applied, with warmth externally and stimulants internally. The swelling slowly extended backward, but did not become more tense. In ten days she was discharged.3 Rupture of the axillary vein is more deadly than even rupture of the axillary artery. Of the five examples, Dr. Agnew’s was the only one which ended in recovery. I have related it with considerable minuteness, in order to illustrate the symptoms and treatment of this accident. In some rare- instances the axillary artery and vein are simultaneously ruptured during efforts to reduce old dislocations of the shoulder-joint. The chief danger in. all these cases is that which arises from the subtegumentary bleeding; and unless adequate measures to restrain it are instantly taken, the patient will succumb to it. These measures are: (1) To compress the subclavian artery against the first rib; (2) to place an extemporized tourniquet, for instance, a handkerchief, around the upper end of the arm ; (3) to confine the arm to the side of the chest with a firm bandage. In cases where the artery and vein are both ruptured, should the extravasation of blood happily be restrained from the first, and should the patient happily escape the perils which are denoted by the symptoms of shock and collapse, primary amputation of the, arm at the shoulder-joint should be performed. The great venous trunks may be ruptured in railway accidents, as hap- pened in the following instance where the subclavian was involved:— Valentine K., commissary department, was caught between the buffers of two railway- cars July 20, 1863. The humerus, clavicle, and scapula were fractured, and the neigh.- * Malgaigne, Traite des Fractures, etc., t. li. p» 151. 8 St. Bartholomew’s Hospital Reports, vol. ii. pp.. 107,. 108., 8 Philadelphia Medical Times, Aug. 16, 1873. 654 INJURIES OF BLOODVESSELS. boring soft parts were pulpified, although the skin was not broken. The arm sphacelated, and the man died on the 23d. The subclavian artery was obliterated where it leaves the first rib. The subclavian vein was torn open, and thus the extravasated blood with which the injured parts were distended had been supplied.1 The large veins sometimes get torn open when their coats are weakened by disease, as occurred in the following case where the internal jugular was ruptured during the performance of an operation for epithelioma of the neck:— “ The tumor was removed in September, 1876, the external jugular vein being tied. In March, 1878, the patient returned, and had the growth removed a second time. During the operation the internal jugular vein gave way, its walls being involved and softened, and was tied above and below. The patient made a good recovery, and in July, 1880, was known to be alive and well.”2 When this accident occurs, the vein must he tied above and below without delay, as was done in this case; and when the internal jugular is the injured vein, it certainly is not necessary to tie the common carotid artery, as pro- posed by Langenbeck, unless its tunics are also involved in the disease for which the operation of removal is performed. Spontaneous rupture of the internal jugular vein, with the formation of a cervical thrombus, etc., may occur, as happened in the following instance reported by ISTelaton :— The thrombus caused great swelling of the neck. It was opened to relieve the ex- treme dyspnoea which it produced by pressing on the air-passages, under the supposition that it was an abscess. The hemorrhage that followed was so copious that the incision was prolonged in order to bring into view its source, which was? found to be an oval opening into the internal jugular vein. This Nelaton plugged with a cylinder of agaric, and the bleeding did not return. It came on during scarlatina.3 Moreover, the tunics of the internal jugular vein may be so much weakened by an abscess of a contiguous gland, that they will give way, and allow a thrombus of the neck to ensue; and if the issue of blood from the aperture in the vein cannot be controlled by the application of agaric and pressure, the vein itself must be ligated above and below the aperture with carbolized catgut. In those instances where the aperture in the wall of the vein is small, as it appears to have been in the case reported hy Nelaton, the appli- cation of agaric with compression will probably succeed in restraining the hemorrhage. Gunshot Wounds of Veins.—The nature and importance of the subject can be best shown by presenting brief abstracts of some examples:— A soldier, aged 24,4 was wounded May 22, 1863, and entered a general hospital on the 27th. The ball entered midway between the left trochanter major and the apex of the coccyx, passed obliquely through the lower part of the pelvis and upper part of the right thigh, and emerged in the right femoral region, one inch below Poupart’s liga- ment. Patient stated that very profuse hemorrhage occurred immediately after the reception of the wound ; and, at every considerable motion of the patient, blood escaped from the femoral orifice of the wound, despite the pressure of compresses. Urine escaped from both orifices of the wound. On the 30th, slight diarrhoea, accompanied by deep jaundice, appeared. On June 4, the patient expired. Neci-oscopy revealed that the prostate gland, at its junction with the bladder, was cut away ; that there was 1 Medical and Surgical History of the War, First Surgical Volume, p. 527. 2 Medico-Chirurgical Transactions, vol. lxiii. (1880) ; also American Journal of the Medical Sciences, April, 1881, pp. 481, 482. 3 Journ. de Med. et de Chirurg., t. xxii., November, 1861, p. 499. 4 Med. and Surg. Hist, of the War of the Rebellion, Second Surg. Vol., pp. 304, 339. 655 WOUNDS OF VEINS. not much infiltration of urine; that the right ramus of the os pubis was shattered into fragments ; and that the right femoral vein was widely opened by the wound. The specimen is preserved in the Army Medical Museum, and has been already figured in this work in the article on Gunshot Wounds. (See Fig. 315, supra, p. 211.) The open- ing in the vessel is very large. In this case death was due to anaemic exhaustion, the result of numerous small hemorrhages. The original orifice in the vein probably became enlarged by the separation of a slough. At the outset it appears to have been but small. In the following example the femoral vein was cut almost in two by a pistol-ball. Death ensued from hemorrhage in about two hours, although what was thought to be efficient compression was applied to the wound:— Private John Eberhardt, Co. A, 17th Infantry, aged 21, was shot on October 29, 1868, at Belton, Texas, by a ball from a Colt’s navy-revolver, which entered the right thigh three inches below Poupart’s ligament, internal to the sartorius muscle, passed back- ward and slightly upward, nearly severing the femoral vein, grazed the femur, internally, at the junction of the shaft and neck, passed through the gluteal muscles, and lodged under the cuticle opposite the great ischiatic notch. The patient, unaware of his wound, continued walking or running until he fell, faint from the loss of blood. He was seen some fifteen or twenty minutes after the occurrence ; the missile was extracted, an efficient compress was placed over the wound, and stimulants were administered. But he never reacted. He died in about two hours from hemorrhage.1 This example supports my view, that in cases when the femoral vein is severed, or almost severed, the hemorrhage cannot be restrained by compres- sion, unless by ligature of the femoral artery the supply of blood to the distal part of the limb is cut off at the same time. In cases where it is not advi- sable to tie the artery, the wounded vein should be ligatured without any delay above and below the aperture; or else primary amputation should be performed. In the following case the femoral vein was injured together with the accom- panying nerve. Death ensued in four days from the loss of blood and morti- fication of the leg:— A citizen, aged 17, wras wounded by Indians, at night, while sitting at a camp-fire, just outside the stockade of Fort Philip Kearney, on November 2, 1866. The missiles were supposed to be slugs from a shot-gun. Two entered the inner side of the right thigh, in the middle third, and passed through just behind the femur. Two others passed through the calf of the right leg ; another comminuted the second joint of the right index finger. Liquor ferri persulphat. was used to arrest the hemorrhage, which was venous, and simple dressings were applied. The patient died on the 6th, from shock, venous hemorrhage, and gangrene of the leg. An autopsy revealed laceration of the femoral nerve and injury of the femoral vein.2 In a case reported on the same page, which I have already mentioned in another place, where the femoral artery and vein were both severed by a round pistol-ball, death occurred in a few minutes, from hemorrhage. In another case, reported on page 85, of the same circular, where the femoral artery and vein were severed in a shot wound, the man bled to death, notwithstanding the apparently prompt application of a tourni- quet. In such cases as these two, however, the hemorrhage is mainly arterial. For injuries like those sustained by the citizen above-mentioned, namely, laceration of the femoral vein with laceration of a great nerve and shot-perforations of the calf of same leg, primary amputation should always be performed. There is a case of gunshot wound involving the right femoral vein, recorded in the Medical and Surgical History of the War,3 in Which life was prolonged 1 Circular No. 3, S. Gr. 0., p. 86. Second Surgical Volume, p. 339. 2 Ibid., p. 73. 656 INJURIES OF BLOODVESSELS. for eighteen days, although no particular effort appears to have been made to' suppress the bleeding:— A soldier was wounded October 5, 1864, by a conoidal ball, which entered the left side of the scrotum above the testicle, passed almost transversely to the right, and emerged anterior to the right trochanter major. The discharge from the wound was sanio-puru- lent, and frequently attended with venous hemorrhage, the latter becoming more copious daily. On the 23d the man died. Autopsy—The track of the missile was extensively ulcerated; the femoral vein was severed, and contained purulent matter. The spermatic cord was also severed. The shot-lesion of the femoral vein, in this case, was probably a contusion at the outset; the bruised portion of the vein-wall sloughed, and, as the slough separated, the canal of the vein was opened daily more and more. Thus the bleeding increased from day to day, until death ensued from the frequently-repeated hemorrhages. Perhaps, a patient similarly wounded might be saved by the use of anti- septic dressings and drainage-tubes in the track of the missile, together with deligation of the vein above and below the aperture, performed when the first bleeding appeared; and, with a view to deligation, it would be good practice in similar cases to explore the wound, enlarging it if necessary, in order to lay bare the source of the bleeding. Another large vein, which is not unfrequently opened by small-arm mis- siles and portions of shells, is the internal jugular. The Army Medical- Museum contains a specimen in point:— “ A wet preparation of a portion of the right jugular vein, wounded by a round bullet from a spherical case (shot). A part of the parietes of the vein has been carried away, and in the posterior portion an orifice is seen, through which the contributor considers the missile passed. Private H. O., ‘ A,’ 5tli U. S. Artillery, Suffolk, Ya., 15th April ; died 19th April, 1863.5,1 In such cases, death ensues from hemorrhage, unless the vein is promptly ligatured above and below the lesion. The next two examples will serve to show how insufficient styptics, and compression, and cold applications, and position are to restrain the hemor- rhage from wounded jugular veins:— A soldier was struck, July 18, 1863, by a piece of a shell, in the root of his neck, tearing open the branches of the thyroid axis and the internal jugular vein. Styptics- and compresses, etc., were applied, because it was decided that to operate for ligation would hasten death on account of hemorrhage. He died on the 27th.2 In a case like this the surgeon would be justified in assuming many risks rather than abandon the patient to otherwise almost inevitable death. Again ; Sergeant J. W. J., Jr., Co. D, 28th Mississippi Cavalry (Confederate), was wounded and captured, April 10, 1863. A conoidal ball entered his neck opposite the thyroid cartilage, at the inner border of the left sterno-mastoid muscle, and emerged about an inch and a half to the left of the lower cervical vertebra?. He lost, in the course of three hours, perhaps two quarts of blood, when the hemorrhage ceased. On the second day he was taken with severe chills, which recurred at the rate of two or three a day, followed by high febrile reaction. Death resulted on the 16th, that is, six days after the casualty. The autopsy showed the internal jugular vein completely divided; the surrounding tissues were extensively infiltrated with pus and blood ; and the divided extremities of the vein contained a large amount of pus.* Had both ends of the severed vein been securely tied, without delay, in this case, not only would all bleeding have been suppressed, but also the entrance of purulent matter into the open mouths of the vein would have been prevented; and the patient would have had some chance cf recovery. At least, the risk of death from purulent absorption would have been very much diminished by such a proceeding. 1 Catalogue A. M. M., p. 470. Specimen 1055. 2 Medical and Surgical History, etc., First Surg. Vol., p. 411. * Ibid., pp. 411, 412. WOUNDS OF VEINS. 657 8. Cooper has published a noteworthy instance of an oblicpie gunshot wound opening the internal jugular vein, in which death ensued from the pressure that was exerted on the air-passages by the subtegumentary extravasation of blood:— A soldier was shot, the ball entering behind the mastoid process and passing down- ward and forward toward the sternum. The internal jugular was divided; the man lived more than an hour, but was suffocated by the pressure on the trachea of a large mass of extravasated blood which could not escape outwardly.1 Breaches in the walls of the internal jugular vein made by gunshot mis- siles sometimes heal spontaneously. There are at least two examples on record:— Dr. Stromeyer saw, at Colding, a Schleswig-Holstein soldier who had been shot in the right side of the lower jaw, and across the neck under the tongue, the ball lodging and remaining unextracted. There had been no hemorrhage. The patient died, at the end of three weeks, from pyaemia. At the autopsy an abscess was found behind the left sterno-cleido-mastoid muscle, in which the flattened bullet lay near the verte- bral column. “ The internal jugular vein had been torn to the extent of five lines on its antero-outer aspect; but the rent was completely healed, as the coats of the vein had applied themselves to it from behind, and were united thereto, so that the cylinder of the vessel was diminished one-half.”2 Dr. Schwarz observed the other case : A rifle-ball, entering the mouth, shattered the lower jaw, tore open the internal jugular vein, and, lodging at the aperture, restrained the bleeding. Suppuration ensued, with death from pyaemia. An autopsy showed a completely healed rent in the outer wall of the vein, the cylinder of which was slightly diminished, but free. At the cicatrix, the coats of the vein were thickened by plastic deposits, and a very adherent, semi-organized layer of lymph coated the lining mem- brane. The small veins contiguous to the abscess, in which lay the ball, were filled with broken-down coagula.3 The prognosis in gunshot wounds that involve the internal jugular vein is very bad. Dr. S. W. Gross was unable to find on record a single case of re- covery from this lesion. “ On the contrary, all the cases have proved fatal; 62.5 per cent, from secondary hemorrhage; 25 per cent, from pyaemia, and 12.5 per cent, from primary hemorrhage.”4 Recovery from gunshot lesions of the internal jugular must be very rare; for an extended search has failed to furnish me with even one undoubted case of such a recovery. The First Surgical Volume of the History of the War contains, however, the abstracts of two successful cases of gunshot wound of the neck, in each of which it is probable that the internal jugular was injured.5 Shot wounds of the axillary vein were occasionally noted during our late civil war; but no example was reported of a shot-wound of the subclavian vein that came under treatment. The case reported by Mr. Blenkins,6 where a ball passed between the right subclavian artery and vein, wounding the latter and causing fatal phlebitis, remains the solitary recorded instance. But, as Mr. Fraser observes, the exemption is ideal rather than real, for probably a large proportion of those killed in battle die from torn blood- vessels. Wounds of the Sinuses of the Dura Mater.—Brief mention must be made of the traumatic lesions which have been observed in the great venous 1 First Lines of the Practice of Surgery, vol. i. p. 529. New York, 1822. * American Journal of the Medical Sciences, January, 1867, p. 40. 8 Ibid., p. 40. 4 American Journal of the Medical Sciences, January, 1867, p. 36. 8 Op. cit., pp. 412, 422. 8 Fraser, Treatise on Penetrating Wounds of the Chest, p. 13. 658 INJURIES OF BLOODVESSELS. canals of the encephalon. In the following example, the left petrosal sinus was lacerated by a fracture of the skull; death from cerebral compression speedily ensued:— A young lady (Emma Leiding) in Brooklyn, on October 4, jumped off from an At- lantic Street horse-car, which was running away down hill, the brakes having failed. She alighted on her feet, but, in her fright, fell backward striking upon her head. She was immediately picked up insensible, having a scalp-wound on the back part of the head, and soon afterwards died without recovering consciousness. Autopsy, Oct. 5 The only mark of violence found externally was a contused and lacerated wound of the scalp on the posterior part of the head. On opening the skull, a large quantity of uncoagulated (or liquid) blood was discovered in the cranial cavity. On removing the brain, the base of the skull was found fractured on the left side ; the left petrosal sinus was ruptured, which .-accounted for the hemorrhage. No other lesions were present. Thus, the cause of death was cerebral compression, the result of extravasation of blood from a lacerated petrosal : sinus. Moreover, extravasations of blood from wounds of this vessel are apt to prove quickly fatal, first, because they are rapid and copious, and secondly, because they directly compress the medulla oblongata. In such cases there is no return of con- sciousness. The insensibility of cerebral concussion is succeeded by that of cerebral compression, without any appreciable interval. Such cases are not remediable.1 Other cases, however, are remediable. For instance, Guthrie2 reports the following ease:— A dragoon fell from his horse, in consequence of a wound in the trunk, on to the top of his head. Coma supervened. A swelling of the scalp was noticed at the vertex, where he had struck ; this, on being incised, showed a separation of the edges of the sagittal suture, from which some blood flowed. Two crowns of a trephine were applied on the twelfth day, in order to obtain a free discharge of some blood which had been extravasated from a wound in the superior longitudinal sinus, after which the symptoms subsided, and the man gradually recovered. M. Mouton mentions a similar instance in which he was called to see a man eleven ■days after a fall. The patient was insensible and almost dying, in consequence of an ■extravasation of blood from the superior longitudinal sinus, wounded by a separation of the sagittal suture. Trephining gave vent to the extravasated blood, and the threaten- ing symptoms immediately ceased.3 Wounds of the longitudinal or lateral sinuses are not dangerous, provided the external opening is large enough to allow the blood to escape freely. But when the blood canno.t escape in this way, such wounds are extremely dan- gerous from the attendant compression of the brain. M. Lassus presented two cases in which the superior longitudinal sinus was opened by punctured fractures of the parietal bones at the sagittal suture. In each case a trephine was applied, the fragments or splinters of bone were pulled out of the sinus into which they had been driven, the bleeding was stopped by applying some dry lint to the rent in the sinus, and the patient made a good recovery.* M. Gagniere has reported a case in which the superior longitudinal sinus was wounded by a blow on the top of the head with a dung-fork. He enlarged the opening in the scalp by a cruciform incision, and extracted the fracture-splinters; and he then per- ceived a clot of blood which had formed in the opening of the sinus, which had been made by the fork. The dressing, which was made in the manner usual after trephining, was moistened with spiritus balsamicus, a powerful antiseptic; no severe symptoms fol- lowed, and the wound was quite healed by the end of three months.5 1 Mr. Prescott Hewett records a most extensive extravasation of blood between the bone and the dura mater, which proceeded from a rupture of the right lateral sinus, just as it turns Tinder the petrous portion of the temporal bone, in a case of fracture. (Trans. Patliolog. Soc. of London, vol. iii. p. 229.) 2 Commentaries on Surgery, etc., p. 349, Am. ed. 8 Memoirs of the Royal Acad, of Surgery of France, Sydenham Society’s Translation, p. 8. 4 Ibid., pp. 66, 67. 8 Ibid., p. 69. WOUNDS OF VEINS. 659 Percival Pott, in a hopeless case where the superior longitudinal sinus was laid bare by a compound fracture of the skull, for a space at least two inches in length, wishing to abstract blood, made an opening with a lancet into the sinus, and suffered the blood to run off until the countenance, which was flushed, became pale. He then put a bit of lint on the orifice, and by pressing thereon lightly with a finger, easily stopped the bleeding. This venesection caused no trouble. The patient, however, died on the twelfth day afterward, from a cerebro-meningeal abscess, due to the original injury.1 In some sabre wounds, which divide the skull across the sagittal suture, the longitu- dinal sinus has occasionally been opened and bled profusely, but without inducing fatal consequences. Hennen has seen this sinus opened by splinters, but never saw anything approaching to dangerous hemorrhage from it.2 In the case of a child, aged 3 years, the great longitudinal sinus was opened by a punctured fracture of the skull, made with the sharp point of a pickaxe ; much venous hemorrhage ensued from a small wound over the sagittal suture ; a probe inserted into this wound passed down to the corpus callosum. A pad of lint was applied to the wound, and an ice-bag was kept on the head ; the patient made satisfactory progress to recovery.3 Foreign bodies lodged in a sinus of the dura mater do not readily excite intra-venous inflammation. For example, in December, 1868, one of the demonstrators of anatomy in the Calcutta Medical College met with a cal- varia (now in the College Museum) in which an iron headless nail, about an inch long, had penetrated the frontal bone on the mesial line, and, passing completely through the longitudinal sinus, had divided the layers of the falx cerebri, between which its point is visible; consequently its shaft, which was not corroded, stood in the mid-current of blood in the sinus, and seems latterly not to have caused any inconvenience. The edges of the hole in the frontal bone, which the butt-end of the nail still occupies, are so rounded that it looks like an arterial foramen, and there is not the slightest trace of inflam- matory change within.4 Lastly, I will state a few conclusions derived from the foregoing: (1) Wounds of the sinuses of the dura mater do not possess any peculiar elements of danger. (2) Hemorrhage from wounds of these sinuses is not dangerous unless the extravasation is retained within the skull; in which case it becomes very dangerous because of the compression of the brain that ensues. For its relief the operation of trephining should, if possible, be performed. (3) Ex- ternal bleeding from wounds of these sinuses can generally be restrained, without much trouble, by applying dry lint with slight or very moderate pres- sure. But, under no circumstances, should the persulphate or perchloride of iron be put in such wounds, because of the possibility of its getting into the injured sinus. (4) Antiseptic dressings should be applied, together with the ice-bag if there be any tendency to meningeal inflammation or to a cerebral abscess. Septicaemia from Wounds of Veins.—A wounded vein or sinus of the dura mater, whose open mouth is surrounded by, or bathed in, purulent fluid, may afford an avenue for the introduction of septic matter into the circu- lation, which will infect the blood and the whole system, that is, produce septicaemia. Professor Agnew has seen a trifling wound of the cephalic vein, bolow the line of the deltoid, prove fatal from this cause.5 The writer has seen a lesion of the same vein, made in opening an abscess of the arm, prove 1 Chirurgical Works, vol. i. p. 134, Am-, ed. 2 Principles of Military Surgery, p. 231, Am. ed. 3 Lancet, August 22, 1874, p. 270. 4 British and Foreign Medico-Chirurgical Review, October, 1871, p. 353. 6 Op. cit., vol. i. p. 516. 660 INJURIES OF BLOODVESSELS. fatal in the same way. The extension of morbid processes from unhealthy wounds into the severed veins, through their open mouths, has often been observed. For instance, Dr. Macleod, in his Notes on the Surgery of the Cri- mean war, states: “We had many most beautiful examples, post-mortem, of veins leading from the stump remaining round, patulous, and filled with pus, and sometimes reddened in their interior. It was not uncommon to trace the pus-filled vein from the thigh to the vena cava.”1 There is no doubt that a septicsemio thrombosis is readily started in severed veins whose open ends lie uncovered in unhealthy suppurating wounds; and that this septicsemio thrombosis is much inclined to spread upward toward the right auricle. I have several times found such thromboses on examining, post-mortem, the bodies of those dead from gunshot fractures of the thigh and similar injuries. Hence, I think that Dr. Macleod, with much propriety, raises the question whether it would not be justifiable to ligature the chief veins of amputated limbs, at the time of the operation, especially, if the so-called purulent ab- sorption should he an accident of common occurrence. lie states that “nume- rous cases are on record in which the ligature of veins has not only not been followed by evil results, but has absolutely been the apparent cause of pre- venting inflammation and pus-absorption.” This is particularly well illus- trated in a case related by Mr. Johnston, of St. George’s Hospital, in the journals of 1857. In that case, those vessels which had been tied were free from both inflammation and pus, while those not included in ligatures were full of pus, and “ much inflamed.” I do not doubt that ligatures applied to veins, in wounds likely to become the seat of unhealthy suppuration, may prevent the introduction of septic matter into the blood, as well as the occur- rence of septicemic thrombosis, and septicemia itself. My views fully accord with Velpeau’s, concerning the advisability of oftentimes securing wounded veins with ligatures, when he in substance says : “ The dangers of ligation, which so many surgeons have insisted on for half a century, are shown to he farthest from the truth, and I should not be surprised to find that it would prove more advantageous to close veins immediately with ligatures, than to leave them open at the bottom of wounds.”2 Mr. Liston, too, feared the consequences much more when the ends of divided veins remained open in suppurating wounds, than when they had been closed by applying ligatures. To prevent the occurrence of septicaemia or pyaemia in cases where veins of importance are wounded, it is advisable: (1) To secure the opened veins with carbolized catgut ligatures applied on the cardiac, as well as on the distal, side of the wound. (2) To treat the wound itself on the antiseptic plan. (3) To prevent any collections of purulent matter from forming or burrowing around the injured veins, by thorough drainage, and by frequent renewals of the dressings. In cases where the skull is injured, it is, like- wise, very important to prevent any collections of matter from forming on the sinuses of the dura mater, by early incisions, by changing the dress- ings at short intervals, and by securing as good a drainage of the wound as possible. Ligation of Veins.—When a delicate, strong, and well-waxed silk thread is drawn as tightly as possible around a large vein, its tunics become thrown into longitudinal folds or plaits. Upon slitting the vessel open, these folds are seen to be well marked, but without any division of the tunics; and by holding the vessel between the eye and the light, a decided transverse furrow or indentation, corresponding to the site of the ligature, is discernible, which 1 Op. cit., pp. 350, 351, Am. ed. 2 Operative Surgery, vol. ii. p. 2, Am. ed. WOUXDS OF VEIXS. 661 might at first sight appear due to injury of one or more of the coats. The external and internal tunics can be made to glide over the furrow by the finger, showing that some lesion exists in the middle coat, and a superficial exami- nation would leave the opinion that it had been completely divided. A minute examination and dissection, however, clearly disclose that only the inner layer of the middle coat, consisting of circular elastic fibres, has been eut, or rather separated, leaving the longitudinal fibres unharmed and closely •connected with the uninjured external tunic. 'With the exception, then, of the impression made upon the inner layer of the middle tunic, none of the coats sutler division. The external tunic seems to be as strong as that of an artery in resisting a ligature. The middle tunic differs from that of an artery in having longitudinal as well as circular fibres, the former being composed •of white fibrous tissue with elastic fibres, the latter of elastic fibres arranged in the same manner as those of an artery, with an admixture of a large •quantity of unstriped muscular fibres. The inner tunic is more dense and tough, but not nearly as lacerable as that of an artery, and can be stripped off from the middle coat much more readily and to a greater extent. The inner tunic of the ascending cava has been peeled off in one unbroken patch of more than two inches, and on applying a ligature to it, it suffered no division. It is thus seen that the anatomical structure of a vein differs ma- terially from that of an artery, and that, when ligatured, none of its coats are completely divided, as is the case with the latter vessel.1 Ligatures, however, when tightly drawn around veins, always make enough impression on the deep layer of the middle tunic to keep them from slipping off from the ends after the vessel is severed. Subsequently, the changes wrought by the application of ligatures to veins are strictly analogous to those which take place in ligated arteries. A coag- ulum forms on the distal side of the thread; it becomes organized, and unites with the inner tunic. If a ligature of animal origin, such as carbo- lized catgut, has been applied, the approximated walls grow directly toge- ther, and the ligature itself disappears by absorption, or is replaced by new connective tissue. But if a ligature of silk has been employed, as it cuts its way through the vein by ulceration, the tunics at the ends unite either by the first intention or by adhesive inflammation, and the obliterated por- tion is ultimately converted into a firm fibro-ligamentous cord. Veins may, and often do, undergo repair after ligature without any inflammation whatever, whether adhesive or otherwise, as Mr. Travers was the first to show. Three preparations illustrate this fact. One, in the Museum of St. Thomas’s Hos- pital, is thus described: “ Appearance of a vein divided by the ligature, which came away on the twenty-fifth day. The upper part of the vein is filled with firm layers of coagula, which so tenaciously adhere to the inner membrane as to be separated with difficulty; when separated, the surface was found to be perfectly smooth and natural.” A second preparation, in the Museum of St. George’s Hospital, shows the result of a ligature applied to the jugular vein of a horse for twenty-four hours. The inner vein-wall, thrown into longitudinal folds, is otherwise natural in appearance, whilst a good deal of lymph* is accumulated externally around the ligature. The third, also in the Museum of St. George’s Hospital, shows the effects of a ligature including part of the parietes of the jugular vein of a horse. Some fibrin is deposited in the track of the thread and in a small pouch below, but no evidence exists of any inflammation of the lining membrane, and this three days after the application of the ligature.2 The results of tying the internal jugular vein in man, which were observed by Guthrie and Langen- 1 S. W. Gross, American Journal of the Medical Sciences, April, 1867, pp. 320, 321. 2 Holmes’s System of Surgery, vol. iii., p. 357. 662 INJURIES OF BLOODVESSELS. beck, as already mentioned, teach the same important lesson. In both, union by the first intention occurred. In Guthrie’s case of lateral ligation, the healing was so perfect on the ninth day that there was no mark to indicate where the thread had been applied. In Langenbeck’s case, an autopsy on the twelfth day showed the “ vein completely healed, without trace of clot, redness, or thickening of its walls,” that is, without any trace whatever of any inflammation. All surgical observations prove that ligatures may fearlessly be applied to veins, as Dr. S. W. Gross has ably shown in an exhaustive article on wounds of the internal jugular vein and their treatment, published in the American Journal of the Medical Sciences, for January arid April, 1867. The danger of exciting phlebitis and pyaemia by ligaturing veins is an exploded doctrine among surgeons. The dread of setting up diffuse phlebitis by ligaturing veins is based on prejudice, and not on experience; it is doubtless due to the influence of authorities who have pronounced against the operation (Bryant). This doctrine had its origin in the mistaken views on suppurative phlebitis and thrombosis which were current among pathologists some years ago, but which have long since been abandoned. The truth is, as I have just shown above, that the judicious application to wounded veins of carbolized catgut ligatures, or any other good antiseptic ligatures of animal origin, will lessen'much the risk of diffuse phlebitis, putrefactive thrombosis, septicaemia, and pyaemia. In hemor- rhages, too, from wounded veins, the antiseptic ligatures just mentioned should be fearlessly applied whenever advisable to restrain the bleeding. Lateral liga- tures, however, should not be employed, from the risk of secondary hemor- rhage which attends their use, as Roux’s experience, to which I have already referred, has amply shown. Some writers advise, in similar cases, to stitch together the aperture in the side of the vein with a fine thread; but this practice, likewise, is a dangerous one, and altogether unreliable. "Whenever veins are ligatured, an antiseptic thread of animal origin must be made to encircle the whole vessel; and a separate ligature must be passed around it on each side of the aperture in its walls. Moreover, wounded veins should always be tied in this way without delay, when pressure, properly applied, fails to restrain the hemorrhage. Ligation of Artery and Vein simultaneously for Venous Hemorrhage.—When a large vein is wounded and bleeding, Professor Langenbeck recommends that, as an haemostatic measure, the accompanying artery should be tied as well as the injured vein. He believes that “when both artery and vein are tied, not only does gangrene not follow, but there is less disturbance to the capillary circulation than when the vein or artery alone is tied.” lie states that, by simultaneous ligation of both artery and vein, “ an equilibrium is maintained between the arteries and veins until the collateral circulation is established.” Two observations which I have already presented strongly sup- port these views. One of them was a case related by the late I)r. George McClellan (page 652), in which, the femoral vein being lacerated, the femoral artery was ligatured, the hemorrhage was easily restrained by compression, and the result was successful. The other occurred to Professor Agnew (page 652); in it, the hemorrhage from a punctured femoral vein ceased on apply- ing a ligature to the accompanying femoral artery, and did not recur. That gangrene is not an inevitable result, and is but rarely to be expected in such instances, is well shown by the cases of Professor Grillo, of Naples, who in- cluded the femoral artery and vein in the same ligature in fifteen cases of aneurism of the ham or lower part of thigh. These were all successful; while in fourteen other cases, in which the artery was isolated and tied alone, there were two deaths from secondary hemorrhage.1 1 American Journal of the Medical Sciences, April, 1867, p. 334. WOUNDS OF VEINS. 663 During the late civil war, in a case of secondary hemorrhage to the amount of twenty- ounces, from a gunshot wound of the armpit, the axillary artery was ligated above and below the wound ; and the axillary vein, being injured, was also tied. The bleeding did not recur, but death ensued on the thirteenth day after the operation, apparently from anaemic exhaustion. Autopsy—No evidence of phlebitis or pyaemia was found.1 In another case of secondary hemorrhage, the basilic vein, being open, was tied as well as the brachial artery, above and below the wound. This man recovered.2 I have in one case, however, where the femoral artery and vein were both opened in a gunshot wound, seen gangrene ensue after the simultaneous ligation of these vessels :— Private D. R., “ K,” 7th Indiana, aged 20; wounded November 30, 1863 ; a con- oidal bullet passed from behind directly through the left thigh, dividing both femoral artery and vein, and escaping from Scarpa’s space ; admitted to hospital, Washington, December 6 ; operated on December 9, by Dr. Wm. Thomson, because the aneurismal condition was increasing. He laid the tumor freely open, and found the vessels severed just below the origin of the profunda. He tied each end of both artery and vein. Mortification of the limb followed, and death ensued on the 13th. I saw this case in consultation. Amputation was then out of the question. The man was very pale. His limb was already much swollen and oedematous, looking not unlike the limb in phlegmasia alba dolens. The aneurismal swelling was likely soon to burst. His general condition was failing. The operation was, therefore, one of expediency. In this case, the gunshot wound, the hemorrhagic infiltration, and the inflammatory swelling of the thigh, made the establishment of a collateral circulation much more difficult after the operation, which was performed on the ninth day, than it would have been had the operation been performed without any delay; and it is quite possible that, had the deli- gation of both artery and vein been practised at the outset, and before the advent of any swelling, the occurrence of gangrene would have altogether been avoided. At any rate, it is scarcely fair to infer that a primary ligation of the severed vessels would neces- sarily have been followed by gangrene. When the femoral vein is wounded, but especially in the upper part of its course, it may be very difficult, or even impossible, to stay the bleeding, un- less the femoral artery is ligatured. This fact is well shown by Oettingen's case;— During the removal of a tumor situated in the fossa ovalis, he wounded the femoral vein, and therefore tied both ends of it. Notwithstanding this double ligation, the hemorrhage continued, and the leg became cyanotic. In order to arrest the venous hemorrhage, and to correct the inequality between the afflux and reflux of blood, he tied the common femoral artery. The hemorrhage ceased and the cyanosis disappeared. Gangrene did not ensue. In a case recorded by Rose, there was a punctured wound of the femoral artery and vein, in a butcher, aged 25. Both vessels were ligated in loco, at their proximal and distal ends; the vein had been split by the knife, “ directly under Poupart’s ligament,” the artery a little lower, “ nearly under Poupart’s ligament.” The patient completely recovered, without even oedema of the limb appearing during the after-treatment. Tillmanns ligated the common femoral artery below Poupart’s ligament for profuse hemorrhage from numerous large veins, after the extirpation of a vascular sarcoma of the thigh, the size of a man’s head. The hemorrhage was promptly arrested and the patient recovered.3 Other examples of similar import might be adduced. Beyond doubt, then, it is often, perhaps generally, a good litemostatic measure in wounds involv- ing the femoral or axillary veins, to ligate the accompanying artery as well as the vein itself.* 1 Medical and Surgical History, etc,, First Surgical Vol., p. 555. 2 Ibid., p. 446. 3 International Journal of Medicine and Surgery, vol. i. pp. 224—227. 4 When hemorrhage from the common femoral vein makes deligation of that vessel necessary- in order to stop the bleeding, the common femoral artery should also be ligatured in most cases, in order to equalize the circulation in the limb, as recommended by Langenbeck. “ Under these circumstances, it may be hoped that still other successful ligations of the injured vena femoralis 664 INJURIES OF BLOODVESSELS. Not so, however, in wounds involving the internal jugular vein. The great freedom with which the blood can pass from one jugular to the other through the lateral sinuses, etc., and can be returned toward the heart in this way in case one of them is ligatured, makes it quite unnecessary to tie the common carotid artery in order to equalize the afflux and reflux of blood in the head, when the corresponding jugular vein is closed by ligation. For the same reason, the ligation of a common carotid artery will not restrain the flow of blood from a wounded fellow internal jugular vein; and, therefore, it must be rejected as a haemostatic measure in such cases. Entrance of Air into Veins.—The entrance of air into veins is a most dangerous accident. I can describe it most briefly and accurately by present- ing some examples. The first instance on record was observed in 1818 by M. Beauchesne, while removing a large tumor from the right shoulder. He accidentally opened the external jugular vein, just above its termination in the subclavian, during the extraction of a part of the clavicle; air entered the partly divided vein, and in a quarter of an hour the patient died. In 1822, a striking example of this mishap occurred to Hupuytren:— He was excising a tumor from the postero-lateral part of the neck of a healthy young woman, and, while an assistant raised it up, as he was severing its last attachments a prolonged blowing sound was heard in the wound. “ If I were not so far from the air- tubes,” said Dupuytren, “ I should think we had opened them.” The words were scarcely uttered when the girl exclaimed, “ Je suis morte ;” she trembled, and fell dead. A large vein, connected with the tumor and communicating with the internal jugular, was cut by the last stroke of the scalpel while the tumor was forcibly drawn up. This vein adhered to the sides of a sulcus, so that it remained gaping when cut. The right auricle was found distended with air, which rushed out, unmixed with blood, on laying it open ; the other chambers of the heart contained fluid blood. In all the vessels there was much air mixed with blood. No other abnormity was observed. Many examples of this accident have been reported. In 1829, Amussat had already collected thirty-nine cases. They continued to happen with considerable frequency until the use of anaesthetics during surgical ope- rations became general. Since that time, their occurrence has been very rare. Indeed, it is not difficult to perceive that anaesthesia, by eliminating from surgical operations on the neck, breast, and armpit, the struggles, cries, groans, and sobs, and the deep gasping inspirations they cause, which for- merly obtained, must considerably diminish the risk of air being drawn into wounded veins, in those regions, by the suction power of the chest. Two examples, however, were reported during the late civil war. In one of them, death occurred within two minutes, in the other in from seven to ten minutes after the mishap. The following is a brief account of these cases:— 1. Private E. M. D., Co. E, 1st Maine Heavy Artillery, aged 21, was wounded May 12, 1864, by a conoidal ball, which fractured the left temporal bone and lodged in the neck. On May 22, during an operation for extracting the ball and fragments of bone, hemorrhage from the internal jugular vein took place, and within two minutes death occurred. Surgeon N. R. Mosely, U. S. Volunteers, ascribed the almost instantaneous death of this patient to the entrance of air into the internal jugular vein, which was communis at the ligamentum Poupartii may be added to those already known, the more so, as by means of the antiseptic method of operating, uninterrupted recoveries are more easily obtained ; that is, diffuse inflammatory infiltrations of the soft parts and extensive phlebitis are prevented. And especially as these compressing, extensive inflammatory infiltrations with phlebitis are very probably the main cause of gangrene after ligation of the arteries as well as after ligation of veins.” (Tillmanns.) WOUNDS OF VEINS. 665 found largely opened by ulceration.1 This case is probably unique, for Dr. S. W. Gross asserts that there is not a single recorded instance of death from this accident following a gunshot injury of the internal jugular vein. 2. In the next example of air in veins, the axillary vein was accidentally opened while searching for the artery : Private E. C. Melley, Company K, 2nd West Virginia Mounted Infantry, was wounded November 6, 18G3, by a musket-ball, which entered one inch and a quarter below the middle of the clavicle, and emerged near the middle of the inferior border of the scapula. When admitted to hospital on the 18th, an enormous tumor of coagulum distended the axillary space in every direction, and rendered the surrounding tissues tense ; the subcutaneous veins covering it were enlarged. During his removal to hospital, considerable blood was lost from the anterior orifice ; the posterior orifice was closed and nearly healed. On the 19th, an attempt was made to secure the axillary artery in the midst of this immense clot, at the place where it was wounded. But, in searching for the artery, the axillary vein was accidentally opened; the entrance of air caused syncope, and death ensued in from seven to ten minutes. After death the axillary artery was found almost completely divided about one inch before it becomes the brachial.2 This accident has most frequently been observed in the great veins at the root of the neck and in the armpit. The internal jugular was the seat of the mishap in twelve instances collected by Dr. S. W. Gross, with six deaths and six recoveries. Ten of them occurred while extirpating tumors of the neck, with five deaths and five recoveries; and two in cut-throats or attempted suicides, with one death and one recovery.3 To these twelve cases a thir- teenth, just now related, must be added, in which death from air in veins followed a gunshot lesion of the internal jugular. Moreover, these cases show that the accident is more liable to occur when the vein is opened near its termination in the innominate, as at this point, as well as throughout almost the whole of its lower third, the phenomena of venous inspiration may be witnessed, that is, the free sucking of air and blood, at each inspiratory effort, into the open mouth of the vein, when wounded or divided by an external injury. This accident, too, has not unfrequently occurred in the subclavian and .axillary veins. I have already presented one example in which the axillary was wounded, that occurred during our civil war. In a case recorded by Delpech, there was hypertrophy of the axillary vein, causing it to gap like an .artery, so that the air entered in when it was opened. Bransby Cooper4 having secured the vessels after amputating an arm at the shoulder- joint, proceeded to remove a gland from the axilla, and, while dissecting it out, heard a peculiar gurgling noise, like air escaping with fluid from a narrow-necked bottle ; the patient instantly became collapsed ; countenance deadly pale ; pupils fixed and inobe- dient to light; pulse quite small and fluttering, although, at intervals, regular ; respira- tion hurried and feeble, and, at irregular intervals, attended with a deep sigh; left leg apparently paralyzed. She continually uttered a Avhining cry. Symptoms of great prostration continued for several days, but she eventually recovered. When she left the hospital, six weeks after the operation, she still dragged the left leg in walking. While Roux was disarticulating an arm at the shoulder by the method of Desault, a peculiar whistling sound of air was suddenly and very distinctly heard. Pallor, syn- cope, convulsive movements, and death ensued. Autopsy—Right ventricle soft, and distended with a mixture of air and blood; globules of air in the coronary veins; con- tents of vena cava superior, spumous.5 1 Med. and Surg. History, etc., First Surg. Vol., pp. 255, 256. 2 Ibid., p. 555. s Loc. cit., pp. 38, 39, 329, 333, 338, 339. 4 Medico-Chirurgical Transactions, vol. xxvii. p. 14. 4 Journal des Connaissances Medico-Cliirurgieales, Septembre, 1836, pp. 108, 109. 666 INJURIES OF BLOODVESSELS. Dr. Mussey, in 1837, extirpated the clavicle and scapula, six years after amputating the arm. At the moment of tying the subclavian artery, a faint gurgling sound was heard, and a bubble of air was seen in the mouth of the subclavian vein. The man uttered a faint cry; his eyes rolled and became fixed ; his neck and face were covered with cold sweat; his pulse was imperceptible; there was loss of consciousness during eight or ten minutes; finally, however, the patient recovered.1 Mr. Jessop did a primary amputation of the upper extremity, including the scapula and outer half of the clavicle, for a severe injury.2 While removing the scapula, air was heard to enter the subclavian vein. The patient was suffering from extreme shock at the time, and was almost dead ; but he rallied, and at the end of three weeks the wound was healed. The spontaneous entrance of air into the venous system has also occurred, not unfrequently, during surgical operations which laid open the lesser veins of the sub-clavicular, axillary, and sub-scapular regions, as well as those which involved the subclavian and axillary veins. For instance, on July 4, 1837, Amussat extirpated the right mamma, and, while cut- ting into some suspected tissue under the right clavicle, he suddenly heard a distinct interrupted sound, as of air passing into a cavity through a narrow opening. Syncope,, with cold sweats, etc., ensued, but in the end recovery took place. So, too, a case occurred to Warren, in which the air entered by the sub-scapular vein, the coats whereof were healthy, but in a state of tension, in consequence of the position of the arm. In a case reported by Castara, there was incomplete section of a vein wdiich opened into the sub-scapular, whilst the tumor was raised up, and in this w7ay the air entered.3 I have thus presented nine examples in which air was drawn into the veins of the axilla, both great and small, by the movements of thoracic inspiration, during operations for amputation as well as for the extirpation of tumors. But air has often been drawn into the small veins of the neck when wounded, as well as into the large or deep jugular vein, by the movements of' thoracic inspiration. I have already presented two such examples. In Du- puytren’s case, a vein communicating with the internal jugular was cut. In Beauchesne’s case, the external jugular was partially divided. Besides, there are on record at least three other cases in which air was sucked in through a wounded external jugular vein:— Rigaud4 opened a vein which he believed to be the external jugular, while ligaturing the subclavian artery above the clavicle. The sound of the drawing of air into the vein wTas heard three different times. Malgaigne relates a case in which the accident happened in consequence of the incom- plete section of the external jugular vein, where it was enveloped by a tumor that was being removed. Manec, while ligaturing the subclavian artery for aneurism, opened the external jugular vein, and air was drawn in. The patient’s head was thrown back; the eyes were convulsed ; the face became pale ; but recovery followed. Again, the same accident happened in a case reported by Warren, in consequence of the division of a small transverse branch of communication between the external and internal jugulars, whilst in a state of tension. Moreover, this mishap has ensued from the wounding of a small vein high up in the neck. For instance, Mott, on dividing the facial vein while removing a parotid tumor, heard the gurgling sound of air passing into some small opening. “ The breathing of the patient immediately became difficult and laborious, the heart beat violently and 1 American Journal of the Medical Sciences, February, 1838, p. 390. 2 British Medical Journal, January 3, 1874. 8 American Journal of the Medical Sciences, November, 1837, p. 233. 4 These. Paris, 1836. 667 WOUNDS OF VEINS. irregularly, his features were distorted, and convulsions of the whole body soon followed to so great an extent as to make it impossible to keep him on the table. He lay on the floor in this condition for nearly half an hour, as all supposed him in articulo mortis. As the convulsions left him, his mouth was permanently distorted, and complete hemi- plegia was found to have ensued ; an hour or more elapsed before he could articulate, and it was nearly a whole day before he recovered the use of his arm and leg.”1 Le Gros Clark mentions a case belonging to the same category, but also remarkable for the slowness with which the air was sucked into the vein, and the tardiness with which the symptoms appeared.2 The incision was above the hyoid bone. Dyspnoea came on gradually, and increased until death ensued, in about twenty-four hours. At the autopsy, the blood in the heart was found churned up and frothy. Examination of the wound showed that a half-divided vein, ligatured only on the distal or bleeding side of the aperture, had slowly drawn into its open mouth the air which, admixed with the blood, had proved fatal. “Dangerous Region.”—That there is a space of considerable size, embracing portions of several regions, in which there is a special clanger in performing surgical operations, caused by the liability of air to be drawn into wounded veins by the movements of thoracic inspiration, these thirty examples just presented very clearly prove. They also show that this dangerous space embraces almost all of the cervical region, together with the sub-clavic- ular, the axillary, and the sub-scapular regions, and that the liability to get air in veins increases, on either side, with growing nearness to the brachio- cephalic trunk or the innominate vein. They show, too, that the careless gashing of small veins within these limits is almost as dangerous as that of the large ones; and that the veins to be especially avoided are the external and internal jugulars, the subclavian, the axillary, the thoracics, and the sub- scapular. The operations that need most caution in this regard are amputation at the shoulder-joint, disarticulation of the clavicle and scapula, deligation of the subclavian and other arteries, and the extirpation of tumors, from those consisting of scrofulous glands no larger than a small nut, all the way up to those as large as a child’s head. I must mention some examples of air in veins, which, although not of special interest to operating surgeons, still have enough of importance to demand recognition in this place. For instance, a case is mentioned by Dr. S. W. Gross in which air entered a large vein that was opened by ulceration. One of the jugulars communicated with an open sore through an aperture in its walls made by ulceration. There was a slight bleeding, followed by a gurgling sound, etc., and alarming syncope; from which, how- ever, the woman gradually recovered under the use of stimulants.3 Dr. Cordwent relates a case in which he thinks death was caused by air entering the veins of the uterus after labor.4 Professor John C. Dalton, Jr., mentions a case in which a gutta-percha catheter was used to rupture the membranes and procure abortion. The patient fell back and died. Air was found in the veins and heart; and it was believed by the surgeon that air had been blown in through the catheter, in order to produce the effect desired.6 Depoul related to the Surgical Society of Paris a case in which the douche was used for the purpose of inducing premature labor. A gurgling noise, like that of air, attended the use of the instrument; and suddenly the woman died. On making the Caesarean section for extracting the child post-mortem, air escaped in cutting into the uterus; the uterine tissue was bright red, and the blood was frothy.6 Dr. Parise observed several cases of sudden death in gangrene of the limbs, and in each instance believed that this result was caused by the entrance of putrid gas into the- 1 Gazette Medicate, 1831. 2 British Medical Journal. August 21, 1869. 3 American Journal of the Medical Sciences, April, 1871, p. 337. 4 St. George’s Hospital Reports, vol. iii. 5 American Medical Monthly, June, 1860. 6 Lancet, July, 1860. 668 INJURIES OF BLOODVESSELS. veins, and thus into the heart. Maisonneuve, in 1853, published several cases of rapid gangrene with the development of putrid gas in the veins; but he believed that death was caused by blood-poisoning from this source. Dr. Parise, however, affirms that the putrid quality of the gas determines no septic action, but that the gas produces death in the same way that air does when it accidentally enters the veins.1 The entrance of air or gas into the veins caused sudden death in one case during the Crimean war : A soldier, aged 20, sustained a gunshot fracture of the left leg, June 18, 1855. On September 21, amputation immediately above the knee was performed; but the stump did badly, the discharge being thin, watery, copious, and slightly fetid. At 1 A. M., on the 25th, he was found, unexpectedly by the orderly, quite dead in bed, and nearly cold, although he had conversed with the man in the next bed as late as 11 o’clock. Autopsy—Lungs healthy, but somewhat anaemic. Right auricle distended with bright red froth (air or gas mixed with blood) ; right ventricle also distended, but the propor- tion of air was less ; heart otherwise healthy. Inferior cava, too, distended with scarlet- colored, frothy blood, “ so that it felt like a portion of small intestine before it was cut into.” Interior of stump sloughy, with no attempt to unite ; flaps separated to some extent by fetid gas; the femoral vein lay quite open on the face of the stump, with no attempt at closure, but no sloughing.2 Had the femoral vein been ligatured in this stump, such a misliap could not have occurred. Causes.—The above presented examples of this accident that took place in the dangerous region, show its causes to be the following: (1) The suction- power exerted by the inspiratory movements of the thorax upon the inno- minate and its tributary veins throughout the dangerous region. This suction-power is exhibited by a movement of afflux and reflux of blood in these veins, synchronous with the inspiratory and expiratory movements of the thorax. (2) The gaping of the mouth of the wounded vein which soli- cits the air to enter. This gaping in many situations is due to the adherence of the fascia or aponeurosis to the sides of the vein, whereby it is held open when wounded or divided. The contractions of the platysma and other mus- cles of the neck have a similar effect, (3) The “ canalization ” of veins, or their conversion into rigid, uncollapsing tubes—(a) from inflammatory thick- ening of their tunics, (6) from being surrounded by indurated connective tissue, or (c) from being imbedded in tumors—is an exceedingly favorable condition for the introduction of air into them. (4) The patulous state of veins may be caused by the surgeon himself in lifting up tumors, in making the neck tense by extending the head, in making the axilla tense by extending the arm, also by notching the walls of veins, and, finally, by neglecting to place a proximal as well as a distal ligature around a wounded vein, as happened in the case mentioned by Le Gros Clark. Symptoms.—When the air enters a wounded vein, a whistling, hissing, sucking, gurgling or lapping sound is usually heard; bubbles of air often appear in the wound ; a deathly pallor spreads over the face; the pulse be- comes small and weak, or nearly imperceptible, and the heart’s action labor- ing, rapid, and feeble; the respiration is labored or embarrassed, short, and hurried ; the eyes are fixed, and the pupils widely dilated ; if the quantity of air admitted be small, these symptoms may disappear after a time, and recovery ensue; but if the quantity be large, syncope with convulsions and fatal collapse soon follow. The symptoms, however, may be masked by the anaesthetic action of chloroform or ether. Hence the reports of cases of this accident are, as a rule, much less dramatic since the introduction of anaes- thesia. It is not improbable that some of the deaths attributed to chloroform have in reality been due to air in veins. A whistling, hissing, or sucking sound which is not due to the entrance 1 Archives Gen. de Medecine, Novembre, 1880. 2 Medical and Surgical History of the Crimean War, vol. ii. p. 277. WOUXDS OF VELNS. 669 of air into a wounded vein, is sometimes lieard during operations in the dangerous region. It may occur ou opening the deep fascia of the axilla when made tense by extending the arm, or that of the neck when made tense by extending the head, or that of any space similarly protected from atmo- spheric pressure. Of course there are no constitutional symptoms in such a case. The following is a good example:— In 1830, Professor A. H. Stevens, at the New York Hospital, while extirpating a large' flattened tumor under the left sterno-mastoid muscle, having detached it com- pletely, except at its postero-inner edge, drew the tumor outward and forward, and divided, near its junction with the internal jugular, a vein of considerable size. Half an ounce of venous blood escaped; in an instant afterward a peculiar sound, like that caused by drawing into a syringe the last portion of water from a basin, was heard. “It was a moment of intense anxiety,” says Professor Stevens, “for the fate of Hupuytren’s patient was fresh in my recollection. I immediately placed my finger on the aperture in the vessel, seized the pulse with my other hand, and watched the patient’s countenance. All seemed well, and the patient’s reply to my interrogatory confirmed the favorable indications.” He treated the wounded vein by ligaturing the internal jugular above and below its place of entrance. The ligatures came away on the fourteenth day, and the case went on without any peculiarities.1 The following is likewise a pseudo-example of air in the veins;— Professor Verneuil, while removing a tumor of the right parotid gland, divided a vein (the external jugular or one of its branches) while separating the supra-clavicular prolongation of the tumor; a whistling sound indicated the passage of air into the vein ; the latter was instantly compressed, then tied; but no change occurred in the pulse or breathing. The operation was completed, and the case progressed satisfac- torily afterward.2 It is far more likely, however, that the air did not enter the vein at all, but, instead thereof, passed into the loose connective tissue under the deep cer- vical fascia, in this as in the preceding case. Pathology — Examinations after death from this accident show air mixed with blood in the right auricle and ventricle, often beaten up together into a, spumous froth, with a similar spumous froth in the superior cava and other veins, and an unusually bloodless appearance of the lungs. Several explana- tions of the cause of death have been ottered, none of which, however, are quite satisfactory. Among the most plausible of them is that which sup- poses that the air is carried into the right ventricle, and that, during the contraction of the right ventricle, the presence of this air prevents the clo- sure of the tricuspid and the semilunar valves, in consequence of which the two orifices which they guard remain pervious in both the systole and dias- tole of the heart, allowing the air to reach the pulmonary arteries, and in this way preventing the entrance of blood; hence there is a deficient supply of blood to the brain and nervous centres, and fatal syncope comes on, at- tended generally by convulsions. The heart’s action usually continues some time after respiration has ceased. Some who have recovered from the im- mediate effects have died from pneumonia. Treatment.—The securing of equal and regular breathing in the patient,, throughout operations in the dangerous region, by duly regulating the ad- ministration of anaesthetics, is an important precaution against this accident, which should never be neglected. The surgeon himself should avoid all the causes of this accident which depend upon his own conduct during the ope- ration. There should be as much relaxation of the parts allowed as may be compatible with the safe or convenient performance of the operation.. The 1 Cooper’s Surgical Dictionary, Supplement, Am. ed., pp. 165, 165.. 2 Gazette Hebdomadaire, 1863, p. 722. 670 INJURIES OF BLOODVESSELS. relations of the veins should always be considered before any incisions are made, throughout the operation. Tumors should be detached from their surroundings, as far as practicable, with the handle instead of the blade of the seal] >el; and all veins which it is not necessary to cut should be pushed aside. When it is necessary to divide a vein in the course of the operation, pressure should be made above and below, and should be continued on the cardiac side until the end of the divided vein is securely tied. But especially, when prying out adherent tumors from the deep parts of the neck, or of the axilla, should the surgeon have firm pressure made by his assistants upon the contiguous veins, both above and below. When disarticulating the cla- vicle, special pains should be taken to avoid notching the external jugular vein. When deligating the subclavian artery, special pains should also be taken to avoid wounding the same vein. In amputating at the shoulder- joint, the liability for air to enter the axillary vein, when cut into while the arm is extended, should be suitably met by the application of pressure. But should, unfortunately, the air enter a vein, the surgeon must imme- diately place a finger on the orifice, and pass a ligature around the wounded vessel, on the cardiac as well as on the distal side of the aperture. By sea- sonably stopping the ingress of air in this way, many subjects of this mis- hap have been saved. The symptoms of alarming syncope, and the threatened collapse, must be met by lowering the patient’s head, by artificially maintain- ing the respiration, and by the subcutaneous or rectal administration of diffu- sible stimulants, such as ammonia and brandy. It may, too, be remembered with possible advantage that dogs have been restored by artificial respiration continued for one-half or three-fourths of an hour, when very considerable quantities of air had entered the veins. As a remedial measure of last re- sort, if time permit, a few ounces of blood may be transfused. Wounds of the Aorta, Innominate, and Subclavian Arteries ; the Venje Cavas, and Venae Azygos; the Heart, Pulmonary Artery, and Pulmo- nary Veins. Brief mention must be made of this important class of injuries. Wounds of these vessels very rarely come under surgical treatment. The subjects almost always perish from hemorrhage, or from shock, before surgical aid can be obtained. Wounds of the Aorta.—The following example in which the aorta was punctured by the blade of a penknife is to the point:— James Donohue, aged 8 years, living in the rear of No. 90 Catharine Street, went out about 9 o’clock P. M., on May 1, 1881, to buy an apple. In a few minutes he came back, and meeting his sister, said : “ A boy as big as you are has stabbed me.” There was a small wound in his breast, and soon he fainted in his sister’s arms. He failed rapidly, and although he was taken in an ambulance to the Chambers St. Hospital, he died before midnight of internal hemorrhage. The wound was made with the narrow blade of a penknife, which entered the chest just below the third rib, and punctured the aorta. Afterward, it was shown that the stabbing had been accidental. He lived about two and a half hours. During the civil war no one wounded in the aortic arch, or in any part of the thoracic aorta, lived long enough to receive hospital treatment. Dr. J. B. White mentions a case of bayonet-stab causing a small puncture in the aorta, a few lines external to the pericardium, which proved fatal from hemorrhage. But, since the war, Dr. W. J. Piper reports an accidental pistol-ball perforar WOUNDS OF THE AORTA. 671 tion of the aortic arch, the wounded soldier having lived long enough to be carried across the parade-ground to the post hospital, at Baton Rouge.1 But in the following example, where the abdominal aorta was injured in the late civil war, the patient survived the casualty forty days:— A soldier was wounded, on July 3, 1863, by a conoidal ball, which entered his chest at the right nipple, and lodged. He did badly. About August 1, he rapidly grew worse. A pulsating tumor was discerned in the umbilical region, which steadily grew larger. He sank gradually, and died on August 12, of anaemia. Autopsy—The mis- sile, entering the thorax at the right nipple, passed inward, downward, and backward through the diaphragm, by the side of the aortic sheath, and lodged in the body of the fifth lumbar vertebra, half an inch to the right of the median line. Just above the point of lodgment, a large aneurismal sac communicating with the aorta was found ; it was partially emptied, and there was a large quantity of coagulated blood found extra- vasated beneath, that is, external to the peritoneum, on the left side of the spine, amount- ing to almost two pounds. The aorta, elsewhere, was healthy.3 The bullet grazed the sheath of the aorta, in this instance, and its tunics, being weakened by the textural disintegration, gradually yielded until they burst and allowed a traumatic aneurism to form. Wounds of the great bloodvessels of the trunk are usually passed over cursorily by systematic writers on surgery, and the information concerning them is scattered through theses, monographs, and collections of cases. Guattani3 records the case of a man who survived an incised wound of the arch of the aorta eight years. Pelletan4 relates the case of a man who lived two months after a puncture of the aorta, near its origin, by a foil. Ileil5 details a case in which the patient lived twelve months after receiving a stab in the ascending aorta. T. M. Green, of Macon, Ga.,6 publishes an account he had from Dr. J. B. Wiley—“ a competent and reliable observer”—of an autopsy held on a man stabbed, a month previously, in the aorta near its origin, with a narrow blade. In the Journal de Medecine7 is a similar his- tory, of a man who lived six days. Lerouge inserted in Saviard’s Observations Chirurgicales, which he edited, a similar case, the patient surviving eleven days. Legouest8 quotes a unique instance of recovery from a punctured wound of the aorta, observed by Dr. Neil, of Bamburg, in 1812, the cicatrix having been verified a year subsequently, at the autopsy, after the occurrence of death from pneumonia Demme saw a young Austrian perish from secon- dary hemorrhage four weeks after the reception of a gunshot injury of the descending part of the thoracic aorta. Cases of rupture of the aorta from external violence have been recorded by Morgagni,9 Laurencin, and St. Leger,10 and a specimen of this lesion is preserved in the Museum of St. Bartholo- mew’s Hospital.11 There is also a preparation by Professor Theile in the Museum of Pathological Anatomy, at Bern, showing a laceration of the arch of the aorta which was not fatal until several months after the accident. Our Army Medical Museum contains two specimens of gunshot lesion of the abdominal aorta, in one of which the artery is fairly perforated by a pistol-ball.12 M. Legouest13 saw a case of transverse laceration of the left side of the aorta, one-fourth of an inch long, three fingers-breadth above 1 Med. and Surg. Hist, of the War, etc., First Surg. Vol., p. 519. 2 Ibid., Second Surg. Vol., p. 189. 3 Scriptorum Latinorum de Aneurismatibus Collect, ed. Lautli, pag. 178. Argent, 1785. 4 Clinique Chirurgicale, t. iii. p. 241. 5 Henke’s Zeitsclirift, 1837, Bd. ii. S. 459. 6 Southern Med. and Surg. Journal, 1855. 7 Journal de M6decine, t. xlvi. p. 435. 8 Chirurgie d’Arm6e, 2e ed., p. 333. 8 De Sedibus et Causis Morborum, Epist. liii. 10 These de Montpelier (MS.), quoted by Berard. 11 Med. and Surg. History, etc., First Surg. Vol., pp. 519, 527, Foot-notes. 11 Specimens 910, 4085, Sect. I., A. M. M. 13 Op. cit., 2me ed., p. 372. 672 INJURIES OF BLOODVESSELS. the promontory of the sacrum, in a farrier, who received a kick from a horse at the level of the umbilicus. The bleeding, which, of course, was internal, proved rapidly fatal. Doubtless other arteries of the abdomen may be rup- tured without external wound. The aorta has occasionally been punctured by foreign bodies which had entered it from the oesophagus. I have already presented two such examples in the section on Punctured Wounds of Arteries. The aorta, too, has not been opened by ulcerations caused by foreign bodies penetrating it from the oesophagus. The next four wood-cuts illustrate this accident. Fig. 430. Fig. 431. Perforation of the aorta by a swallowed bone. The point of perforation is indicated by a stylet. C. Car- otid artery. SC. Subclavian artery. (E. (Esophagus. The bone is represented at the side. After Shetter (Archiv f. klin. Cliir., 1878). Taken from Poulet’s Foreign Bodies in Surgical Practice, vol. i. p. 90, Am. edition. Perforation of the oesophagus and aorta by a five franc piece. (Denonvilliers, Mus6e Dupuytren.) Taken from Poulet’s Foreign Bodies in Surgical Practice, vol. i. p. 93, Am. ed. Poulet1 lias collected thirty-three instances of the perforation of bloodvessels by foreign bodies lodged in the oesophagus. In these cases, however, the perforations were effected by ulcerations caused by the foreign bodies, that is, the perforations were secondary to eschars, which, by gradually becoming deeper, finally involved the walls of the vessels. In 17, or over one-half of these 33 cases, the aorta was the vessel per- forated ; in 4 the common carotid artery ; in 2 the vena cava ; in 1 the inferior thy- 1 Foreign Bodies in Surgical Practice, vol. i. p. 91, Am. ed. WOUNDS OF THE AORTA. 673 Fig. 432. Fig. 433. Perforation of the inferior thyroid artery by a swal- lowed hone. (Pilate, Musee Dupuytren.) Taken from Poulet’s Foreign Bodies in Surgical Practice, vol. i. p. 94, Am. edition. Perforation of the aorta and oesophagus by a very irregular bone. (Bousquet, Musee Dupuytren.) A. The aorta. P. The perforation. O. The foreign body. tE. The opened oesophagus. Taken from Poulet’s Foreign Bodies in Surgical Practice, vol. i. p. 95, Am. edition. void artery; in 1 the right coronary vein; in 1 the vena azygos ; in 1 the right subcla- vian artery (abnormal) ; in 1 the oesophageal arteries; in 1 the pulmonary arteries ; and in 4 eases the arteries penetrated were unknown, as autopsies were not made. The position of the oesophagus in the midst of the large vascular trunks of the neck and chest sufficiently explains the frequency of this grave accident. These vessels are : 1st, the aorta, which is situated behind and to the left of the oesophagus ; 2d, the vena azygos ; 3d, the pulmonary artery ; 4th, the superior vena cava ; 5th, the carotid ; 6th, the inferior thyroid artery; 7th, the right subclavian artery, when abnormally situated ; 8th, the oesophageal arteries. The much greater frequency of aortic perfora- tions is not wonderful, in view of its great size, and of the intimate manner in which the two organs are connected over a considerable space. The foreign bodies causing this accident have most often been pieces of bone. Next in the order of frequency are coins, fish-bones, artificial teeth, etc., and any irregular, dense, flattened, or pointed body can produce it. After what lapse of time are these perforations of bloodvessels developed? This period is very variable. In a large ma- jority of the cases, however, the first hemorrhage occurs from the fifteenth to the twenty-fifth day ; but the exceptions are numerous. Moreover, surgical interference is not immaterial ; and, more than once, it has happened that the surgeon has forced a foreign body, which he thought he had pushed into the stomach, into the oesophageal walls. Such a manipulation would only, by so much, hasten the occurrence of vascular perforation and hemorrhage. In such cases, too, the appearances may be very decep- 674 INJURIES OF BLOODVESSELS tive. Thus, Wagret’s patient, after a physician had made attempts to propel the bone, “ experienced entire relief, and said to his benefactor that he thanked him very mucli, and that he had saved his life.” But a few days later this patient died of perforation of, and hemorrhage from, the descending aorta. (Poulet.) The first hemorrhage, in these cases, generally does not cause death; it ceases, for the time being, and the patients merely remain in a state of ex- treme weakness. Surgeons have been struck by this intermittence of the hemorrhage, and have endeavored to explain the manner in which a vessel as large as the thoracic aorta may cease to bleed after its walls are perforated. Shetter attributes the intermittence to two causes : 1, a temporary occlusion of the opening in the artery; 2, the weakness of the cardiac contractions. The process is a natural haemostasis, like that described by Valsalva. The blood, being pushed with less force by the weakened heart, and being changed in composition, is in a condition the most favorable for forming obstructive clots. But when the heart recovers its energy, and the condition of collapse gives place to commencing reaction, the clot is displaced, and the hemorrhage reappears. The interval between the hemorrhages is usually not considerable, varying from a few hours to a few days. In some cases, especially when the perforation is small and is situated low down, all the blood extravasated flows' into the stomach and thence passes into the intestines. The patient then suddenly presents, in the midst of perfect health, all the symptoms of an in- ternal hemorrhage, whose explanation is very difficult. In one case this internal hemorrhage was manifested by some colicky pains, as the only sub- jective symptom. It is hardly necessary to add that all the remedial measures thus far tried have proved fruitless.1 Wounds of the Innominate.—During the late civil war, two cases in which the innominate artery was wounded came under treatment. The first patient survived twenty-four days, as follows :— A soldier, aged 20, was wounded July 1, 1863, by a rifle-ball, which entered above the clavicle, passed behind the sternum, and emerged between the fourth and fifth ribs. On the 22d, hemorrhage from the arteria innominata occurred, for which compression was applied. Death followed on the 25th.2 It is highly probable that in this case the missile contused the tunics of the innominate artery, and that the bruised tissue exulcerated or separated as a slough at the end of three weeks, whereby the canal of the artery was opened, thus allowing a secondary hemorrhage to ensue. The second patient lived six days after the casualty, as follows:— A soldier, aged 26, was wounded October 27, 1864, by a conoidal ball, which entered at the right upper angle of the sternum, passed behind the clavicle, and lodged in the thorax. The wound was plugged with lint, and the man was kept as quiet as pos- sible. On the 31st, under choloroform, the wound was explored for the ball, which caused profuse hemorrhage. Plugging the wound, with the use of a compress and bandage, was the only resource. On November 1, the patient had much dyspnoea, caused by haemothorax. The trachea was compressed by blood extravasated in the mediastinum. On the 2d he died. Necroscopy—The missile was found resting against the innominate artery, whose canal it had opened, causing a diffused aneurism. The aperture was oval, nearly half an inch in length, situated on the front part of the vessel, just below its bifurcation.3 By exploring the wound with a finger, in this case, the surgeon might have detected the orifice in the innominate artery, and by covering the 1 Ibid., p. 94. 2 Medical and Surgical History of the War of the Rebellion, First Surg. Vol., p. 520. s Ibid., pp. 520, 521. WOUNDS OF THE VENLE CAViE. 675 Orifice with this finger in the wound, he might have restrained the hemor- rhage until the artery had been exposed and ligatured on each side of the aperture. The proceeding here recommended is exactly that which has many times been practised with complete success in wounds of the femoral and carotid arteries. Wounds of the Subclavian Artery.—The traumatic lesions of this artery are not always hopeless. During the late civil war, at least five cases required surgical treatment, and in one of them the left subclavian was successfully ligatured by a Confederate surgeon. The others survived the casualty from two to sixteen days.1 In cases belonging to this category, the hemorrhage should, if possible, he restrained by digital compression, applied in the way just pointed out, until the artery can be tied above and below with carbolized catgut. Wounds of the VenvE Cav.®.—In this class of injuries, death usually occurs so speedily from hemorrhage that examples of them are but rarely seen by surgeons during life. I will present a few illustrative cases:— During the late civil war, a soldier re- ceived a shot-wound through the chest; “ a great stream of blood is said to have gushed from his mouth as he fell forward, dead.” Necroscopy—The ball entered at the right edge of the sternum, between the first and second ribs; pierced the descending cava, one inch above the heart; struck the right bronchus, severing three rings (thus giving a ready exit to the large stream of blood); and emerged between the seventh and eighth ribs without wounding the lungs. There was a little clotted blood in the mediastinum under the sternum.2 In another case, death ensued not quite so rapidly:— A soldier during the late civil war, through the stock of whose musket a con- oidal ball had passed, was fatally wounded thereby. The missile entered his chest through the second right intercostal space, divided the descending cava, crossed the chest diagonally beneath the aorta, emerged through the third left intercostal space, shattered the left humerus, and was found thirteen feet from where the man fell, in a battered state. Externally there was scarcely any hemorrhage; but the left pleural cavity contained much bloody serum mixed with jelly-like clots. The hemor- rhage was exclusively due to the division of the cava. The patient lived long enough to be carried from his post to the hospital, near by, where he immediately died. The missile also perforated the superior lobe of the left lung. The specimen is preserved in Fig. 434. Showing from behind the relations of the aorta, venae cavae, heart, pulmonary artery and veins, etc., to the other viscera. 1 Medical and Surgical History, etc., First Surgical Vol., p. 521. 2 Ibid., p. 520. 676 INJURIES OF BLOODVESSELS. Fig. 435. the Army Medical Museum, and is represented in the accompanying wood-cut, Fig. 435.1 Iii the following example, the patient sur- vived still longer:— A soldier was wounded with arrows, and scalped by Indians, six miles from Fort Philip Kearney, D. T., September 26, 1866. The steel point of one arrow entered at the junction of the first (right) rib and the sternum, and penetrated downward and inward three inches, cutting the upper margin of the right lung, and making a wound in the descending cava one-eighth of an inch long, just without the pericardial sac. Although scalped, and otherwise wounded, the unfortunate man survived until 10 A.. M. on the 28th, over forty hours after the casualty. Large masses of coagula were found in the thoracic cavity.2 Shot-wound dividing the descending cava and perforating the left lung. Heart and great vessels also represented. A soldier, during the late civil war, was wounded February 24, 1862, and lived only a few minutes. The ball entered the right side of his thorax, fracturing the ninth rib near its angle, and wounding the lower border of the right lung. It then passed through the diaphragm, tearing open the liver, the ascending cava, the stomach, etc. etc. The heart Avas found empty, while the cavities of the abdomen and thorax were entirely filled by the hemorrhage.3 The ascending cava sometimes sustains a rupture from the operation of a comparatively trivial cause: Dr. Minor presented an illustrative specimen to the ISTew York Pathological Society, November 28,1855. It was taken from a woman in the fifth month of pregnancy, who, tvhile dancing at a ball, sud- denly fell to the floor and died.4 There are on record a few examples in which the abdominal bloodvessels- were ruptured. Legouest’s case I have already presented. Velpeau5 refers to three cases of rupture of the ascending cava. Bourguignon® cites another such case. A specimen of the vena cava ruptured by a blow is preserved in Guy’s Hospital Museum. Professor Gross mentions a fatal case of laceration of the splenic vein recorded by Dr. Miling.7 "Wounds of the Vena Azygos.—Hennen8 reports the case of a soldier- injured by a twenty-four pound shot, which brushed along the right pectoral muscles without raising the skin or fracturing any bone, who died thirty-six hours afterward with all the symptoms of suffocation. Necroscopy—The vena azygos was found ruptured; also, the intercostal artery accompanying the fourth right rib; and Gvo pounds of blood were found extravasated in the thoracic cavity. Blandin9 observed the case of a young man who sur- vived a short time a pistol-shot wound of the vena azygos, near its terminal curve. Breschet10 records the autopsy of a man, aged 25, who survived for Wounds of the ascending vena cava, as a rule, also prove quickly fatal 1 Specimen 5567, Sect. I., A. M. M. ; Circular No- 3, S. G. 0., 1871, p. 34. 2 Circular No. 8, S. G. O., p. 146. 3 Medical and Surgical History, etc., Second Surgical Vol., pp. 138, 139. 4 Transactions of New York Pathological Society, vol. i. p. 99. 6 Diet, de M6d., etc., t. i. 6 Bull, de la Soc. Anat., t. xiii. p. 507. 7 System of Surgery, 5th ed., vol. ii. p. 687. 8 Military Surgery, p. 95, Am. ed. 9 Anatomie Topographique, p. 287. 10 Repertoire Gen. d’Anat., etc., t. iv. p. 196'. WOUNDS OF THE PERICARDIUM AND HEART. 677 three days a punctured wound, received in a duel, of the azygos vein in the •curve it describes before entering the cava.1 Wounds of the Pericardium.—The examples of this lesion which were reported during the late civil war tend to confirm the conclusions of Fischer —derived from the analysis of 51 cases with 22 recoveries—that wounds of this membrane, unless gravely complicated, are not as dangerous as has gen- erally been supposed.2 Two specimens preserved in the Army Medical Museum illustrate the subject, viz.: Specimen 504, a conoidal musket-ball imbedded between the arteria innominata and the descending cava within the pericardium, provoking pericarditis;3 and Specimen 2243, exhibiting shaggy deposits of lymph on the heart and pericardium, following gunshot injury.4 Eight cases with three recoveries are recorded with considerable minuteness of detail in the first surgical volume of the “ History of the War” (pp. 528, 529). Wounds of the Heart.—The traumatic lesions of the heart, though justly ranked among the most dangerous of all injuries, are not in every instance mortal. A man was killed5 in an affray at Fort Dodge June 2, 1867. He had inflicted, with a large sheath knife, several stabs upon his antagonist, when the latter, seizing his wrist, turned the point of the knife toward him, and suddenly drove the blade with great force into his chest, the handle being still grasped in his own hand. He fell at Fig. 436. Fig. 437. The heart, showing the incised wound of the right auricle. (Spec. 4870, sec. 1, A. M. M.) The sternum, showing an oblique incision through it, which penetrated the right auricle of the heart. (Spec. 4869, sec. 1, A. M. M.) once, gasping for breath, with his face deadly pale, and expired in about eight minutes. Autopsy—The knife-blade, after cutting cleanly through the sternum, had traversed the mediastinum, and freely opened the right auricle of the heart. The pericardium and the mediastinum were tilled with extravasated blood, and the cardiac cavities were empty. The specimens are represented in the accompanying wood-cuts (Figs. 436 and 437). 1 See Medical and Surgical History, etc., First Surgical Vol., p. 527. Foot-note. 2 Ibid., p. 528. 3 Catalogue, p. 453. 4 Catalogue, p. 454. 5 Medical and Surgical History of the War of the Rebellion, First Surg. Vol., p. 534 ; Circular No. 3, S. G. 0., 1871, p. 91. 678 INJURIES OF BLOODVESSELS. The traumatic lesions of the heart consist of punctured and incised wounds; contusions, lacerations, and ruptures; and gunshot wounds. Formerly, punctured and incised wounds were most frequently met with; at present, however, the lesions from firearms are much more common. Of twenty cases which occurred in our army during a period of five years after the civil war, the patients in eighteen were wounded by firearms, and in two were stabbed with knives. Death occurs instantaneously in some of the cases. But, in most instances, a brief interval elapses before life is extinguished. When severe blows on the chest from falls, or from the kicks of animals, or from spent shot or large fragments of shells, rupture the heart without external wound, death almost always occurs on the spot. M. Terrillon, however, in an article on traumatic rupture of the heart, has presented a case in which the heart was ruptured by a fall, and the patient lived four hours; also the case of a man whose heart was ruptured from being kicked in the chest by a horse, and knocked backward, who was able to get up, put on his hat, and walk toward the stable, falling dead on the way.1 When, too, the heart is wounded by firearms, death does not always imme- diately follow. In the surgical history of the late civi] war, four cases of this sort are recorded. In one of them the patient lived one hour and a quarter after a perforation of the right auricle and left ventricle by a conical pistol-ball; in another, the patient lived forty-six hours after a perforation of the left auricle and left ventricle by a pistol-ball, although the case was complicated by wounds of the abdomen and axilla; in still another instance the patient survived, for fourteen days, a wound of the right auricle made by a round musket-ball; and in the fourth example, the patient survived, for two and a half years, a gunshot wound of the right auricle. This patient was a sharp-shooter, aged 42, who was wounded at Spottsylvania May 12, 1864, by a conoidal musket-ball, which entered his left breast and emerged from his left shoulder, passing completely through the left thorax, injuring the heart and left lung. On November 22, 1866, he very suddenly died. At the autopsy, the evidence of the original injury of the heart was found. On tracing the track of the ball a cicatrix was distinctly seen on the right auricle ; softening and rupture of the muscular tissue of the auricle had resulted, with almost instantaneous death.2 An important specimen illustrating a pistol-shot wound passing through the pericardium, the right ventricle, and the septum, together with the semi- lunar valve next the septum, into the aorta, with apparent recovery, was- shown to the New York Pathological Society :3— A farm-hand, aged 18, was accidentally shot in the left breast July 7, 1878, with a small revolver (calibre inch). In less than a fortnight he was again at work, ap- parently well. He continued in good health, performing the ordinary labor of a farm- hand without inconvenience, until August 30, when he was found dead at his work behind a plough, fifty-four days after the accident. The autopsy showed that death had resulted from extravasation of blood into the pericardium and left pleura. The missile was found in the left ventricle, lying behind a columna carnea. The track of the ball was found to be as stated above. The explanation of the lodgment of the ball is, that it encountered a well-filled left auricle, and, being spent, it dropped down through the left auriculo-ventricular opening to the place where it was found. The wound through the right ventricle was valvular, and the pericardium, healing quickly here, prevented the escape of blood. This finally rupturing, from over-distension, death ensued. With 1 Le Prosjres Medical, Mars 29 et Avril 5, 1879 ; also American Journal of the Medical Sciences, October, 1879, pp. 566, 567. 2 Medical and Surgical History of the War of the Rebellion, First Surg. Yol., pp. 530, 531. 8 Medical Record, December 14, 1878. 679 WOUNDS OF THE HEART. needful rest for a time, instead of labor, no reason appears why this young man should not have in reality recovered. Velpeau mentions the history of a man who was stabbed in the left side. The symptoms which ensued were such that at the time the heart was supposed to have been pierced. Nine years afterward he died from other causes. The autopsy established the truth of the former diagnosis, as the cicatrix of the wound was found in the right auricle as well as in the pericardium.1 Dr. George Fischer2 has collected 452 cases of heart-wound, of which 380 ended in death, and 72 in recovery. Death was immediate in 104 cases, while in 270 it occurred after intervals varying from one hour to nine months. There were 44 punctured wounds with 10 recoveries; 260 punctured and incised wounds with 43 recoveries; 72 gun- shot wounds with 12 recoveries ; 76 contusions and traumatic ruptures with 7 recoveries. In 36, or exactly one-half of the 72 recoveries, the diagnoses were verified by post-mor- tem examinations held long after the original injuries; and this circumstance affords good ground for supposing that the remaining 36 cases were likewise correctly diagnosed. Fischer also notes the relative frequency with which different parts of the heart were wounded. In 123 cases it was the right ventricle ; in 101, the left ventricle ; in 28, the right auricle; in 13, the left auricle; and in 17, the apex of the organ. The right ventricle and the right auricle are wounded much oftener than the left ventricle and the left auricle, because they occupy by far the larger share of the front or the exposed por- tion of the heart; the statistics collected by M. Ollivier and by M. Jamain support Fischer’s conclusions. Additional examples of recovery from wounds of the heart, which have appeared during the last twelve years, may be found reported as follows:— In the London Lancet3 a case is recorded of the removal of a needle from the heart on the ninth day, recovery ensuing. Dr. C. L. Ford4 reports a case of heart-wound from buck-shot, which was successfully treated. In the British and Foreign Medico- Chirurgical Review5 there is related a case of bullet-wound of the heart with recovery ; on the twentieth day the external wound was already healed, and the cicatrix moved synchronously with the systole of the heart. Additional examples of long survival after wounds of the heart, which have been noted during the last twelve years, may be found reported as follows;—• Mr. West,® in an article on wounds of the heart, gives a summary of twenty cases. In one of them, the patient lived 19 years and 7 months after both ventricles had been wounded with a knife. Dr. P. S. Conner7 reports a case of gunshot wound of the heart, wherein both ventricles and the right auricle were involved, and yet the patient survived 3 years, 2 months and 13 days. Steudener,8 of Halle, is quoted as reporting a case of pistol-shot wound of the heart, with survival for 15 weeks. On autopsy, a cicatrix was found at the apex of the left ventricle, corresponding to the wound of the pericardium ; grains of powder were also found embedded in the substance of the heart. Sir James Fayrer9 mentions a case of bullet-wound of the heart, with survival for 72 days. The missile was found in the apex of the left ventricle. Tillaux is quoted10 as having exhibited at the Soci&e de Chirurgie, the heart of a woman who had survived two gunshot wounds for 18 days, one missile lodging in the left ventricle of the heart. Dr. H. W. Boone11 relates a case of gunshot heart-wound, with survival for 13 days. A case of stab-wound of the right ventricle of the heart is reported, in which the patient 1 Traite d’Anat. Chirurg., t. i. p. 604, 2e ed. 2 Archiv f. klin. Chir., Bd. ix. H. 2, S. 571. Berlin, 1868. 3 Lancet, 1873, vol. i. p. 272. 4 Medical Record, 1875, p. 173. 5 No. for July, 1876, p. 205. 6 St. Thomas’s Hospital Reports, 1870, p. 237. 7 St. Louis Clinical Record, 1876. 8 London Medical Record, 1874, p. 212. 8 Lancet, 1879, vol. i. 658. 10 Canada Lancet, 1876, p. 242. 11 American Journal Med. Sciences, October, 1879, p. 509. 680 lived 5 days.1 Dr. G. F. Dudley2 reports a case of pistol-ball in the heart, in which the patient lived 4 days. Symptoms of Heart Wounds.—These are often very obscure. There may be present, in cases of wound which penetrate the region of the heart, great prostration of strength with swooning or syncope, a thready, weak, irregular pulse, a feeble and tumultuous action of the heart, precordial distress and anxiety, with dyspnoea and other signs of hemorrhage into the pericardial and pleural sacs, pallor, cold sweats, a husky voice and excessive thirst, to- gether with a systolic bellows murmur or other abnormal sounds, without establishing anything more than a strong presumption that the heart itself is wounded. But, although the traumatic lesions of the heart are not attended by any symptoms that are peculiar to, or characteristic of thenl, the concurrence or coincidence of most of the phenomena just mentioned, in a case where the patient is wounded in the cardiac region, will render the diagnosis of a cardiac wound highly probable. According to Dr. Fischer’s statistics, the phenomena which usually predominate in cases of sudden death from this lesion are those of sudden syncope or collapse; not unfrequently a hurried exclamation or a convulsive gasping occurs; but the popular notion that persons spring into the air when shot or stabbed through the heart, is not supported by the facts. In the causation of sudden death from traumatic lesions of the heart, there are three important factors: (1) Shock; (2) Anaemia of the brain and lungs, directly caused by the escape of blood from the chambers of the heart: (3) Arrest of the cardiac movement by compression resulting from disten- sion of the pericardium with extravasated blood. Oftentimes, in such cases, a necroscopy shows the heart firmly contracted and empty, with much extra- vasation of blood in the pericardial and pleural sacs. Traumatic carditis is a very infrequent complication, if, indeed, it ever does occur. During the late civil war, enough examples of cardiac wounds in which the fatal issue was sufficiently delayed to afford time for the develop- ment of inflammatory phenomena, were observed, to warrant the conclusion that inflammation of the heart is as infrequently the result of injury, as of disease. The late Dr. Otis carefully examined two specimens from patients who had survived, for a fortnight or more, shot wounds grazing the heart, in which the pericardium was thickened, and the visceral as well as the re- flected layer of the pericardium thickly coated with shaggy exudations; but the muscular structure presented no alterations discernible by the microscope.3 Professor Gross is possessed of a pericardium, taken from a man, aged 22, which contains an encysted needle two inches in length, giving evidence of having been long a harmless intruder. This specimen illustrates the indis- position of the parts to take on inflammatory action. Treatment.—At first, the posture of the patient must be recumbent, with the head low, in order to avoid a fatal syncope from cerebral anaemia. Ex- ternal warmth should be applied to the extremities and along the spine. Opium or morphia should be administered to quiet alarm and restlessness, as well as to allay pain. In many cases the surgeon’s hope must rest upon the continuance for some time of a condition approaching collapse, by which the power of the heart will be greatly lessened and the stability of a clot more assured. If signs of a dangerous reaction appear, the tincture of veratrum viride should be employed to restrain the heart’s action (Agnew). Should life be prolonged, and inflammatory phenomena arise, reliance must be placed on blisters, opium, and cardiac sedatives; and should distension of the peri- INJURIES OF BLOODVESSELS, 1 St. Thomas’s Hospital Reports, 1874, p. 420. 2 Medical Record, 1871-2, p. 156. 8 Med. and Surg. History, etc., First Surg. Vol., p. 622. 681 WOUNDS OF THE MIDDLE MENINGEAL ARTERY. cardial sac with inflammatory products cause much dyspnoea or cardiac embarrassment, they must be withdrawn by paracentesis. Absolute quietude of body and mind must be maintained for a long time, with liquid alimen- tation in concentrated and easily digestible forms. Wounds of the Pulmonary Artery.—Traumatic lesions of this vessel almost always prove quickly fatal. But Timacus of Colberg records the case of a nobleman, stabbed through the right axilla, between the third and fourth ribs, the blade wounding the pulmonary artery. Frothy blood flowed externally, and there were frequent syncopes; still the wounded man lived three days.1 Wounds of the Pulmonary Veins.—In the first surgical volume of the history of our civil war, at page 588, is recorded a case in which a conoidal ball penetrated the left chest, and lodged, on October 27, 1864:—• The patient suffered much from dyspnoea and frequent painful cough. He steadily grew worse, and died on November 11 of secondary hemorrhage from the left pulmonary vein. Autopsy—The missile, as shown in the accompanying wood-cuts (Figs. 438 and 439), was found lodged against the left pulmonary vein, which had been opened by it. Fig. 438. Fig. 439 Showing the upper half of left lung with a conoidal ball ■embedded in its substance, and partially occluding the left pulmonary vein. (Spec. 3388, sec. I, A. M. M.) Showing the ball and a piece of lead removed from Spec. 3388. Dr. Otis refers to Specimen 3388, A. M. M., represented above (Fig. 438), as suggesting a possible explanation of the way in which balls and other foreign bodies may gain admission to the cavities of the heart without leaving any trace of wound in the walls of that organ, viz., by gradual absorption of the wall of the pulmonary vein compressed by the extraneous body.2 In the above case, the missile probably contused the tunics of the pulmonary vein, and thus laid the foundation for secondary hemorrhage to occur when the bruised tissue should separate by ulceration, and open the vessel. Wounds of the Middle Meningeal Artery. This vessel, from its peculiar position and wide distribution, is much exposed to injury in simple as well as in compound fractures of the skull, and in the 1 Ibid., p. 527. Foot-note. 2 Ibid., p. 613. 682 INJURIES OF BLOODVESSELS. common accidents of civil life as well as in the casualties produced by fire- arms and sabre-cuts in time of war. Furthermore, from the situation of this vessel and its branches in bony canals on the inner surface of the skull, there results, when it is torn across or severed, that the ends are held open by the surrounding structures, and that their expanded mouths cannot contract or retract; and for this reason spontaneous haemostasis does not occur here, as it usually does in other parts of the body when arteries of a similar calibre are lacerated. Therefore, when the middle meningeal artery is wounded, the extravasated blood, if it cannot escape externally, collects be- tween the dura mater and the bone, and compresses the brain ; and the ex- travasation continues to go on, and the compression of the brain continually increases, until life is extinguished thereby. This is the reason why wounds of this small artery, in cases where there is no external vent for the extra- vasated blood afforded by the accident itself, or by the surgeon’s art, always- prove fatal. This inability for spontaneous haemostasis to occur, is also the reason why the hemorrhage from this small artery, when it flows into an open wound, is often so persistent, and so difficult to suppress, that it demands the application of a ligature to the wounded vessel itself, or to the parent trunk, in order to save the patient from death by anaemic exhaustion. The symptoms which hemorrhage from this artery causes when the blood is imprisoned within the skull, I shall not recite, for they are the symptoms of cerebral compression, and will be found set forth in full in the article on Injuries of the Head. What I have here to say is that, in such cases, the artery must be laid bare where it is wounded, in order to arrest the hemor- rhage and avert its consequences, by performing the operation of trephining; and that, without the timely performance of this operation, there is no hope for the patient. If the application of one crown of a trephine does not bring the injured vessel into view, by reason of the clot covering it, or from any other cause, the instrument must be again applied over the normal track of the artery, either alongside the first perforation, or at the anterior inferior angle of the parietal bone; the search must be continued until the bleeding vessel is found, and when that is done it must be ligatured with carbolized catgut. The coagula must also be removed, and the wound must be treated antiseptically. If the symptoms of compression follow the injury very quickly, the inference, in the absence of other indications, is that the artery is wounded near the point where it enters the skull, that is, near the anterior- inferior angle of the parietal bone, and there the trephine should be applied. The middle meningeal artery is sometimes torn in cases of slight fissure of the inner table of the skull, when the outer table is uninjured. Such a. case is the following d— A boy, of strong, muscular build, was struck on the right temple by a cricket ball. The symptoms of cerebral compression ensued,, and he died three and one-half hours after he received the blow. Autopsy—No bruise was found. On reflecting the scalp, however, a very scanty extravasation of blood was discovered under the right temporal aponeurosis. The external table of the skull was uninjured; but there was a slight crack which extended across the inner table. At this part, the middle meningeal artery ran in an osseous canal. A piece of bone was broken off, and the artery was torn com- pletely across at this point. A clot, half the size of the fist, lay between the cranium and the dura mater, and the corresponding portion of the brain presented a distinctly- bruised appearance. The operation of trephining, seasonably performed, with antiseptic precau- tions and antiseptic after-treatment, would pretty certainly save such a patient, 1 Edinburgh Medical Journal, vol. iii. p. 191. WOUNDS OF THE ABDOMINAL AND PELVIC BLOODVESSELS. 683 and the case just related serves well to illustrate, in other respects, the sound- ness of the views above presented. But compound fractures of the skull, especially when caused by fire-arms, are not unfrequently attended by secondary hemorrhage from the middle menin- geal artery, which will prove fatal unless it is suppressed by the surgeon in a timely manner. What is the best plan of treatment? In two cases of gunshot (shell) fracture of the skull involving also the middle meningeal artery, that were reported during the war of the .Rebellion, in which the hemorrhage was uncontrollable by other means, it was perma- nently arrested by tying the common carotid artery. The following is a brief account of them:— Private Wm. C. Andrews, Co. A, 30th Iowa Volunteers, aged 19, was wounded by a fragment of shell in the left temporal region, at Vicksburg, December 28, 1862. He was treated in a field hospital until January 17, 1863, when he was admitted to Law- son Hospital, St. Louis. On the 18th, hemorrhage amounting to twelve ounces occurred from the middle meningeal artery, and, all other means failing, was arrested by Dr. C. T. Alexander, U. S. Army, by tying the common carotid artery. The hemorrhage did not recur. The patient was discharged from the service on May 28. He was a pensioner in March, 1868, and the Pension Examiner reported that he had dizziness and faintness on exertion or stooping, and partial anaesthesia of the left side of the face, being compelled to keep his room in the cold winters of Madison, Iowa, from liability of the left ear and side of the face to be frozen. He continued in tolerable health on June 4, 1872, nearly ten years after the operation.1 Sergt. Joseph Dougherty, Co. B, 69th New York Vols., aged 23, sustained a fracture of the right parietal bone by a shell, at Spottsylvania, May 13, 1864. He was brought to hospital at Alexandria. A fragment of bone was removed. Hemorrhage from the middle meningeal artery occurred, of such a character as to compel Dr. E. Bentley, U. S. Vols., to ligate the common carotid artery. “ The hemorrhage did not recur; but the patient succumbed on the thirteenth day, after a series of chills and other phenomena of pyamnic infection.”2 When we are sure that the hemorrhage proceeds from the middle menin- geal artery, we should ligature the external carotid, of which the middle meningeal is a branch, instead of the common carotid artery; for the ligation of the former is much less likely to be followed by cerebral softening and other bad consequences, per se, than the ligation of the latter, while it is quite as likely to control the bleeding. In cases of secondary hemorrhage from the middle meningeal artery, as well as in those of primary hemorrhage, the bleeding vessel should, if possible, be ligatured by the surgeon where it is injured. But when it is not feasible to do that, as will not unfrequently happen, while the wound is suppurating, the external carotid should he tied. Moreover, the performance of the operation should not be delayed from any expectation that because the artery is a small one, the bleeding can be stanched by minor procedures. Should, unhappily, the operation be deferred while the trial of compression and styptics is continued in such cases, the hemorrhage will continually recur as soon as the patient rallies from each successive bleeding, until finally he- will become so much exhausted from loss of blood that the successful ligation of the external carotid will be impossible. Wounds of the Abdominal and Pelvic Bloodvessels. These wounds are extremely dangerous, and their great, perilousness results from the hemorrhage—which usually is internal, and therefore concealed from 1 Med. and Surg. Hist., etc., First Surg. Vol., p. 314. 2 Ibid., pp. 255, 256. 684 INJURIES OF BLOODVESSELS. view—by which they are attended. The dictum of Jourdan, that surgery is powerless in lesions of arteries within the cranial, thoracic, and abdominal cavities, should be expunged, because it is not true. If the surgeon, with cautious temerity, explore a penetrating wound of the abdomen or pelvis with his linger, he will not unfrequently discover that a hemorrhage which threatens life proceeds from a vessel which he can ligature above and below the wound with carbolized catgut; and thus he may save his patient from an otherwise certain death. Extravasation of blood into the peritoneal cavity may proceed from wounds of the abdominal aorta and its branches; or from wounds of the ascending vena cava and its tributaries; or from lesions of the vena portal is and its ramifications; or from lacerations of the viscera, especially the liver and spleen. The sudden occurrence of a copious extravasation of blood into the abdo- minal cavity is indicated by the sudden appearance of the well-known consti- tutional signs of hemorrhage, even without any external bleeding, in cases where wounds penetrate the abdominal cavity or involve the organs contained in it. These signs are pallor of the face, and of the surface generally, from bloodlessness; faintness; smallness, quickness, and feebleness of the pulse; cold sweats, etc. A slow, gradual bleeding into the abdominal cavity may, however, continue unsuspected to a dangerous or even to a fatal extent, so slight are the symptoms caused by it. For instance, Follin mentions a case in which death resulted from the puncture of a terminal ramification of the mesenteric artery by a bayonet, and in which the hemorrhage was not sus- pected until revealed by the autopsy. The hemorrhage from a ruptured liver or spleen should be treated by placing the patient on the injured side and enforcing absolute immobility, by applying ice-poultices over the injured organ, and by freely administering gallic acid, with ergot, and with dilute sulphuric acid, to assuage thirst. To allay pain and quiet apprehension, opium or morphia must bo exhibited. The same plan of treatment should be applied to all the hemorrhages which occur into the abdominal cavity without external wound, to those from ruptured veins and arteries, as well as to those from ruptured viscera. Moreover, phlebotomy must be rejected in all of them. But in cases where there is an external wound which penetrates the ab- domen, the possibility of restraining the hemorrhage by ligaturing the injured vessel must always be considered. It is a disgrace to modern surgery that patients should be allowed to die of internal hemorrhage, in cases of wounds penetrating the abdominal cavity from the front or the sides, without any 'effort being made to save them by cautiously exploring the wound with a finger, ascertaining through the sense of touch the source of the hemorrhage, and securing the bleeding vessel with carbolized catgut ligatures. Sometimes the blood flows inwardly into the peritoneal cavity, from a wounded artery belonging to the abdominal walls, such as the internal epigastric, instead of escaping externally. In such a case, the exploration of the wound with a finger may instantly reveal the source of the bleeding. And then the surgeon can make his patient secure without delay, by enlarging the wound so as to bring the injured vessel into view, and tying it on each side of the aperture with carbolized catgut. I have already dwelt upon the disastrous conse- quences of neglecting this paramount procedure. I also believe that operative interference should be carried in this direction to the utmost verge of the limits which prudence enjoins. Examples are not wanting in which branches of the mesenteric, epiploic, gastric, and colic arteries, have been successfully ligatured. If the finger, introduced into a wound penetrating the belly, recognizes the warm jet of a bleeding artery, the bleeding point must be •exposed and securely tied. It would be more rational to ligature even the WOUNDS OF THE ABDOMINAL AND PELVIC BLOODVESSELS. 685 vena cava or tliQ aorta, than to stuff the wound with lint saturated with Monsel’s solution, as has been done in more than one mortal hemorrhage.. (Otis.) When, therefore, the abdomen has been penetrated by a wound, and con- siderable bleeding takes place, it is necessary to search for the injured vessel.. When it comes from one of the mesenteric arteries or from the epigastric,, the wound should be enlarged until the bleeding artery is exposed, and then ligatures should be placed on both ends. (Guthrie.) To the dictum of Guthrie just presented, I would add that the vessel from which the deadly hemorrhage is issuing, whatever its name and rank may be, must be found, and ligatured above and below, if possible. Effusions of blood into the abdominal cavity which do not directly kill by syncope, may do so indirectly. When the quantity is large, the blood fails to become absorbed; it then decomposes,, and causes death by inducing septicaemia or by exciting peritonitis. In penetrating wounds, therefore, after the hemorrhage has been suppressed by ligature, the extravasated blood should be evacuated as completely as pos- sible, and antiseptic precautions should be employed. Wounds of the pelvic bloodvessels have been but little studied. In civil as- well as in military practice, the cases belonging to this group will sometimes, present the most difficult as well as the gravest problems to the surgeon. Wounds of the Common Iliac Artery.—The first ligation of the common iliac artery, it will he remembered, was performed by Gibson, to suppress the' hemorrhage from a shot-wound. Our Army Medical Museum contains a specimen in which the right common iliac artery is perforated by a pistol- ball. A wood-cut illustrating this specimen has already been presented., (Fig. 311, supra, p. 200.) The patient survived the casualty twelve minutes ; and had a competent surgeon been at hand, the injured vessel might have been successfully tied on each side of the perforation, the main trunk meanwhile being firmly compressed, and the distal ligature first applied. Bogros, in Velpeau’s presence, dissected a subject with a similar wound. Larrey1 records a case of sword-puncture of the iliac vein and artery, treated apparently with success by provisional compression and the method of Val- salva. Such instances, however, are rare; but wounds of the branches of these vessels—of the gluteal, pudic, obturator, and sciatic arteries—often come- under treatment, and their management requires the utmost discrimination.2- During the late civil war, hemorrhage was the most important complica- tion in numerous cases of wounds penetrating the pelvis, and in many of them the precise source of the bleeding was not determined. It was not always decided even whether the bleeding vessels were branches of the external or of the internal iliac. In no region, too, was the application of the cardinal rule of ligaturing a wounded vessel above and below the lesion more difficult, and in none were the consequences of neglecting this rule more disastrous.3 Wounds of the Internal Iliac Artery.—The primary lesions of this vessel, like those of the common iliac artery, but seldom receive surgical treatment, because death from hemorrhage too speedily ensues. A case, however, is reported in the history of the late civil war, in which this artery appears to have been wounded by a musket-hall, and the man was taken to a field-hospital, where he died from internal hemorrhage fifteen hours after 1 Clinique Chirurgicale, 1829, t. iii. p. 156. 2 Medical and Surgical History of the War of the Rebellion, Second Surg.t Vol., p. 323. 3 Ibid., p. 325. 686 INJURIES OF BLOODVESSELS. Fig. 440. Showing the bloodvessels, nerves, and viscera of the pelvis. the casualty.1 Moreover, there are six cases of gunshot wound of the pel- vis reported, in which secondary hemorrhage occurred from lesions of the internal iliac artery, between the twelfth and twenty-first days, and death ensued.2 The tunics of the artery in each instance were probably bruised by the missile, and when the disintegrated tissue was separated from the sound tissue by ulceration, the artery was opened, and hemorrhage ensued. In three cases the internal iliac artery was ligatured on Hunter’s plan to sup- press the hemorrhage from a wounded branch, but without success in every instance.3 In the following case, the inferior hemorrhoidal arteries were wounded by a conoidal musket-ball, and death took place from secondary hemorrhage on the fortieth day:— A soldier, aged 20, wounded May 8, 1862, in the buttocks and rectum, had hemor- rhages several times which were checked by liquor ferri persulph. and opium, until June 16, when hemorrhage again occurred from the bowel, and he died in half an hour. Necroscopy—The ball entered the pelvis at the obturator foramen, passed directly through the rectum, broke off the spinous process of the ischium of the opposite side, and lodged in the fibres of the gluteus medius. The bleeding vessel was one of the inferior hemorrhoidal arteries; the space between the sacrum and rectum was filled with coagula; the recto-vesical fold was elevated, and its peritoneal surface was dark in color.4 « Ibid., p. 331. 8 Ibid., pp. 332, 334. * Ibid., pp. 330, 331. 4 Ibid., p. 326. 687 WOUNDS OF THE ABDOMINAL AND PELVIC BLOODVESSELS. Wounds of the Iliac Veins.—A few eases were reported during tlie late ■civil war in which traumatic lesions of the pelvic veins were the most im- portant complications. Wounds which open widely the common iliac vein or its two principal tributaries, as a rule, prove quickly mortal from the primary bleeding. There is, however, a case recorded, in which a conoidal musket- ball penetrated the pelvis through the right isehiatic notch, and divided the corresponding internal iliac vein, the man surviving more than twenty- four hours. On opening the abdominal cavity after death, it was found to be full of blood.1 In cases where the external iliac vein is wounded, or the femoral vein near its entrance into the pelvic cavity, should the primary hemorrhage be suppressed, gangrene of the corresponding extremity does not of necessity ensue, as I have already shown in the section on wounds of veins. The symptoms resulting from an intra-pel vie extravasation of blood, when the quantity is small or but moderate, may be obscure or almost wanting. Baudens, however, mentions, as a characteristic sign that a quantity of blood is being collected in the pelvis, the incessant and insupportable desire to micturate, which is caused by the pressure that is exerted on the bladder by the extravasation, and which is present although there is no urine in the viscus. In some cases, important aid in diagnosing the lesions of the pelvic blood- vessels may be obtained by introducing the hand into the rectum, as has been practised in two instances by Professor II. B. Sands, of Hew York.2 By manual exploration with the hand in the rectum, the condition of the lower part of the abdominal aorta, and of the common, internal, and external iliac arteries, can be satisfactorily ascertained. By the same means pressure can be directly applied to the common iliac artery as well as to the external and internal iliacs, so as to readily control the flow of blood through them, as Dr. Woodbury had already shown.3 The bowel should be evacuated by a large enema of warm water. The hand anointed with lard, and the fingers foiled into a cone (the patient being anaesthetized), is gradually introduced into the rectum with its dorsum toward the sacrum, till it reaches the sigmoid flexure, when the hand may be pronated, and, as the vessels are directly under the fingers, they may then be examined or compressed at will. The sphincter recovers its tone in a few days, and, if the hand be slowly introduced, lacera- tion is not apt to follow. To suppress hemorrhage from the external iliac vein, when wounded, it will generally be necessary, as in cases where the femoral vein is wounded, to liga- ture the corresponding common femoral artery. The mode of applying instrumental compression to the abdominal aorta, or the primitive iliacs, with Lister’s or Erichsen’s artery compressor, or Skey’s or Pancoast’s abdominal tourniquet, I have already pointed out (pp. 524, 577). Operative procedures should be pushed to the utmost bound of pru- dence when the pelvic arteries are wounded. In cases where gunshot mis- siles penetrate the pelvis, the liability to the occurrence of secondary hemor- rhage from contusion of the internal iliac artery, or its branches, should always be remembered, and provided for as far as possible. The timely application of instrumental pressure to the common iliac artery, together with the enforcement of absolute immobility of the patient, in cases of hemorrhage (whether primary or secondary) from wounds penetrating the pelvis, where ligatures cannot be-applied, may possibly so restrain the bleed- ing that an occluding clot of a permanent character will plug the orifice, or ■that, at least, a traumatic aneurism amenable to treatment may result. 1 Ibid., p. 190. 3 Ibid., January, 1874. 2 Am. Journ. Med. Sciences, April, 1881, pp. 366-373. 688 injuries of bloodvessels. Traumatic Aneurism. Definition.—A traumatic aneurism is a tumor tilled with blood poured out from, and communicating with, the canal of a wounded artery. Between traumatic and spontaneous aneurisms there is another important distinction: namely, that in the former there usually exists before the accident a sound condition of the injured vessel, whereas, in the latter, the arterial tunics are diseased. Etiology.—Traumatic aneurisms are caused by punctured, contused, lace- rated, gunshot, and incised wounds of arteries, and I have already presented many examples of them in the foregoing pages, while discussing the several kinds of arterial wound. Varieties.—Of traumatic aneurisms, two varieties are recognized: (1) the diffused; (2) the circumscribed. Each variety may, and often does, exist with- out an external wound. I. Diffused Traumatic Aneurism.—The diffused variety occurs imme- diately after the puncture, rupture, or division of an artery when there is no external wound; or, if there is an external wound, when it is valvular, or perchance closed in some other way, so that the blood cannot outwardly escape. Thus, the diffused variety of traumatic aneurism consists of an extravasation of blood into the connective tissue of the part. It is, in real- ity, not an aneurism at all, but a wounded artery with internal or concealed hemorrhage, instead of external bleeding. The tendency of a diffused aneu- rism is to constantly extend itself, or to expand by stretching and separating the anatomical components of the part wherein it is situated, and filling the space with soft coagula, until it bursts open from the mechanical distension of the part; or until inflammation, abscess, or sloughing takes place, when, an external opening being formed, the patient will perish from hemorrhage, unless the surgeon by timely interference stop the bleeding. If left to themselves, these tumors never undergo spontaneous cure. Symptoms.—The diffused variety of traumatic aneurism is a subcutaneous, soft, and fluctuating tumor, often of considerable size, containing extrava- sated blood, and rising up or appearing immediately or very soon after the wounding of an artery. At first the skin covering it is not affected ; but in a few days it frequently becomes discolored with ecchymoses, caused by the infiltration of blood. If the aperture in the artery he large and free, the tumor will exhibit pulsation, synchronous with the heart-beat, accompanied by a thrilling, purring, or jarring sensation, and often by a loud bruit. If',, however, the injured artery be small, or if the aperture in the arterial tunics be oblique, or of a limited size, or obstructed, there will be no distinct pulsa- tion or bruit; in such cases, the tumor will be indolent and semi-fluctuating, or will, perhaps, exhibit an impulse which is communicated to it by the sub- jacent artery. In the section on lacerated wounds and ruptures of arteries, I have presented many examples of diffused traumatic aneurism in which there was neither pulsation, nor thrill, nor bruit. The size of an aneurism of this variety will, in great measure, be determined by its locality. For instance,, in the armpit, where the subcutaneous connective tissue is very loose, or at the root of the neck, or in the thigh, it may rapidly attain a very great bulk; whereas, in the palm of the hand, or at the bend of the elbow, in consequence of the strength and resistance of the fasciae, its growth is corres- pondingly restricted. When the blood is suddenly effused in great quantity, TRAUMATIC ANEURISM. 689 in a traumatic aneurism of the axillary or femoral region, all the constitu- tional signs of hemorrhage—pallor, cold sweating, pulselessness, and syn- cope—may arise; and sometimes, in such cases, death from anaemic exhaus- tion, as well as from syncope, may ensue. Of this I have already presented a number of illustrative cases. Treatment.—Diffused traumatic aneurisms require the same treatment as wounded arteries, which has already been minutely set forth in the foregoing pages. Erichsen well observes:— The treatment of these cases must be conducted on precisely the same plan as that of an injured artery communicating with an external wound, the only difference being, that, in the case of the diffused traumatic aneurism, the aperture in the artery opens into an extravasation of blood, instead of upon the surface. We must especially be upon our guard not to be led away by the term aneurism that has been applied to these cases, and not to treat such a condition, resulting from wound, by the means that we employ with success in the management of that disease.1 The safety of the patient generally depends upon exposing the injured artery, and ligaturing it above and below the lesion. In deeply-seated arteries, e.g., the gluteal in the buttock, or the posterior tibial in the calf of the leg, this is not always an easy operation. In some cases, however, compression with absolute quietude of the injured part should be tried before resorting to liga- tion. When arteries are ruptured by fragments of bone in simple fractures of the leg or thigh, compression, digital or instrumental, continuous or inter- mittent, should be applied to the main trunk of the femoral artery. This, together with the immobility of the injured limb and the moderate degree of pressure on the tumefaction which are furnished by the dressings of the frac- ture, has proved much more successful in such cases than any other plan of treatment, as I have already shown in the section on lacerated wounds and ruptures of arteries. So, too, in cases where the axillary artery is ruptured in reducing old dislocations, and a diffused aneurism forms in consequence thereof, compression should be applied to the subclavian artery over the first rib by means of a door-key, while the arm is immovably fastened to the chest by a roller, as I have already pointed out in the same section. Should com- pression fail in either class of cases, deligation of the main artery on the plan of Hunter will generally succeed, provided the arm be kept immovably fixed to the chest in one class of cases, or the leg be held motionless by the fracture dressings in the other. But, in cases where immobility of the in- jured part cannot be secured, the wounded artery should be laid bare and ligatured above and below the lesion, that is, the “ old operation” for aneu- rism should be performed without delay. When an aneurism upon which the “ old operation” is about to be performed is so situated that the circular tion in the main artery cannot be controlled by digital compression, nor by a tourniquet, nor by Esmarch’s elastic ligature—as, for example, at the root of the neck—the surgeon should commence the operation by making a puncture just large enough to admit one or two fingers of his left hand, which he should quickly thrust into the swelling in such a manner as to plug up the orifice in the integuments ; with a finger he should then search the bottom of the cavity, and find the aperture in the wounded artery, be it primitive carotid or subclavian ; and with a finger or fingers he should cover the aper- ture in the wounded artery so as to prevent any outflow of blood from it while he lays the tumor freely open, removes the coagula, and ligatures the artery on each side of the lesion, as was done in the following instance, during the late civil war :— 1 Science and Art of Surgery, vol. i. p. 162. 690 INJURIES OF BLOODVESSELS. A soldier, aged 23, was wounded in the right side of the neck, at Antietam, Sep- tember 17, 1862, by a buckshot which hit the common carotid artery. A diffused trau- matic aneurism ensued. On the 30th, the tumefaction, already enormous, was rapidly increasing; it crowded the trachea considerably to the left side. The covering of the aneurism was tense, and pulsation with a hard thrill was perceived on palpation. A plug of lint held firmly by clotted blood filled up the wound. Dr. R. F. Weir, U. S. Army, having carefully assigned their duties to his assistants, withdrew the plug, and quickly enlarged the wound with probe-pointed instruments, sufficiently to admit two of his fingers to the bottom of the cavity. lie “ was so fortunate as to reach and com- press the opening in the artery with very little difficulty, and thus effectually control the hemorrhage. Throughout the whole of the operation it was noticed with what ease the bleeding from the artery was checked—so little pressure was required. The clots were turned out, and the incision prolonged downward to the clavicle, and upward about one inch—the length of the entire incision being three and one-fourth to four inches.” Ligatures were passed around the artery with Mott’s aneurism needle (Fig. 441), below and above the aperture, “which the end of the fore-finger neatly Fig. 441. Mott’s aneurism needle. closed.” Less than eight ounces of blood were lost during the operation. Death, how- ever, ensued, from a gunshot lesion of the spinal cord, and from cerebral softening. Nevertheless, the case very clearly shows the entire feasibility of this operation for diffused traumatic aneurisms at the root of the neck.1 The wound after the “old operation” for aneurism cannot be healed like an ordinary incised wound, but must be left to granulate; and great attention must be paid to the dressing. Having cut oft* the ends of the carbolized cat- gut ligatures close to the knots, and carefully washed out the cavity with a solution of potassium permanganate or of boracic acid, and afterward well sprayed it with carbolic acid, a drainage-tube should be introduced ; and over all should be placed some carbolized lint or very soft oakum. As soon as suppuration begins, the wound must be dressed antiseptically every night and morning. The constitutional state of the patient must be provided for by administering nutrients, stimulants, and tonics. II. Circumscribed Traumatic Aneurism.—This variety of aneurism does not, as a rule, present itself until some time after the injury that causes it occurs. In it, the blood that escapes from the canal of the injured artery is inclosed by a distinctly formed sac, which, in one large class of instances, consists of the external coat together with the sheath of the injured artery, and, in another large class, of laminae of connective tissue condensed by the expansion-pressure, and by the products of inflammatory irritation. The accompanying wood-cut (Fig. 442) illustrates the first-mentioned class:— It represents a preparation belonging to our Army Medical Museum,2 of a circum- scribed aneurism of the superior mesenteric artery, in which the sac consists of the outer tunic and the sheath. The inner and middle coats of the artery have burst; and, 1 Med. and Surg. History, etc., First Surg. Vol., pp. 456, 457. 2 Specimen 503, Sect. II. TRAUMATIC ANEURISM 691 inasmuch as no atheromatous change is discernible in them, and nothing ap- pears to account for a spontaneous rup- ture, it is believed that they were lace- rated by some traumatic cause. The tumor was recognized by its position and pulsation during the life of the pa- tient, who died of another disease ; but the antecedent history is, unfortunately, not recorded.1 This sort of circum- scribed traumatic aneurism is often pro- duced by blows and strains ; and I have presented a considerable number of ex- amples of it in the foregoing pages. The inner and middle coats of the in- jured artery, on being torn through in this manner, gape open, and the pressure of the blood-stream expands the outer tunic and the sheath into an aneurismal tumor. The other frequent sort of cir- cumscribed traumatic aneurism is illustrated by the following wood- cut (Fig. 443):— It also represents a preparation be- longing to our Army Medical Museum,2 which was obtained from the following case : A soldier, aged 28, received a shot-wound through the right shoulder and walls of the upper part of the tho- rax, implicating also the axillary artery, Fig. 442. Circumscribed traumatic aneurism of the superior mesenteric artery. Fig. 443. Circumscnbed traumatic aneurism of the right axillary artery ; ligature of the subclavian performed too late. •on June 9, 1863. The external wound appears to have healed without any trouble. Internally, however, an aneurism was developed from the w'ounded axillary artery in I the latter part of the following month (July). On the 28th of that month, “ the true nature of the disease became manifest,” on making a careful examination, “ as the pul- sation of the tumor—at that time about the size of a large horse-chestnut—was very apparent; and, upon auscultation, the aneurismal bruit could be distinctly heard, cor- 1 Med. and Surg. Hist, of the War of the Rebellion, Second Surg. Vol., p. 25. 2 Spec. 2609, Sect. I. 692 responding with the contractions of the left ventricle of the heart.” The treatment by compression was tried in vain. By August 16, the tumor had become much larger, and now caused great pain. It was decided to ligature the subclavian artery; but, early the next morning the aneurism broke, and discharged from thirty to forty ounces of blood. The operation was performed, but death occurred six hours afterward, in con- sequence of the previous loss of blood.1 In this case the external wound healed, but the injured tunics of the axillary artery, which doubtless were texturally disorganized by the graze or bruise caused by the impact of the missile, slowly gave way, and, as they yielded, the extravasation of blood was restrained by laminae of connective tissue thickened by the products of inflammatory irritation, which ultimately formed the aneurismal sac. Besides these, which are the common forms of circumscribed traumatic aneurism, two others are occasionally met with. One of them is hernial aneurism, an excellent example of which is reported in the American Jour- nal of the Medical Sciences.2, In this case a small slice had been accidentally cut off from the sheath and outer tunic of the brachial artery, about two and one-half inches above the place of its divi- sion in an amputation of the arm. Secondary hemorrhage of an alarming character occurred from the stump, a consultation was held, aneurism of the brachial artery was diagnosed, and reamputation was recommended and performed. Examination of the reamputated portion showed a hernial aneurism of the brachial artery about two and a half inches above the ligature, where a small piece of the external coat had been shaved off by the amputating knife. Through this opening or ring, one-eighth of an inch in diameter, the inner and middle coats of the artery protruded, forming an aneurismal tumor, at least half an inch in diameter, and reminding one of the protru- sion of a femoral hernia through its ring. The secondary bleeding had issued from a rent in the walls of this aneurism. Afterward the case did well. In the second of these two rare forms of circumscribed traumatic aneu- rism, all the arterial tunics have been perforated, but the sac consists only of the external tunic and the sheath. It usually arises from a small puncture of a large artery, such as the axillary or the femoral. At first, the bleeding is profuse, but, being stopped by local compression, the external wound and the wound of the artery both heal up. Afterward the arterial cicatrix gra- dually yields, forming, at the end of weeks and months, a tumor which pulsates excentrically, with distinct bruit and thrill, and presents all the symptoms that characterize an aneurism from disease. The sac, too, is quite distinct, being formed by dilatation of the cicatrix in the sheath and external coat of the artery, without any blood being effused into the surrounding tissues. (Erichsen.) Symptoms.—The circumscribed variety of traumatic aneurism is usually of less magnitude than the diffused, while it is much more tense and sharply defined. It pulsates excentrically, and exhibits the aneurismal bruit and thrill. It grows soft on compressing the parent trunk, and its pulsation, bruit, and thrill cease, to return again on discontinuing the pressure. Treatment.—At first compression should always be tried, and, should it fail, ligation must be resorted to. In treating circumscribed aneurisms, traumatic as well as spontaneous, ligatures have been applied according to the plans of Anel, Hunter, and Brasdor, as well as according to the method of Antyllus, which is the “old operation.” On July 14, 1863,1 ligatured the left subclavian artery, on Hunter’s plan, for circum- scribed traumatic aneurism, in a Confederate captain, aged 31, who, on June 21, had been shot through the left shoulder by a conoidal carbine-ball which severed the axil- lary artery. The bleeding ceased spontaneously, the wound healed kindly, and the INJURIES OF BLOODVESSELS. 1 Med. and Surg. History of the War of the Rebellion, First Snrg. Vol., p. 545. 8 No. for October, 1865, pp. 417, 418. TRAUMATIC ANEURISM, 693 Fig. 444. Diagram showing where the ligature is applied in Anel’s, Hunter’s, Brasdor’s, and Wardrop’s operations. (A.) In Anel’s operation the ligature is applied to the artery on the cardiac side of the lesion, hut between it and the first collateral branch. (H.) In Hunter’s operation the ligature is applied to the main trunk on the cardiac side of the lesion, at a point much further from the lesion, and above the first collateral branch. (B.) In Brasdor’s operation the ligature is applied to the main trunk on the distal side of the lesion. (W.) In Wardrop’s modification of Brasdor’s operation, the ligature is applied to a branch on the distal side of the lesion. lesion of the artery gave no trouble until July 12, when a circumscribed traumatic aneurism as large as. a pullet’s egg was discovered. Between the 12th and 14th the tumor grew so rapidly that I feared to experiment with compression, lest meanwhile a rupture of the sac might ensue. It was so distinctly circumscribed, and resembled a spontaneous aneurism so closely in look and feel, that I thought Hunter’s operation would almost certainly succeed, and accordingly I performed it. The wound made by the operation did well, and the ligature came away on the eighteenth day. Not so, however, with the aneurism ; for on July 19 the sac suppurated, and discharged its contents through the anterior orifice made by the missile. The flow of purulent matter from the sac continued. On August 6, a violent secondary hemorrhage occurred, and several times recurred, until the patient died, on the 29th, worn out by the suppura- tion and the loss of blood. Autopsy—The distal end of the artery was found closed. The proximal end was found open, and from it the secondary hemorrhage had issued, the blood being derived from a reflux through the axillary branches into the axillary Fig. 445. Ligation of the left subclavian artery for circumscribed traumatic aneurism of the axillary; failure from secondary hemorrhage occurring in the wound. trunk, and so through its open mouth, on the establishment of a collateral circulation. The only operation which could have prevented this mishap was the old one. The artery is preserved as a preparation in our Army Medical Museum.1 It is also repre- sented in the accompanying wood-cut (Fig. 445). In all cases like this, the “ old ■operation” will afford a much better chance of saving the patient than the operation of Hunter or of Anel. The best method of performing the “ old operation” in the arm- i Spec. 1684, Sect. I. 694 INJURIES OF BLOODVESSELS. pit I have already described with minuteness, while describing the lacerated wounds and ruptures of the axillary artery (p. 610). It is unnecessary to repeat it here. On July 16, 1863, I was brought as consultant to the Post Hospital at Camp Barry, to see an immense pouch-shaped, though circumscribed, traumatic aneurism of the left femoral artery, in a soldier, aged 26, who had been w.ounded in the left thigh on May 26, by a pistol-ball, which grazed the femoral artery. The aneurism had already been treated by compression without benefit. So illy satisfied was I with the operation of Hunter in the case just related, that I imperatively insisted on the performance of the “ old operation” in this case, and I also aided in its execution. The extent of the aneu- rismal tumor and the method of performing the operation are well shown by the accom- panying diagram (Fig. 446). The aneurism extended from about two inches below Fig. 446. Diagram illustrating tfie length and course of the incision, the aperture in the artery, and the site of the liga- tures, in a case of immense pouch-shaped circumscribed traumatic aneurism, which was treated successfully by the “ old operation.” A, The aperture in the artery. II, The incision. LL, LL,' Ligatures placed above and below the aperture. Poupart’s ligament down to within four inches of the knee-joint. The femoral artery was compressed digitally on the os pubis during the operation. The tumor was opened by an incision about eight inches in length. The sac was quite smooth internally, and contained but little coagulum. The aperture in the artery was small and oval-shaped. The blood that flowed from the distal part of the artery was venous-hued and without jets. No unpleasant symptoms whatever followed. The patient began light duty seven weeks after the operation, and soon was as well as ever. The scar of the wound of operation measured six and one-half inches in length.1 When secondary hemorrhage occurs after the “ old operation” for aneurism, the blood usually issues from the distal orifice because it lias been insecurely tied. In such a case the wound should be reopened, and the ligature should be reapplied without delay. Thus Mr. Joseph Bell, in a case where he had performed the “ old operation” for traumatic axillary aneurism, on the occur- rence of secondary hemorrhage from the distal end of the artery, laid the wound open and tied the end again. The patient recovered.2 Many instances are related in the surgical history of the late civil war, in which the “ old operation” for traumatic aneurism proved successful; and many instances, also, in which there was failure because other plans of opera- ting were employed. Esmarch’s elastic ligature and elastic bandage are capable of affording great assistance in performing the “old operation” for traumatic aneurism in the extremities, both upper and lower. By a judicious application of these devices, this procedure can generally be executed with but little or no loss of blood. 1 The histories of this and of the preceding case are reported at length by the author in the- U. S. Sanitary Commission Surgical Memoirs, vol. i. pp. 101-120. New York, 1870. 8 British Medical Journal, Feb. 22, 1879, p. 289. 695 ARTERIO-VENOUS WOUNDS; ANEURISMAL VARIX AND VARICOSE ANEURISM. Palmar aneurisms are best treated by applying Esmarch’s apparatus, laying the tumor freely open under ether, turning out the clots, bringing into view the ends of the wounded artery, and tying them with carbolized catgut, with- out any loss of blood. Traumatic aneurisms of the vertebral artery are not very uncommon. Kocher has collected twenty-one cases. No instance of spontaneous aneurism of this artery is on record. For vertebral aneurisms the treatment by compression must be tried. Should the tumor burst, or appear likely to burst, it should be freely opened with suitable precautions, and an effort should be made to tie the artery above and below; or, that failing, the artery must be cautiously plugged above and below with prepared agaric or some similar substance. In examining traumatic aneurisms of the pelvis for therapeutic, as well as for diagnostic purposes, important information may sometimes be obtained by exploring the pelvic cavity with a hand introduced within the rectum, as I have already pointed out in the section on Wounds of the Pelvic Blood- vessels. Arterio-Venous Wounds ; Aneurismal Varix and Varicose Aneurism. Several examples have already been presented, in which the vulnerating body simultaneously opened a large artery and its accompanying vein, thus producing an arterio-venous wound. The following abstract, with the ac- companying diagram, represents another case, which was reported by Dr. David Prince:— A soldier, aged about 20, accidentally shot himself with a small pistol, October 21, 1864. The missile entered the left side of his neck, an inch from the median line, and on a level with the pomum Adami; it passed almost through, and lodged un- der the integuments just below the left occiput. The bleeding ceased spontane- ously, and a considerable swelling formed. Oct. 28, a very distinct thrill was felt, and a loud whizzing murmur was heard in the tumor. Oct. 29, the wound having bled slightly in the night, the common carotid was ligatured below the omo-hyoid. Nov. 3, at 3 A. M., the patient died of cerebral softening or anaemic gangrene of the brain. Au- topsy—The common carotid artery was found notched, and the internal jugular vein perforated, as shown in the accom- panying wood-cut (Fig. 447). No dis- tinct aneurismal sac had formed, and no embolism of the cerebral arteries had occurred.1 But wounds which simultaneously open the carotid artery and internal jugular vein, as well as wounds which open other large arteries and their at- tendant veins, do not always prove fatal; for, if their extent be small, and the circumstances otherwise favorable, they may result in forming aneurismal Fig. 447. Diagram to illustrate an arterio-venous wound of the neck. 1 U. S. Sanitary Commission Surgical Memoirs, vol. i. pp. 146-148. New York, 1870. 696 INJURIES OF BLOODVESSELS. varices or varicose aneurisms. When the lips of the wound in the artery adhere closely to the lips of the wound in the vein, and the blood flows from the artery directly into the vein, aneurismal varix results ; but when the lips of the wound in the artery adhere less closely to the lips of the wound in the vein, and the pressure of the arterial current separates the wall of the artery from the wall of the vein, and the blood, by condensing before it the lamina of fascia and connective tissue at the wound, forms a pouch or sac lying be- tween the two vessels, varicose aneurism results. The prognosis in a case of aneurismal varix or varicose aneurism is much less serious than it is when the artery alone has been opened; for a portion of the arterial blood is pro- jected into the vein at each pulsation, and thus the pressure or strain upon the injured parts is considerably lessened. Thus, too, the occurrence of great swelling and of rupture is usually avoided. Aneurismal Yarix.—By this term is meant an enlarged and tortuous, or varicose, condition of a vein, resulting from a simultaneous wounding of the vein and its contiguous artery, whereby a communication between the two vessels is established. The arterial blood which is projected into the vein at each pulse-beat, dilates it more or less extensively, and causes its wall to thicken. Dr. William Hunter first described this lesion.1 Scarpa, however, claims that Guattani should equally share the merit of the discovery, because he Fig. 448. Diagram illustrating aneurismal varix. A, The artery. V, The vein. X, Site of the aperture of communication between the artery and vein. 2, 2,2, 2, Varicose enlargements of the vein, with thickening of its walls. published two undoubted cases of aneurismal varix.2 But, Dr. Hunter’s observations on this disorder were published in the years 1757 and 1764 ; while Guattani did not see his first patient until the year 1769, and his book was not published until the year 1772. An instance of this disorder had previously been mentioned by Sennertus. Symptoms.—With the history of a previous wound, aneurismal varix is characterized by a circumscribed tumefaction, usually small and bluish in color, formed by a dilated vein, possessing a peculiar tremulous motion, and attended with a peculiar thrilling, hissing, or buzzing noise which arises from the passage of blood through a small aperture in the artery into the dilated vein. This peculiar sound is sometimes said to be like that made by a fly on a pane of glass, or in a paper bag. The tumor is generally accompa- nied by a varicose state of the neighboring veins. It is soft, and disappears entirely under direct pressure. It subsides when the limb is elevated so as 1 Medical Observations and Inquiries, vol. i. p. 340; and vol. ii. p. 390. 8 Treatise on Aneurism, Wisbart’s translation, p. 190. ARTERIO-VENOUS WOUNDS; ANEURISMAL VARIX AND VARICOSE ANEURISM. 697 to favor tlie return of venous blood toward the heart, and, in the same way, its pulsation is lessened. But, when the limb hangs down, or pressure is applied to the vein on the cardiac side of the tumor, it enlarges or forms .a more considerable swelling. Compressing the vein on the distal side of the tumor does not lessen either its size or its pulsation. When, however, the :artery is compressed on the cardiac side of the tumor, the pulsation imme- diately ceases, and it instantly returns on raising the compression. The trunk of the artery, after a time, becomes considerably enlarged ; and it pul- sates more strongly than the corresponding vessel in the other limb. But, on the distal side of the tumor, the arteries get smaller and pulsate less strongly than they do in the corresponding part of the other limb. The sounds can often be heard in the veins at a considerable distance. Aueurismal varix usually progresses but very slowly. There are cases on irecord in which no increase was observed for 18, 20, and even 35 years. When, however, the varicosities do enlarge, much evil may ensue from the pressure exerted by them. The obstruction to the venous circulation will cause oedema and cyanosis of the affected limb, and a lowered temperature, with ulceration or sloughing of the varicosities themselves, followed by hemorrhage, and sometimes by gangrene. The following example was reported during the late civil war; it will serve to illustrate the symptoms and progress of this lesion:— The patient was a soldier, aged 24. When a youth of 16, he was accidentally wounded with a pocket-knife, at the inner part of the left thigh, about two inches below Poupart’s ligament, the blade puncturing the femoral artery and vein near the origin of *the profunda. Profuse hemorrhage ensued, but it was arrested by compression ; the wound healed, and in a week the patient went to work again as a farmer. After- ward he had no trouble, except sometimes a slight pain in the track of the wound after unusual exertion, until August, 1863, eight years after the accident, when, being now in the army, his limb suddenly swelled, in consequence of hardship and a long, fatiguing march, so as to measure thirty-two inches in circumference. On Fig. 449. Aueurismal varix of left thigh. Terminal portion of aorta and both iliac arteries also shown, with a ligature in position on the left one. (Spec. 3597, A. M. M.) November 12, he entered the military hospital at Newark, N. J. The left thigh was much swollen, with oedema and varicosities, and presented a cyanosed appearance; an aneurismal thrill and bruit were also observed. On February 6, 1864, the external iliac artery was ligatured, but without benefit. In the following summer, the thigh became enormously distended, and a number of openings which had formed in it put on a gangrenous appearance. At the end of August the thigh measured thirty-seven inches in circumference, and its veins appeared more distended than before the operation. On September 17 the common iliac artery was ligatured, and on the ■fifth day afterward the patient died of peritonitis. A preparation was made of the vessels involved, which is preserved in our Army Medical Museum.1 It is repre- sented in the wood-cut above (Fig. 449). The ligature on the common iliac is shown 1 Spec. 3597. 698 INJURIES OF BLOODVESSELS. in situ. A constriction shows where the external iliac had been tied. The femoral artery appears constricted from imperfect injection. The much expanded and vari- cose condition of the femoral vein is well exhibited.1 The oedematous and cyanotic tumefaction, with gangrenous ulcerations, which the aneurismal varicosities produced in this case, was well marked. The failure of the operations of Anel and Hunter to afford relief was also quite conspicuous. Varicose Aneurism.—By this terra is meant a circumscribed traumatic aneurism which communicates on one of its sides with the artery from which it springs, and, on the opposite side, with an aneurismal varix. This lesion is well illustrated by the accompanying wood-cut (Fig. 450). Fig. 451. Fig. 450. A varicose aneurism ; the sac lies between the brachial artery and the median basilic vein, and communicates with both. (After Sir C. Bell.) A, the brachial artery; V, the median basilic vein with an aneurismal varicosity ; N, the aneurismal tumor, which is connected with the artery beneath it by a minute aperture, and with the aneurismal varicosity above it by another small opening. The symptoms of varicose aneurism are those of aneurismal varix, just presented above, together with the symptoms of circumscribed traumatic aneurism. On expelling the blood from the vari- cosity by applying direct pressure, the aneurismal tumor still remains. In some very rare instances varicose aneurism has had a spontaneous origin. (See Fig. 451.) A remarkable varicose aneurism involving the aorta at its bifurca- tion, and the vena cava (Syme). A, Aorta; B, Vena cava ascendens; C, Aneurism ; D, Site of a round ap- erture, somewhat larger than a six- pence, through which communica- tion between the vessels was held. (Bennett’s Lectures, p. 217, Am. ed.)< Aneurism supposed to be sponta- neous. Localities of Arterio-venous Aneurism.—Ar- terio-venous aneurisms have most frequently been met with at the bend of the elbow, where they have arisen from punctures during venesection. M. Goupil states that in thirty-one out of fifty- seven cases the lesion was caused in this way. Dr. S. W. Gross lias col- lected ten examples in which arterio-venous aneurisms occurred in the neck; in eight there was aneurismal varix, and in two, varicose aneurism. In all of them the internal jugular vein was involved, together with the primitive carotid artery in six instances, and the internal carotid in the remaining four. In none did the lesion appear to shorten life or cause much inconvenience. The lesion was caused by incised or punctured wounds in seven, and by gunshot wounds in three instances. In several of them the aperture in the integuments was so made that it did not gape when the 1 Medical and Surgical History, etc., Second Surg. Vol., p. 336. arterio-venous wounds; aneurismal varix and varicose aneurism. 699 weapon was withdrawn.1 Baron Larrey recorded three cases in which aneurismal varix of the axilla occurred in consequence of incised wounds in- volving the axillary artery and vein. M. Berard reports a case observed by Dupuytren, in which it was caused by a gunshot wound of the axilla. Dr. J. C. Nott., in 1841, reported a case of successful ligation of the subclavian artery for arterio-venous aneurism. Dr. J. P. C. Wederstrandt also reports an aneur- ismal varix following a gunshot lesion of the subclavian vein and artery, which the patient survived seven years, finally dying of another disease. M. Legouest, too, relates a case that resulted from a musket-ball wound of the left axilla, at Balaclava.2 Above I have presented an example of aneurismal varix of tlie left thigh, which was caused by an incised wound of the femoral vein and artery. Ilennen records a case in which aneurismal varix of the right thigh was caused by a musket-ball wound of the same vessels.3 Many examples of arterio-venous aneurism of the thigh have been reported. Furthermore, Dorsey has detailed a case in which aneurismal varix of the leg resulted from a gunshot wound.4 Treatment of Arterio-Venous Aneurisms.—Arterio-venous aneurism in the neck, as far as the published cases enable us to judge, does not often prove fatal, if it be let alone. This lesion should not be interfered with,, unless, from its growth, inconvenience arises or danger is threatened. In some comparatively rare instances this will happen. Then the treatment by compression should first of all be tried. Medini reports a very unpromising case of arterio-venous aneurism of the neck, which was completely cured by steady, long-continued pressure applied with Signorini’s tourniquet.5 Should compression fail, ligation must be resorted to. On theoretical grounds, Anel’s- and Hunter’s plans of ligation have often been employed, but, on the whole, with very disastrous results. I have already presented such an example of disastrous failure. Foil in has collected ten instances of arterio-venous aneu- rism occurring in the lower extremity, of which five were treated by placing a ligature on the cardiac side of the lesion, as in Anel’s or Hunter’s opera- tion, all of these ending fatally. He also has collected nine examples of arterio-venous aneurism occurring in the upper extremity that were treated in the same way; three terminated fatally; in five cases there were relapses; in one a cure was reported. The most frequent cause of death was gangrene.® The late Prof. Spence published an example of arterio-venous aneurism of the thigh, which was successfully treated by ligaturing the femoral artery above and below the lesion.7 There are on record a considerable number of cases that were successfully treated on this plan. When it becomes imperative to operate, the proceeding which promises the best result is to carefully dissect the skin from the tumor, having pre- viously applied Esmarch’s apparatus for the bloodless operation, and, on exposing the injured artery, to ligate it above and below the lesion with car- bolized catgut. When feasible, a third ligature should be passed around the- channel of communication between the vein and the artery, in order to avoid any possible failure arising from that source. The difficulties attending this- operation must not be underestimated; and the surgeon, when about to under- 1 American Journal of the Medical Sciences, 1867, January, pp. 44-46 ; April, pp. 339—340. 2 Med. and Surg. History of the War of the Rebellion, First Surg. Vol., p. 612. 3 Military Surgery, pp. 158, 159. 4 Nouveau Dictionnaire de Med. et de Chirurg. pratiques, t. xix. p. 586. Paris, 1874. 5 Bulletino delle Scienze Mediche, Jan. 1880; London Medical Record, April 15, 1880 ; Med.. News and Abstract, June, 1880, pp. 363, 364. 6 Med. and Surg. History, etc., Second Surg. Vol., p. 337. Foot-note 3. 7 Edinburgh Medical Journal, July, 1869 ; American Journal of the Medical Sciences, October,. 1869, p. 562. 700 INJURIES OF BLOODVESSELS. take its performance, should call to mind the regional anatomy of the part, and the structural changes which may possibly have taken place. The wound of operation must be treated antiseptically. The accompanying wood-cuts illustrate two ingenious forms of instrument well suited for the compression treatment of any form of aneurism:— Fig. 452. May’s tourniquet for the treatment of aneurism. A. Pad of pressure. B. Pad of counter-pressure. C. Ball •and socket-joint in the pad of pressure, which is governed by the screw and nut D. E. Key by which, when applied on F, the pads can be approximated or separated. G. Fenestrae, by which the pads can be adjusted. H. Strap and buckle. The action of Briddon’s instrument (Fig. 453), is made elastic by running the screws through tense India-rubber bands; it can be tolerated for a long time without producing any annoying complication. Fig. 453. Briddon’s artery-compressor for the treatment of aneurism. Pressure can be made at two points, the distance between which may be varied according to circumstances, or the instrument may be taken apart, and then a single 701 gangrene from arterial and venous occlusion. compressor may be used as a tourniquet. A smaller instrument can be made for the upper extremity; also a larger one for compressing the abdominal aorta. The hard rubber compressors are attached to the screws by ball and socket-joints, and they are fitted into concavo-convex caps of wood, protected by several layers of buckskin, which are put on just before screwing down, and should be well powdered each time that they are applied. Gangrene from Arterial and Venous Occlusion. When, from the injuries of bloodvessels, mortification ensues, it is because- the supply of normal blood, that is, of blood which is fit to sustain calorifi- cation and the normal processes of cellular and molecular nutrition, is so much impaired by the injuries themselves, that molecular as well as cellular life is extinguished, and putrefaction inaugurated, throughout the affected area. Gangrene from this cause is frequently met with, and very often proves fatal. Many instances have been mentioned in the foregoing pages,, and in nearly all of them death occurred. The subject is therefore very interesting and important to the surgeon. Symptoms.—Calorification being suspended, the temperature of the affected part sinks to that of the surrounding atmosphere, unless it is kept up by arti- ficial heat. The nervous sensibility, muscular contractility, and muscular elas- ticity are likewise abolished ; and a great weight, with, sometimes, great pain also, is felt in the affected limb or area; the beating of the arteries, too, is no longer perceived in the affected region, but still the part is not yet wholly dead. The natural heat, sensibility, motility, and arterial pulsations, have been known to return eight days after these and other signs of gangrene had been observed and accepted. Changes in color also take place. The integu- ments assume a tallowy-white, dirty-yellowish, marbleized, or brownish appearance. Dark-red streaks may form over the course of the superficial bloodvessels. Large vesicles or blebs, filled with a pale or a dark serum, not unfrequently appear. The epidermis becomes detached ; the color blue-black, then greenish; putrefaction ensues; emphysema from decomposition may distend the subcutaneous connective tissue and crackle under the fingers when pressed on; and the peculiarly fetid odors which characterize mortifica- tion are sent forth to taint the air, oftentimes in spite of the liberal use of deodorizers and disinfectants. Occasionally, the sphacelus does not extend above the middle of the limb, as has been observed after the operation for popliteal aneurism; more frequently it extends up to the ligature or the wound which produces the vascular occlusion; but very rarely to a higher point. Causes.—The proximate cause of antemic gangrene is insufficiency in the supply of nutrient blood. The efficient causes are the vascular lesions which produce this insufficiency. The traumatic lesions of bloodvessels which eventuate in mortification affect, (1) the main arteries ; (2) the main veins ; and, (3) the collateral channels. The office of the collateral channels is vicarious as well as supplemental to that of the main channels, and is of such extreme importance in the animal economy that, when their constitution is normal and their operation wholly unembarrassed, it is almost impossible for anaemic gangrene to result from traumatic causes. The injuries of the arterial and venous trunks which induce mortification are always complicated with traumatic lesions, or im- paired action, or imperfect development of the collateral branches. This 702 INJURIES OF BLOODVESSELS. point is mentioned, in limine, because of its great practical importance. When the great vessels of the extremities are occluded in accidents or in -surgical operations, our sole hope of maintaining the vitality of the member often rests upon protecting the collateral branches from pressure and from obstruction in every form. I. Gangrene from Arterial Occlusion.—The lesions of the main arteries which cause anaemic gangrene are (1) complete division, of which a considerable number of instances have been mentioned in this article; (2) occlusion from the division and recurvation of their inner and middle coats, of which a conside- rable number of cases were mentioned in the section on lacerated wounds and ruptures of arteries ; (3) occlusion by compression from blood extravasaied within the arterial sheath in consequence of contusion ; (4) occlusion from traumatic thrombosis, the result of arterial contusion and inflammation; (5) occlusion from traumatic embolism, the migratory plugs consisting of blood-clots formed or detached in consequence of injuries; and (6) occlusion from ligation, or the application of ligatures. Several examples illustrating the last three forms of arterial lesion, in which gangrene ensued, have also been mentioned in the foregoing pages. When anaemic gangrene results exclusively from arterial obstruction, and no impediment whatever exists to the flow of venous blood, it is always a dry gangrene. II. Gangrene from Venous Obstruction.—If we apply to a limb circular compression sufficient to intercept the course of the venous blood, as some- times has been done by bandaging fractured limbs too tightly, the limb swells, turns livid, and mortifies. The tissues perish because the effete or venous blood cannot pass out so as to give room for the fresh arterial blood to enter and nourish them. Thus, venous obstruction, in rare instances, causes mortification, by leaving no way of escape for the blood which has been car- ried into a limb by the arteries, and has there become exhausted of its nutrient properties, or effete. This, however, cannot well happen unless the compres- sion be circular. The venous canals are, as a rule, more numerous, as well as more capacious, than the arteries, so that when one trunk happens to be ob- structed, the others are usually found ready to perform its office. Hot so, however, when several contiguous trunk-veins are occluded; or in cases, where all the vessels of a limb are strongly compressed by a profuse infiltra- tion of serum, or by a copious extravasation of blood, or by a wide-spread offusion of the products of inflammation into the connective tissue of a limb, where the fasciae or aponeuroses, both superficial and deep, being strong and unyielding, act like circular bands to strangulate the parts. Gangrene from venous obstruction is always humid. The injuries which obliterate the venous canals are severance, traumatic thrombosis, deligation, and compression. Many examples of these have been presented in the foregoing pages. The occurrence of venous obstruction is denoted by the development of a cyanotic tumefaction of the limb, wherein the swollen subcutaneous veins can usually be discerned beneath the purple or venous-hued skin; also, by the development of a wide-spread cedematous infiltration, by which the affected limb sometimes becomes enormously dis- tended, presenting the features characteristic of phlegmasia alba dolens. III. Gangrene from Obstruction of the Collateral Circulation.—Do the anastomosing branches of arteries (that is, their collateral channels) really perform the important part which I have claimed for them in the causation of anaemic gangrene ? Here, as everywhere else in the domain of practical surgery, the lessons derived from clinical observation are all-important; and GANGRENE FROM ARTERIAL AND VENOUS OCCLUSION, 703 the two annexed examples will serve to answer this question, and to illustrate the subject in a useful maimer:— A man was wounded in the axilla by a sword, and much blood was instantly lost; a large tumor rapidly filled the axilla, and the man fainted. On the fourth day, the fore- arm was cold, and the skin on it of a yellowish tint; hemorrhage recurred. The tumor increased, and was attended with obscure pulsation ; the skin covering it was red and tense. In this state, on the seventh day, the man entered the IIotel-Dieu. Desault laid the swelling open by an incision six inches long, commencing underneath the acromial third of the clavicle, and extending downward and outward. A great quantity of coagulum, followed by a stream of fresh blood, rushed forth, in spite of the compression which was applied to the subclavian artery above the clavicle. Desault seized the mouth of the artery (it was divided above the origin of the subscapularis) with his finger and thumb, and thus commanded the hemorrhage. The lower as well as the upper end was then ligatured. In the evening, after the operation, obscure pulsation was observed at the wrist, and the limb had in some degree regained its natural heat. The veins on the back of the hand and arm were filled with blood. No doubt existed that the circulation was re-established. On the third day after the operation, suppura- tion had commenced, and sloughs were observed in the wound. On the fourth evening an erysipelatous redness was noted on the forearm. On the next day the temperature of the limb fell, the nails became dark-colored, and purple spots appeared on the arm. On the sixth day after the operation the limb was vesicated and gangrenous, and the patient died.1 In this case, mortification had occurred after the circulation had been re- established through the collateral channels; and must, therefore, have been due to obstruction of those channels, which might readily have resulted from compression caused by infiltration of the connective tissue surrounding them with inflammatory products, that is, from compression caused by inflamma- tory swelling, the inflammatory process having spread from the suppurating and sloughing armpit to the shoulder. Hodgson mentions another example of the same sort:— An officer received a stab-wound of the axillary artery by a sword. He soon fainted, and the hemorrhage ceased. The vessel was ligatured a short distance above the wound. The arm was then cold, and no pulsation could be felt in its arteries. On the third day, however, the arm was perfectly warm, and its veins were turgid with blood; but on the fourth day gangrene attacked the shoulder, and the patient died in the even- ing. Autopsy—The axillary artery was found completely divided below the origin of the circumflex. The ligature included also three of the brachial nerves. The axillary vein was wounded, but not included in the ligature.2 In this case, also, mortification occurred after the circulation had been perfectly re-established by means of the anastomosing branches or collateral channels at the shoulder. Inasmuch as the appearance of gangrene cannot be accounted for by the lesion of the brachial nerves, it must be ascribed to obstruction of the collateral circulation, which was probably caused by the extension of inflammatory swelling from the wounded armpit to the shoulder. The collateral channels may be dangerously obstructed by pressure exerted upon them from careless bandaging, or by the position in which a limb may be placed, as well as by the compression which arises from cedematous, inflam- matory, and hemorrhagic swelling. The aponeuroses or fasciae cause strangu- lation only by acting as unyielding bands. The simultaneous occlusion of the main artery and vein of a limb does not cause mortification, unless the collateral channels are also obstructed. In 1 (Euvres Chirurgicales de Desault, par Bichat, t. ii. p. 553. 2 Op. eit., pp. 355, 356. 704 injuries of bloodvessels. some examples of this sort, wherein gangrene occurred, that have been related above, the collateral channels, both arterial and venous, were obstructed by pressure from cedematous and inflammatory swelling. The cerebral softening which sometimes follows deligation of the common carotid artery is usually anaemic gangrene of the brain. Treatment of Gangrene from Vascular Obstruction.—When wounds have been received, or when surgical operations have been performed, which are liable to cause anaemic gangrene, the treatment should be so conducted as to keep the collateral channels free from obstruction. When from any cause wre ligature the principal vein as wTell as the principal artery of a limb, special care should be taken to cherish the collateral circulation, both at the time of and subsequent to the operation. The causal indications must always be met, as far as possible, by abating inflammatory and other swellings. Strangu- lating aponeuroses or fasciae should be divided by appropriate incisions. The old plan of treating gunshot wounds by dilating them with the knife, les- sened the liability to mortification. In some situations, as, for instance, at the bend of the knee, obliteration of the main artery, when it is attended with much injury of the surrounding parts, is so sure to be followed by gangrene as to make primary amputation advisable. In gangrene from the occlusion of bloodvessels, no line of separation, as a rule, is formed. There is, therefore, nothing to prevent the flow of putrid blood and other products of decomposition from the mortified part into the rest of the organism. Hence arise the great risk of septicaemia and the great fatality in these cases. Hence, too, amputation should be performed not very far below the site of the vascular lesion, as soon as gangrene appears. Early amputation, likewise, affords the only means of preventing the gases which result from decomposition in the gangrenous part, from entering the veins and passing onto the right side of the heart, thus causing sudden death, as happened in several cases reported by M. Parise,1 which I have already mentioned in speaking of air in veins. Antiseptic precautions during, and antiseptic treatment after, the operation are of great importance. Hemophilia, or the Hemorrhagic Diathesis. This disease is attended with a remarkable propensity to bleed, on very slight or even without any apparent provocation. Hence those subject to it have been familiarly called bleeders. Definition.—Haemophilia may be defined as a congenital and habitual dis- position to the occurrence of hemorrhage. The extremely obstinate and dangerous hemorrhages for which bleeders are noted, usually begin in the very earliest years of life, and habitually recur. It is very uncommon for this peculiar hemorrhagic habit to originate in middle life so as to warrant us in regarding the disposition as acquired. It is equally uncommon for one who was a marked bleeder in infancy, and in whom the disposition was congenital, to completely lose the idiosyncrasy in early youth, and remain thereafter free from hemorrhagic attacks. In fact, the congenital origin and habitual nature of the disposition are so constantly observed together in the so-called bleeders, that although each of these attributes is doubtless important by itself, it is 1 Archives Gen. de Med., Novembre, 1880. 705 HAEMOPHILIA, OR THE HEMORRHAGIC DIATHESIS. unquestionably their combination that constitutes the chief characteristic of haemophilia. (Immermann.) It is just these two attributes which chiefly distinguish haemophilia from other hemorrhagic affections, particularly scurvy and purpura haemorrhagica. All of the other forms of hemorrhagic dia- thesis, especially the two just mentioned, present neither of these attributes, but are essentially acquired and transitory processes. Haemophilia, on the contrary—at least as far as we can judge from the clinical phenomena—does not appear in any true sense a pathological process or morbid “ accident,” but rather an abnormal “ condition ” of the living organism, and probably depends for its material substratum not upon any tissue-change which runs a definite course, but rather upon an original vice of structure. History and Geographical Distribution.—Our knowledge of haemophilia as a specific disorder is, excepting the reports of a few ancient cases, entirely a modern acquisition. Toward the close of the last century, reports of families whose members were peculiarly subject to it began to be published in England (1784), in Germany (1793), and in America (New York, 1794). The word “bleeder” appears to have been first used in America. Nevertheless, it is to German writers that we are principally indebted for our knowledge of the subject. This disorder, geographically, is not uniformly distributed, but is much more prevalent in some countries than in others. For, of 219 families, in which occurred 650 authentic cases, 94 lived in Germany, 52 in Great Britain, 23 in North America, 22 in France, 10 in Russia and Poland, 9 in Switzerland, 6 in Sweden, Norway, and Denmark, 2 in Holland and Belgium, and 1 in the island of Java; total, 219. (Immermann.) Thus, it appears that the Anglo- Germanic race is peculiarly susceptible to this disease. The Latin races, however, are not entirely exempt, for France is credited above with 22 bleeder families. Etiology.—Family transmission is unquestionably the most striking and important of all the known causes of haemophilia. Grandidier speaks of it as “ the most hereditary of all hereditary diseases.” Immermann finds that the 650 authentic cases of bleeders have been distributed among 219 families, or very nearly three bleeders to a family. In fact, when one case occurs in a group of blood-relations, other members, sooner or later, are almost always affected. The disease, when having its starting-point in a single individual, or in several members of a family whose parents and ancestors were entirely free from it, is capable of direct transmission from one generation to another. For instance, the disease could be directly traced in two of the American bleeder families through the entire interval from 1720 to 1806; and of two unrelated bleeder families at Tenna, in Granbunden, one at least has been affected since 1770, and in the two families together the affection had gained such headway by the year 1854, that, at Tenna alone, out of a total popula- tion of 165, there were at that date no less than 15 bleeders. But the most important mode of propagation is by means of what may be called indirect transmission. Thus, after one or more cases have appeared among the chil- dren of healthy parents, the disorder is usually handed down, not as much by the bleeders themselves as by their non-bleeder brothers and sisters, and this singular mode of transmission of the outward manifestations of the disease may be repeated for several generations. A very large number of actual bleeders die from the disease so early in life as to be unable to take any share in the propagation of the anomaly. But the bleeder families pre- sent another remarkable peculiarity, to which attention was first called by Wachsmuth, namely, the extraordinary fruitfulness of the non-bleeder bro- 706 INJURIES OF BLOODVESSELS. tliers and sisters; for direct investigation has shown that the average num- ber of legitimate births in bleeder circles is nearly twice the general average. (Immermann.) Hence, haemophilia is a disorder of terrible importance to the welfare of the families concerned. Haemophilia, fully developed, occurs in males much more frequently than in females. Of 650 authentic cases, there were 602 in males and only 48 in females. In hardly any other disorder is the predisposing influence of sex so strikingly apparent. So, too, in bleeder families, it is much more common for the sons alone to be affected than for the sons and daughters, or the daughters alone. When the disease appears in both sexes in such families, the number of male bleeders usually exceeds that of the female bleeders; and, Anally, the in- stances are much more numerous where all the sons without exception are bleeders, than where the disease attacks all the children, daughters as well as sons, or all the daughters alone. Such facts clearly show that the predis- posing influence of sex, in this regard, is not merely a general law governing the gross statistics, but is likewise a radical differential principle, the opera- tions of which are special in character, and discernible even in the smaller groups that are represented by the children of single families. But, while females are far less subject to fully developed haemophilia than males, the actual share of the female sex in cases which, although not fully developed, really belong to the pathological domain of haemophilia, is in all probability much larger than appears from the statistics just given, or perhaps than can possibly be shown by any statistics. It is not unlikely, as Grandi- dier has pointed out, that imperfectly developed and anomalous outbreaks of the bleeder disposition, which are manifested only transitorily and at certain times, e.g., at the first appearance of the menses, and in childbirth, etc., are really more frequent in females than is commonly supposed, the true relation of these attacks to haemophilia being overlooked. In girls, the diathesis often remains latent to a certain extent, and frequently is first brought into activity by fixed causes apparently connected with the period of reproductive activity. How often may not, indeed, hemorrhage in a haemophilic puerperal woman have been quoted as the result of defective involution of the uterus, or fatal flooding as the result of atony of the womb ? Moreover, the female sex is in reality to be regarded as the more intensely affected, because it possesses in a far higher degree than the male the capacity for transmitting the disease by inheritance to its offspring. For, as Grandidier also has pointed out, the males in bleeder families who themselves are bleeders, do not, as a rule, beget bleeder children by women who belong to non-bleeder families ; in fact, the children in such cases are usually healthy and non-bleeders; but the children of women who themselves are bleeders are quite uniformly affected with haemophilia. Again, the males in bleeder families who themselves are not bleeders, almost never beget bleeder children by women from other families; but among the children of women who belong to bleeder families, and are not themselves bleeders, some are almost always found who suffer from pro- nounced haemophilia. In the transmission of this disorder, therefore, the mater- nal influence is far more important than the paternal; and, since the females are but rarely fully developed bleeders, while the male bleeders either die prematurely, or, as a rule, fail to reproduce the disease in their children, it follows that the non-bleeder women in bleeder families are, in fact, the most frequent and most efficient “ conductors” of haemophilia, and to them the hitherto constantly increasing spread of this affection is mainly due. The first bleedings of haemophilia take place in very early childhood, in a very large majority of instances. A considerable number of deaths have Been reported in Jewish families from the rite of circumcision on the eighth day, as well as similar results in other families from cutting the fraenum lin- HEMOPHILIA, OR THE HEMORRHAGIC DIATHESIS. 707 guse soon after birth, or from accidental wounds. But the most common time for the full outbreak of the disease is at the end of the nursing period, or at the beginning of the first dentition, not only because the traumatic bleedings now become more frequent in consequence of slight contusions, excoriations, etc., but especially because the apparently spontaneous hemor- rhages begin to appear about this time. There are also certain ages when the disposition to bleedings is particularly marked; and Grandidier calls attention to the fact that the second dentition, puberty, and in females the first appearance and the cessation of the menses, are specially critical periods for these patients. The general correctness of this view is proved by the experience of most of the reported cases. Finally, it is to be noted that with the advance of age there is very generally a gradual decline in the ave- rage intensity of the affection, and that accordingly the manifestations of the congenital anomaly are usually found to be most marked in youth, and to become much feebler toward middle life. In exceptional instances, how- ever, the symptoms of haemophilia recur again and again with undiminished intensity up to old age, and even then death may result directly from one of the hemorrhages. Ho definite form of 'physiological constitution exhibits a specially marked predisposition to haemophilia. There is, however, one peculiarity, namely, a certain delicacy and transparency of the skin, together with a superficial position and marked fulness of the subcutaneous bloodvessels, particularly the veins, which is mentioned by many trustworthy observers as so com- monly noticeable in bleeders, that we can scarcely deny it a certain causal relation to haemophilia. The Anglo-Germanic race in both the old and the new world, exhibits a special disposition to the affection, as already mentioned. A similar predisposi- tion, it may be added, appears to exist in the Jewish race also, for the disease has repeatedly been noticed among this people in connection with the rite of circumcision, and a considerable number of Israelitish bleeder families have likewise been reported. The primordial causes of haemophilia and the nature of the influences which ■originally operate in its genesis are entirely unknown. But the exciting causes of the bleedings, that is, the influences which are able to produce an outbreak when the disposition, however acquired, already exists,are briefly as follows: Cuts, punctures, lacerations, contusions, wrenches, and strains, may all excite interstitial as well as external extravasations ; but it is especially characteristic of bleeders that extremely obstinate and copious external hemorrhages, as well as very extensive interstitial hemorrhages, occur in them, not only after severe wounds and injuries, but also quite commonly after even the most insignificant traumatic accidents. Indeed, it seems as if it were just these very trifling injuries, so harmless in healthy persons as scarcely to attract attention, that are specially dangerous in bleeders; in fact, the mortality statistics of haemophilia show that hemor- rhages result far oftener from very slight than from severe wounds. Thus, simple punctures, the opening of small superficial abscesses, the application of leeches and cups, the extraction of teeth, cutting the fraenum linguae in young children, circumcision, and numerous other trifling operative proce- dures, have been followed by uncontrollable and ultimately fatal hemorrhages in so large a number of cases that any operation upon these patients, how- ever slight, attended with bleeding, must be considered dangerous. The same is also true of slight accidental wounds of all sorts, such as pin-pricks, cutaneous abrasions, trifling contusions, etc.; for they likewise are very apt to be followed by most obstinate and alarming external hemorrhages, or by very diffuse ecchymoses. But some of these minor wounds are, as a rule, 708 INJURIES OF BLOODVESSELS. attended with much more risk than others. For instance, circumcision, the extraction of teeth, and accidental wounds of the head and face are spoken of as exceptionally dangerous in bleeders, while venesection and vaccination are regarded as less hazardous. Still, all clinical observation shows that any traumatic lesion in a bleeder, whatever be its cause or situation, may excite a characteristic hemorrhage externally or interstitially. Again, the danger from the same kind of wound in a bleeder, for instance, a leech-bite or a pin-prick, is not equally great at all times (Wachsmuth, Martin, Grandidier); thus, it appears that the individual disposition to hsemophilic hemorrhages varies considerably at different times. The critical periods of life for bleeders have already been mentioned. But it must he added that variations in the individual disposition of bleeders to the occurrence of trau- matic hemorrhages, result from other causes which have not yet been fully determined. The change of season in spring and autumn, and the sultriness of air preceding a thunderstorm, have been mentioned with some plausibility *r the evidence, however, is too imperfect to be conclusive. Moreover, the occurrence of a traumatic hemorrhage in bleeders, at times, not only awakens a hitherto latent haemophilia, but also materially aggra- vates, at least temporarily, the manifestations of an already developed hemor- rhagic diathesis. To this almost all writers testify. Virchow, Grandidier, and others, have noticed that after the occurrence of a traumatic hemorrhage the patient is specially subject to the so-called spontaneous hemorrhages, those which are external as well as those which are interstitial. But the spontane- ous bleedings of haemophilia may occur independently of such a connection, and may even constitute the initial manifestation of the disease. Concerning them it is to be particularly noted that sometimes the hemorrhage occurs without any known exciting cause—entirely without prodromata, suddenly, as it were of its own accord. But more frequently the spontaneous hemorrhages are preceded by precursory signs. The patient complains, before the hemorrhage, of flushings, of a hot sensation, and of more forcible pulsations in the heart and arteries. The face, especially the cheeks and the lobes of the ears, is markedly reddened, and feels hot; and there is also headache, together with mental excitement and sen- sitiveness of sight and hearing. The symptoms, however, as a rule, gradually decline, and entirely disappear when the bleeding is once established. These prodromata are obviously to be interpreted as the expression of an increased arterial tension, perhaps also of an abnormal fulness of the entire vascular system ; hence the spontaneous hemorrhages thus characterized may properly be distinguished as fluxionary (Virchow), or even as plethoric hemorrhages. Grandidier also has observed that many of these hemorrhages are induced by influences which excite a more forcible action of the heart, such as alcoholic stimulants, mental emotion, and physical exercise, or which suddenly increase the volume of the blood, as for instance, copious drinking. To summarize the exciting causes of the hemorrhages in bleeders: Most frequently they have a directly traumatic origin, but they also occur spon- taneously, that is, without any kind of wound or mechanical injury. Still, many of even the latter hemorrhages are indirectly traceable to the influence of re- cent wounds, whereby the tendency to spontaneous hemorrhage is considera- bly increased, or, perhaps, is, for the first time, awakened. But when there has been no antecedent traumatic hemorrhage, the spontaneous bleedings generally manifest a distinctly jluxionary character, and are preceded by vari- ous symptoms of congestion and plethora. Finally, in rare instances spon- taneous hemorrhages occur independently of any obvious cause, with every appearance of actual spontaneity, and must therefore be considered to result from unknown influences. (Immermann.) HEMOPHILIA, OR THE HEMORRHAGIC DIATHESIS. 709 Symptoms.—The phenomena of haemophilia are essentially of a hemorrhagic character. The external hemorrhages that are traumatic always occur at the place of injury, which is most frequently situated in the skin and superficial parts. They are usually due to trifling accidents. The external hemorrhages that are spontaneous, or non-traumatic, occur in a majority of instances from the mucous membrane of the nose and mouth, more especially the former, for epistaxis is by far the most frequent form. In 308 carefully described cases, hemorrhage occurred from the nose 152 times, from the gums 38 times, from the intestines 35 times, from the lungs 17 times, with the urine 16 times, from the stomach 14 times, from the female geni- talia 10 times, from the tongue 6 times, from the external meatus auditorius 5 times, from the tips of the fingers 4 times, from the scalp 4 times, from the carunculee lachrymales 3 times, from ulcers of the skin 2 times, from the upper eyelids 1 time, and from the umbilicus long after the healing 1 time. (Immermann.) In very rare instances, among bleeders, hemorrhage occurs into the abdominal and other serous cavities. The external bleedings, whether traumatic or spontaneous, are almost always capillary, that is, parenchymatous in character. All the descriptions agree that the hemorrhage takes place, as a rule, not from large vessels, but from numerous vessels of the smallest size (capillaries), and from a great number of minute openings, as if from the pores of a compact sponge satu- rated with a liquid. Nevertheless, the blood is poured out under a compara- tively very strong pressure. The danger, however, results not so much from the profuseness of the hemorrhage as from its persistency; in fact, it is this obstinate persistence of every hemorrhage, whatever its origin, which is the most important as well as the pathognomonic peculiarity of the bleeder diathesis. Not unfrequently, an originally trifling hemorrhage which there was every reason to expect would soon cease spontaneously, or yield to treat- ment, persists in bleeders, in spite of all efforts to restrain it, for hours and days and weeks, until extreme anaemia or death is produced. But the tole- rance with which bleeders bear the great losses of blood, and the rapidity with which restoration of the lost blood is usually effected, are still more remarkable. Interstitial hemorrhages, particularly those of an undoubtedly traumatic origin, often constitute the earliest visible manifestations of haemophilia; they frequently occur during the first few days of life, or even during birth, from pressure or other mechanical injury of the body of the child during parturition. In after-life, interstitial bleedings occur not only as the direct results of injuries, but are also quite often observed in connection with the external hemorrhages, whether spontaneous or traumatic. In such cases, the surface of the body very frequently becomes covered more or less universally with numerous hemorrhagic efflorescences, which indicate the occurrence of multiple interstitial hemorrhages. The usual anatomical seats of the interstitial bleedings of haemophilia are the skin and subcutaneous connective tissue. The regions most often involved are the back, the fundament, the neighbor- hood of the trochanters, and the back of the neck ; in brief, those parts of the body which are most subjected to pressure from posture. The spontaneous in- terstitial extravasations, however, are most frequently observed in the hairy scalp, the genitalia, particularly the scrotum, and the extremities; more rarely on the trunk and face. The subtegumentary extravasations sometimes are very copious, and constitute veritable lipematomata. These blood-tumors have been noticed most frequently in the region of the false ribs, on the back ; and especially on the inner surface of the thigh, the popliteal region, etc., in the lower extremities. These blood-tumors have varied considerably in size in the 710 INJURIES OF BLOODVESSELS. reported cases; many of them were as large as a goose-egg or an apple, while several instances are mentioned of enormous tumefactions, as large as a child’s head or larger, which had been produced by trifling contusions, or had appa- rently arisen spontaneously. The so-called rheumatic affections are also of such frequent occurrence in bleeders, and their immediate relations, as to deserve special mention. The most important of these rheumatic diseases in bleeders are unquestionably the joint-affections. They comprise all the grades of arthritic rheumatism, from simple inflammatory arthralgia up to the most copious synovial effu- sion. But rheumatic muscular affections completely resembling, in their clini- cal features, the ordinary forms of rheumatic myalgia, are met with in bleeders still more frequently than the joint-affections, and very often are superadded to the latter. Besides, those subject to haemophilia are peculiarly liable to neuralgic attacks, which most frequently involve the dental branches of the trigeminus. Grandidier mentions the striking frequency with which bleeders suffer from periodic attacks of violent tooth-ache, often indepen- dently of any obvious cause such as caries. Morbid Anatomy and Pathology.—With regard to anatomical changes, no apparatus of the body seems to be abnormally affected in bleeders so uniformly as the vascular system (Virchow). Both the older and more recent writers speak of the striking superficiality and abnormal distribution of the cutaneous and subcutaneous veins and arteries, and especially of the abnormal structure and width of the arteries. Thus, in quite a large series of cases, the intima of the smaller and larger arteries (the temporal and radial, the aorta, pul- monary, carotid, etc.), was found to be remarkably thin, and sometimes actually transparent, without any apparent diminution, however, in the elastic retractility of the coats of the vessels (Virchow); while in a certain number of these cases the lumen of the large arteries (aorta, pulmonary, etc.), and of their main branches, was abnormally narrow throughout the entire extent of the vessels (Schliemann, Virchow, Uhde). Very generally, also, where the autopsy was carefully made, the intima of both the large and the small arteries was distinctly seen to have undergone a partial fatty degeneration, quite analogous, as regards its locality and other characters, to the degen- erative changes of the inner coat of the vessels in anaemia and chlorosis (Im- mermann). There is, however, a second factor which may possibly be of the highest importance in producing the bleedings of haemophilia—a factor, moreover, which is not dependent upon the configuration of the vessels, but is directly connected with the absolute quantity of the habitual supply of blood. The greater this habitual supply, and the more the vascular apparatus is perma- nently overfilled in consequence of it, the more readily the clinical phenomena peculiar to the bleeder disease may arise, and the greater will be the tendency not merely to hemorrhages in general, but particularly to those of a profuse and scarcely controllable character. Thus, it may readily be conceived that, in cer- tain instances, the habitual existence of a high degree of absolute plethora maj of itself be sufficient to maintain a bleeder disposition, without the interven- tion of the vascular anomalies above described. Or, in other words, we may suppose that although, in moderate degrees of habitual plethora, haemophilia requires for its development the concurrence of certain favoring conditions on the part of the vessels—e.g., delicacy of their walls and narrowness of their channels—still, the affection may now and then manifest itself as a clinical form of disease entirely unconnected with the vascular lesions above described (Immermann). The introduction of this second factor, that is, variations in the volume of blood, enables us to account satisfactorily for the fact that the dis- HAEMOPHILIA, OR THE HEMORRHAGIC DIATHESIS. 711 position of bleeders to hemorrhages, and the severity of the hemorrhages themselves, are usually by no means the same at all times of life, but present all sorts of fluctuations and differences. To this second factor must be added the habitually forcible contractions of the heart, of which we have ample evidence in the unusually hard pulse and apex-beat of many hsemophilic individuals, and particularly in the cardiac hypertrophy occasionally found at their autopsies. To epitomize our present knowledge of its pathology, we may state that haemophilia is, in general, a congenital and habitual form of the hemorrhagic diathesis, in which the oft-recurring and easily-induced hemorrhages for the most part owe their extraordinary vehemence, obstinacy, and danger, to an equally congenital and habitual disproportion between the volume of the blood and the capacity of the vascular apparatus, resulting in an abnormal increase of lateral pressure within the vessels. Moreover, in many instances, functional erethism of the heart, as well as cardiac hypertrophy, by inducing a tendency to congestions, affords important aid in producing the hemorrhages themselves, and in imparting to them their abnormal clinical character. Finally, neurotic influences occasionally act as an additional factor by tem- porarily increasing the habitually congestive diathesis. Prognosis.—The idtimate result of haemophilia in a great majority of cases is death, possibly in the first attack, but usually from one of the hemor- rhages in later life. The mortality of the disease is therefore very high, and at the same time very premature, on account of the generally very early out- break of the diathesis, and its intensity during the first period of life. A very large number of bleeders succumb to the murderous affection in early youth, the rate of mortality between the first and seventh years being parti- cularly excessive, while only a comparatively small proportion of bleeders, suffering from the well-marked and fully developed form of the disease, escapes the constantly-threatening danger of a fatal hemorrhage until the age is reached when the diathesis is frequently observed to abate sponta- neously, or to become latent (Immermann). There can be no question, there- fore, as to the extremely pernicious character of haemophilia, especially in childhood and youth. This view is confirmed by the results noted in 212 fatal cases of haemophilia that were collected by Grandidier. Of the entire number of patients, 121, or more than one-half, died from hemorrhage before reaching the eighth year, and only 24 survived the twenty-second year. Treatment.—Every precaution should be taken to avoid all kinds of injury, and likewise all influences which determine the occurrence of 'plethora and congestions. If a tendency to constipation be present, it should be com- bated with saline cathartics, especially Glauber’s salt; and not unfrequently the manifestations of plethora can be palliated by the vigorous use of that remedy when constipation is not present. The traumatic external hemorrhages of haemophilia always demand imme- diate interference. Internal medication should always be employed in such cases, as well as local measures. Among the latter, compression continued for a considerable time, perhaps for days, is the most reliable. The actual cautery rarely suffices, and therefore should not be employed in these cases. The* twisted suture has in many instances been found of great service, when the wounds were very small, such as leech-bites, or consisted of simple linear inci- sions, and has but rarely been followed by secondary hemorrhage. To arrest bleeding from the dental alveoli after the extraction of teeth, which is often very difficult, the most effectual plan of treatment consists in applying a tampon saturated with perchloride of iron, and retaining it in place by a piece 712 INJURIES OF BLOODVESSELS. of cork, or by a metallic plate fastened to an adjacent tooth, so as to effect permanent pressure for weeks, if necessary—an operation which can be readily performed by any dentist. Of internal remedies, the most trustworthy are acetate of lead and ergot, in large doses frequently repeated. The mineral acids, alum, tannin, etc., are less reliable. In every case, therefore, where the hemorrhage is at all serious, either plumbic acetate in doses of two grains every two hours, or fluid extract of ergot in doses of thirty minims every two hours, should be given until either the bleeding is arrested, or symptoms of poisoning ensue. In bad cases both remedies should be simultaneously administered. At the same time restless- ness should be quieted by exhibiting opium or morphia. It lias not unfre- quently happened that this method has succeeded in rapidly arresting the hemorrhage after local measures have proved entirely fruitless. In cases of internal bleeding, we are, of course, compelled to rely on this method exclu- sively. The spontaneous external hemorrhages, that is, those of non-traumatic origin, when preceded by various symptoms of plethora and congestion, should not be interfered with until the engorgement of the vessels has passed away; for in checking the hemorrhage prematurely, we might do far more harm than good. Otherwise, the plan of treatment is the same as the above. The interstitial cutaneous hemorrhages (petechial, ecchymoses, vibices) require no special treatment in bleeders, inasmuch as the loss of blood is inconsider- able ; but as to the subcutaneous interstitial hemorrhages, that is, the hcemato- mata, it is of the first importance to protect these tumors from mechanical injury, and to abstain from opening them prematurely by incision or punc- ture. The rheumatic complications of haemophilia are to be treated in the same way as under ordinary circumstances, with the important exception that all remedies should be carefully avoided which may possibly excite hemorrhage. (Immermann.) Grandidier and others assert that the administration of mercury in any form in the treatment of these rheumatic affections is commonly attended by a temporary aggravation of the hemorrhagic diathesis, and it should therefore be strictly avoided. The following example of haemophilia was-reported during the late civil war. It will serve to show how much the operation of deligating the main artery is worth in preventing haemophilia bleedings from gunshot wounds:— Sergeant Henry B., Co. D, 12th New Hampshire Volunteers, aged 21, was admitted to Emory Hospital, Washington, June 11, 1«64, with a gunshot wound of the right shoulder, received at Cold Harbor on the 3d. A minie-ball had entered below the clav- icle and passed out at the anterior aspect of the arm, about three inches below the shoulder-joint. There was also a flesh- wound of the upper third of the right thigh. The patient had a hemorrhagic diathesis, which his father stated was hereditary in the family—for example, a simple cut of the finger would cause hem- orrhage to such an amount as to endanger life. Under these circumstances, and upon consultation, it was decided after his first attack of hemorrhage to ligate the subcla- vian. The operation was successfully per- formed on June 17, by Surgeon N. R. Mosely, U. S. V. Strong hopes were enter- tained of the patient’s recovery ; but, unfortunately, in addition to his peculiar diathesis, Fig. 454. Showing the right subclavian artery divided by a liga- ture in its third part. The preparation was taken from a bleeder. It has been opened longitudinally, behind, to display the small fibrinous coagula. Spec. 2812, Sect. X., A M. M. (Posterior view.) 713 INTERMEDIARY HEMORRHAGE. the had a severe cough, which it seemed almost impossible to relieve or arrest tempo- rarily. On the morning of the 29th, while in conversation, the artery gave way, and death from hemorrhage was almost instantaneous. The accompanying wood-cut (Fig. 454) represents the specimen which was obtained at the autopsy. It consists of the right subclavian, of the inferior part of the right carotid, and of the distal end of the innominate. The commencement of the vertebral and of the superior intercostal are also shown, together with the thyroid axis and transversalis colli. There were slight fibri- nous exudations on either side of the point at which the ligature cut through.1 This patient survived the operation for twelve days. During this period there was no hemorrhage from the original wound. Nevertheless, he died almost instantaneously from a hemorrhage that resulted from the sudden giving way of the ligatured artery. The wood-cut shows that the occluding coagula were very small. But, upon the whole, the manifestations peculiar to the bleeder diathesis were not very striking in this case. It is, however, not improbable that the privations and hardships attending a soldier’s life in the field, by lessening plethora and the tendency to plethoric congestions, had considerably modified the diathesis in his person. Intermediary Hemorrhage. The term intermediary hemorrhage embraces all the effusions of blood from wounds or from wounded bloodvessels which occur in the intermediary period, that is, subsequent to the arrest of the primary bleeding or close of the primary period, on the one hand, and prior to the establishment of suppuration on the fifth of sixth day which marks the beginning of the true secondary pe- riod, on the other hand. In this interval of time, the phenomena of reaction, whether it be simply normal or more or less strongly inflammatory, present themselves, and thus the intermediary period itself becomes distinctly marked •or characterized, and distinguished both from that which precedes and from that which follows it. The hemorrhages which occur in this period are, for the most part, products of the more or less violent reaction and excitement of the vascular system that properly belong to this period; wherefore, the division of traumatic hemorrhages into the primary, the intermediary, and the secondary, is not an artificial classification, but is founded on natural distinc- tions or differences of an important character. Even those writers who •classify the hemorrhages which occur during the reactionary period with secondary hemorrhages, recognize an essential difference between them, which has been well expressed by the late Dr. George McClellan, who says, while speaking of the bleeding which often presents itself in wounds in the course of three or four days after their infliction: “ This is called by all writers a secondary hemorrhage, but as there is still an ulterior form of bleeding in some classes of wounds, it is best to qualify this by the epithet jirst form of secondary hemorrhage, or secondary hemorrhage from reaction.’’2 But, inasmuch ns the pathogenesis of these bleedings is totally different from the pathoge- nesis of the bleedings which occur after suppuration is established, and which are known par excellence as secondary hemorrhages, it is beyond a doubt far preferable to designate them as intermediary hemorrhages. Moreover, the term itself will serve to show in most instances, with precision, not only the period when the bleeding took place, but likewise the nature of the forces concerned in its production. 1 Medical and Surgical History of the War of the Rebellion, First Surgical Volume, p. 540. * Op. cit., p. 187. 714 INJURIES OF BLOODVESSELS. Intermediary hemorrhages in general are obviously connected with in- creased vascular action, and result from the increased force with which the blood is driven through the arteries, during the period of reaction and inflam- matory irritation that follows the “ shock” of severe wounds, and the depres- sion of profuse primary hemorrhage. During at least three or four days after the infliction of such wounds, it is always possible for a return of the hemorrhage to be effected by the violent reaction or excitement of the vascular system driving out the occluding coagula and forcing open the con- tracted orifices of the wounded arteries. The following example affords a good illustration of the intermediary as well as of the primary and secondary forms of traumatic hemorrhage:— A temperate and healthy young man, aged 21, accidentally received in his right armpit the charge of one of the barrels of a bird-gun, loaded with pheasant shot, which produced “ an enormous burnt wound in the centre of the axilla, with blackened and burnt edges, passing up along the course of the vessels toward the coracoid process. The powder, wadding, and shot had all been driven into the wound, and the physicians hoped, therefore, that the contusion of the surfaces, in addition to the coagulation, would enable them to prevent a return of the hemorrhage by the pressure of compresses and bandages.” It should be stated that the infliction of the wound had been imme- diately followed by “an enormous hemorrhage,” that he had fallen “into complete syn- cope at the door-step of his father’s house,” and that “ the discharge had entirely ceased under fainting.” “ About thirty hours afterward, however, a severe hemorrhage returned from the wound in consequence of vascular reaction forcing otf the coagula from the torn vessels. He fainted again almost unto death, and remained several hours exceedingly prostrate, during which period [McClellan] was first called in consultation. As large tents well graduated in the form of compresses had been forced into the wound with styptics, to the total suppression of the hemorrhage,” McClellan did not interfere. “The case progressed very well after that for ten entire days, when, on turning over in his bed at night, a tremendous hemorrhage broke out again. He fainted, and they were able to suppress the bleeding until [McClellan] arrived and secured the subclavian artery just above the upper verge of the inflammatory swelling and engorgement. The sloughs of dead cellular tissue, and shot, and wadding, afterward came away through the original w'ound in the axilla, along with the suppuration, and the patient got well with a good use of his arm.” 1 In this case the primary hemorrhage ceased on the occurrence of syncope; and the wound appears to have been dressed with compresses, retained in place by applying a roller bandage. Nevertheless, the blood coagulating in the wound did not succeed in effectually plugging up the open mouths of the injured arteries; wherefore it happened thirty hours afterward, when re- action supervened, that the increased blood-pressure, or the increased force of the circulation, drove out the plugs of coagula and started the bleeding afresh, thereby causing an intermediary hemorrhage of a most profuse character, which, however, again ceased on the occurrence of syncope, and was after- ward held in check by strong compression. Finally, when suppuration was fully established in the wound, and the sloughing tissues had begun to separate, secondary hemorrhage ensued, which, however, was suppressed by deligation of the subclavian artery, with probably a continuance of the local pressure; and the young man had the good fortune to recover with a useful arm. But intermediary hemorrhage sometimes takes place from the great arte- ries of the trunk, as happened in the following instance, which occurred during the late civil war:— 1 McClellan, op. cit., p. 191, foot-note. 715 INTERMEDIARY HEMORRHAGE. A soldier, aged 23, received, near Petersburg, Va., on June 18, 1864, a gunshot wound of the right nates, the ball entering the pelvis at the sacro-iliac symphysis, and on the following day he was admitted into the Hampton Hospital at Fortress Monroe. O11 the 20th hemorrhage from the common iliac artery occurred, three quarts of blood being lost, and on the 21st death ensued. Autopsy—The ball was found lodged at the superior sacro-iliac symphysis, and the common iliac artery wounded.1 The following case came under my own observation A soldier, aged 37, received, at Spottsylvania C. H., Va., May 18, 1864, a gunshot fracture of the left humerus, for which the arm was amputated at the upper third by the double-flap method. On the 21st he was admitted to Stanton Hospital. On the 22d, profuse intermediary hemorrhage, arterial in character, suddenly occurred from the stump. The stump was immediately opened, and the bleeding was found to pro- ceed from the brachial artery, the ligature having slipped off from it. The artery was again tied on the face of the stump, and the bleeding was permanently arrested. Most unfortunately, however, the patient was attacked with pytemic pneumonia, and died on June 4. In this case, intermediary hemorrhage occurred in the stump of an ampu- tated arm, because the ligature slipped off from the end of the brachial artery; it appears that the ligature had been carelessly applied too near the end of the vessel, and that it had not been drawn with sufficient tightness- before knotting. In consequence of this inexcusable negligence, the liga- ture was gradually pushed off from the end of the artery by its pulsations after reaction had taken place. When secondary amputations of the extremities are performed through inflamed tissues, intermediary hemorrhages of a 'parenchymatous character not unfrequently ensue, as happened in the following example:— Lieutenant-Colonel Maxwell, aged 22, was wounded at Five Forks, April 1, 1865, by a conoidal ball, which opened the left knee-joint. An attempt was made to save the limb, but suppurative inflammation ensued, and the thigh became infiltrated with purulent matter between the muscles, as high as the apex of Scarpa’s triangle. On April 17, amputation at the middle of the femur, by the circular method, under ether, had to be performed, and the stump was dressed with cold water. On the 18th it was observed that hemorrhage continued, although twelve ligatures had been applied, and that altogether about eight ounces of blood had been lost. The stump was then opened,, and liquor ferri persulph. f'ortis was applied with a camel’s-hair brush to the whole sur- face of the wound, which was also left open and exposed to the air for about fifteen minutes ; this proceeding entirely checked the sanguinolent oozing. The patient ulti- mately made a good recovery.* [Notwithstanding that all the arteries of appreciable size had been tied in this case, when reaction came on, bleeding took place from the capillaries of the stump, because they had lost the ability to spontaneously contract, and thus close their open mouths. Moreover, this paralysis of the muscular coats- of these vessels appears to have been caused by the inflammatory process,, which spread from the wounded knee-joint upward into the thigh. But whenever the arteries are not completely nor transversely divided, but are only cut into or punctured, intermediary hemorrhages are very common. Sometimes a temporary arrest of the bleeding can be repeatedly effected in such cases by coagulation, contraction, and syncope, or by the application of pressure, and still, at every recovery or return of vascular power and excite- ment, the bleeding will be reproduced. The next two examples are in point:— 1 Med. and Surg. History of the War, Second Surg. Vol., p. 333. 2 U. S. Sanitary Commission, Surgical Memoirs, p. 176. New York, 1870. 716 INJURIES OF BLOODVESSELS. Dr. Robert Battey ligatured the common carotid artery, in a man, for the relief of repeated hemorrhages following a deeply incised wound near the angle of the jaw, in the subparotid space. Tendency to syncope, following the loss of blood and the tying of the artery, was noticed for several days. Facial paralysis also appeared, but after- ward subsided, and the man’s health was subsequently entirely restored.1 The hemorrhage appears to have recurred in this case whenever the reac- tion rose high enough to give the arterial pulsations a force sufficient to drive out the plugs of coagula which temporarily restrained the bleeding. A soldier, aged 25, was wounded at Missionary Ridge November 25, 1863, by a ball which entered anterior to the left angle of the lower jaw, making a ragged opening nearly one inch long, and, fracturing that bone, passed downward and to the right under the tongue, cutting the floor of the mouth, and escaping from the right side of the neck behind and a little below the great cornu of the hyoid bone. On the evening of the 29th, intermediary hemorrhage from the mouth and the orifice of exit suddenly oc- curred, and between three and four pints of blood were lost before the hemorrhage was suppressed by tying the right common carotid artery, just above the omo-hyoid muscle. The hemorrhage was supposed to proceed from some wounded branches of the lingual artery. On December 2, the hemorrhage recurred both morning and evening; about midnight it again recurred with considerable force, necessitating the ligation of the left •external carotid artery. After that the bleeding did not return, and the patient did well.2 Iii this case, too, the intermediary hemorrhage appears to have been caused by the bursting open of traumatic orifices in arteries which had been imper- fectly plugged up with coagula, the reopening of these orifices being pro- duced directly by an increased force in the arterial current of blood that was due to the reaction. Moreover, the hemorrhage recurred a number of times, and continued to recur until the circulation in both lingual arteries had been controlled by the application of ligatures. Treatment.—I have repeatedly seen an intermediary hemorrhage produced by leaving a coagulum in the wound, which there acts like a warm sponge, and constantly promotes a tendency to hemorrhage during the reactionary period. In such cases, the coagula should always be thoroughly removed by the fingers, or by a suitable sponge: and the contact of fresh air will then often stop the bleeding. At all events, the surgeon can then find out the situation of the bleeding orifice, and can close it by a ligature or by a well- .adjusted compress. Such wounds should always be cleansed with carbolized water, and should be dressed antiseptically. Drainage tubes, likewise, may often be advantageously inserted. , The occurrence of intermediary hemorrhage in the stump of an amputated limb generally makes it necessary to remove the dressings, to open the flaps, and to wipe off' the coagula without delay. If the bleeding result from the careless or imperfect ligation of any artery, it should immediately be tied again, and in a secure manner. Likewise any artery that may have been overlooked should be securely tied. If the hemorrhage proves to be paren- chymatous, and does not subside on wiping oft' the clots, the whole face of the stump should be washed with alcohol; in case this tails, the solution of the perchloride or persulphate of iron must be applied with a brush, or on lint, to the bleeding surface, a proceeding which was attended with admirable success in one of the cases related above. Intermediary hemorrhages in stumps always necessitate the employment of drainage tubes and antiseptic dressings. , 1 American Journal of the Medical Sciences, April, 1881, p. 505. * Ibid., July, 1864, p. 276. 717 SECONDARY HEMORRHAGE. lntermediary hemorrhages from wounds where from any cause the bleed- ing vessel cannot be tied on each side of the aperture, and in the wound itself, not unfrequently require that the main artery should be ligatured as near the wound as practicable, on the cardiac side. This operation was at- tended with success in two cases related above. Professor Hamilton says:— “ These intermediary hemorrhages are pretty frequent in military practice, and do not receive the attention they demand. If it were not that surgeons cannot always spare the time, when the number of wounded is very great, to make a very critical search for vessels which do not at first bleed, we would say that such bleedings implied culpable negligence on their part; but, however this may be, the omission to give it prompt and careful attention now, can only be excused on the ground of an extraordi- nary necessity. Some of these patients, left to themselves, bleed to death ; but it more often happens that, in the hope of arresting the bleeding by pressure alone, or by cold applications perhaps, the surgeon entrusts the matter to an attendant, until the track of the wound and the adjacent structures become filled with coagula, which greatly increase the difficulties of subsequent ligation of the vessel; and which coagula, if the bleeding finally ceases, become depots for the formation of pus, thus greatly retarding the final cure. In the case of amputations made on the field, the same observations will apply. The intermediary hemorrhages lift the flaps, and prevent all possibility of immediate union. It is far better in such cases to re-open the wound, remove the clots, and tie the vessels ; although it may be somewhat mortifying to the surgeon who made the original dressing, since it is apt to be construed into a reflection upon his skill.”1 Secondary Hemorrhage. By the term secondary hemorrhage we designate all bleedings from wounded vessels which occur subsequently to the establishment of suppura- tion, that is, subsequently to the fifth or sixth day after the infliction of the wound, and, likewise, all losses of blood occasioned by the spontaneous rup- ture or opening of the sac in cases of traumatic aneurism. This accident, in general, belongs to the secondary period in the history of wounds, strictly so called, and is closely connected with the processes of suppuration, ulceration, and sloughing, which pertain to that period, but especially with the unhealthy forms of suppuration. It may occur during any part of the secondary period; but, according to the statement of surgical writers, it is more liable to hap- pen between the seventh and twentieth days, and especially about the four- teenth day. Before the seventh and after the twentieth days it is not often met with. I have, however, known several instances in which secondary hemorrhage occurred on the fifth and sixth days, on the one hand, and on the twenty-seventh, twenty-eighth, thirty-first, forty-first, forty-second, sixty- ninth, and eighty-fifth days, on the other. Causes.—On investigating the clinical history of secondary hemorrhage, we find that it is produced by a considerable variety of proximate physical agencies:— (1) This form of after-bleeding often results from contused wounds and contusions of the coats of arteries. A great many examples have already been mentioned in this article. In such cases, the bleeding is restrained until the bruised portion of the arterial tunics which becomes a slough is separated from the sound portion by a suppurative exulceration, and then the blood immediately begins to escape from the byuised vessel. The following ab- 1 Military Surgery, pp. 213, 214. New York, 1865. 718 INJURIES OF BLOODVESSELS. stract and the wood-cut accompanying it (Fig. 455) afford good illustrations of this topic:— A soldier,1 aged 25, was wounded June 3, 1864, by a conoidal ball which entered the left axilla, and lodged at the posterior border of the scapula ; it was extracted, and simple dressings applied. On the 15th secondary hemorrhage to the amount of twenty ounces occurred. The wound was filled with lint, soaked in a solution of the persulphate of iron, and a compress applied. On the 16th hemorrhage again occurred, but yielded to strong pressure on the compress. On the 17th the patient was very pale and anaemic, and was suffering much pain in the arm and shoulder. The compress and plug were removed, and the blood gushed out alarmingly. The wound was at once freely dilated, Fig. 455. Gunshot contusion of left axillary artery; profuse secondary hemorrhage on the twelfth day; the vessel tied in vain. Spec. 2576, Sect. I., A. M. M. and the axillary artery tied. The hemorrhage stopped, and at the same time the heart ceased to beat. Necroscopy—The axillary artery was found w idely opened by slough- ing, about the middle of its course, on the side next to the track of the ball. The specimen is represented in the accompanying wood-cut (Fig. 455), which exhibits a large, deep perforation, with jagged edges, involving nearly half the cylinder of the artery, about an inch above the origin of the subscapularis. The missile which penetrated the axilla in this case was nearly spent, and lodged. In passing, it doubtless struck the side of the axillary artery (wdiere the jagged aper- ture is shown in the wood-cut), and strongly bruised all its tunies, so that when the slough came awray the canal of that vessel wras widely opened. (2) This variety of hemorrhage not unfrequently occurs in consequence of simple ulcerative inflammation, by which the coats of the arteries are per- forated and their canals are opened. Displaced fragments of bone, through pressure, not unfrequently cause ulcerations in the walls of arteries, making apertures through which secondary hemorrhages take place. Several in- stances have already been mentioned. The following example came under my own observation: — A soldier, aged 24, wras uTounded at Cold Harbor June 3, 1864, by a conoidal ball, which entered the right ankle in front of the external malleolus, and emerged below the inner malleolus, having fractured the lower end of the tibia and the astragalus. An effort was made to save the limb ; on the 12th he was admitted to Stanton Hospital, where this effort w'as continued. He did tolerably well until August 27, when a pro- fuse flowrof arterial blood unexpectedly occurred from the wround, and reduced him very much. Without delay, and as a last resource, I amputated his leg, at the place of election, under ether. On dissecting the amputated limb it was found that the posterior tibial artery was the source of the bleeding; that the pressure of a piece of bone had caused ulceration and sloughing of its walls, and that the piece of bone itself had been displaced and driven against the artery by the missile. The articular surfaces of the tibia and astralagus were extensively comminuted. A strongly supporting course of treatment was pursued, the pat.ient receiving nutri- ents, stimulants, and tonics, as required, but these did not enable him to overcome the effects of the bleeding. He died from anaemic exhaustion twenty days after the hem- orrhage. 1 Med. and Surg. Hist, of the War of the Rebellion, First Surg. Vol., p. 554. SECONDARY HEMORRHAGE. 719 The following history and the wood-cut which accompanies it (Fig. 456) furnish good illustrations of the same topic. The operation of ligaturing the subclavian artery in the first part of its course was performed by Assistant- Surgeon S. C. Ayres, U. S. Volunteers:— Fig. 456. Ligature of the right subclavian artery within the scaleni muscles for hemorrhage from the subclavian, occa- sioned by a sharp fragment of bone, which had caused ulceration and perforation of the wall of the artery. Spec. 4729, Sect. I., A. M. M. A scout1 was shot on November 15,1864, while on an expedition. The hall struck the external third of* the clavicle, fracturing it, passed obliquely inward and backward, and emerged behind, near the spinal column, having opened the right pleural cavity. On December 14 a severe hemorrhage from the subclavian artery occurred, and this vessel was promptly tied, in the first part of its course, in the following manner: “A triangular flap was made by cutting parallel with the upper border of the clavicle and along the inner border of the sterno-mastoid—the two incisions meeting at the sterno- clavicular articulation. The sternal and part of the clavicular insertion of the sterno- mastoid, as well as the sternal attachments of the sterno-hyoid and sterno-thyroid. muscles, were divided and turned backward with the fingers, and the cellular tissue carefully divided upon a grooved director. The par vagum was recognized and drawn inward, and the internal jugular vein outward. The artery was found lying quite deep below the clavicle ; with some difficulty the aneurism needle was passed around the artery from below upward and the ligature drawn.” The hemorrhage immediately ceased ; but the patient sank rapidly, and died in half an hour. “Autopsy, twelve hours after death— Body mueh emaciated. The ball had fractured the outer third of the clavicle and the first rib. It had opened the pleural cavity in its course, and had fractured the spinous processes of the seventh and eighth vertebras and made its exit on the left side of the spinal column. The hemorrhage from the subclavian was occasioned by a sharp spiculum of bone, which had caused ulceration of the coats of the artery. The right pleural cavity contained a large quantity of bloody serum, such as was discharged from the wound previous to death, and the lung was found completely hepatized. It is pro- bable that a vein was ruptured by the ball, .... and that the bloody fluid dis- charged from the pleural cavity before the arterial hemorrhage occurred was a mixture of venous blood and serum ; but from the disorganized condition of the tissues it was impossible to tell which branch had been severed.” If the hemorrhage had not occurred, the patient could not, in all probability, have lived many days. The accompanying wood-cut (Fig. 456) shows the terminal portion of the innominate, the lower part of the right carotid, and the right subclavian arteries, with a ligature, in situ, upon the sub- clavian, three-fourths of an inch from its origin. The following case, likewise, is in point:— Samuel Steinberger was wounded at Williamsburg, May 5, 1862, by a musket-ball, which entered the left side of his chin, fractured the lower jaw, carried away several 1 Med. and Surg. History of the War of tlie Rebellion, First Surg. Vol., p. 546. 720 INJURIES OF BLOODVESSELS. teeth, a part of the tongue, and the posterior wall of the pharynx, and lodged. He had' extreme difficulty and distress in swallowing food or drink. On the 13th, the missile and several teeth were removed from an abscess above the clavicle. On the 16th, copi- ous hemorrhage from the mouth occurred, and was suppressed by tying the common caro- tid artery, under ether. On the 23d, secondary hemorrhage again occurred, but this time, however, from the aperture through which the ball and teeth had been extracted, ten days before. An unsuccessful attempt was then made to find the bleeding point; and death occurred .from hemorrhage, on the same day. An autopsy showed that the transverse process of the third cervical vertebra had been fractured by the missile, and that the vertebral artery had rubbed against a displaced fragment of it until the arterial tunics were worn or ulcerated completely through ; hence the last hemorrhage.1 The first of the two secondary bleedings which occurred in this case,, appears to have proceeded from wounded branches of the external carotid, particularly the lingual artery, and was readily suppressed by tying the com- mon carotid. But simple ulcerative inflammation may spontaneously occur in the walls of arteries, and open their channels, as sometimes happens in depraved conditions- of the organism; for example, those induced by typhoid diseases, by purulent infection, by scrofulosis, and by great losses of blood. McClellan relates the case of a man who had, as a sequel of epidemic influenza, a critical abscess of one of the submaxillary glands, which, on being lanced, discharged an ichorous sanies. Next day, a violent hemorrhage broke forth, and continued until complete syncope. The bleeding recurred, and McClellan, who was called in consultation, dilated the orifice of the abscess, and, on sponging out the coagula, found that the facial artery had been opened by ulceration. The tissues were so much softened that ligatures cut through them. The actual cautery was then applied to the bleeding orifice, and the hemorrhage permanently ceased. The patient perfectly recovered.2 In the following example, the internal carotid artery was opened by spon- taneous ulceration, and surgical hemorrhage took place:— E. Schwartz3 relates the case of a man, aged 61, who had necrosis of the right angle of the lower jaw, with profuse and very fetid suppuration. One day profuse hemorrhage from the cavity of the abscess occurred ; it was arrested by introducing a plug through the mouth. The next day it returned, and caused death. Autopsy—The internal carotid artery was found exposed, and infiltrated with ichorous pus; it presented ante- riority an oval aperture, one-fourth of an inch long, about an inch and a half from the bifurcation of the common carotid. Sometimes the internal carotid artery, or a branch of the external carotid, is spontaneously opened by ulceration in cases of acute abscess of the tonsils, as happened in the following instructive instance :— • Ehrmann4 reports the case of a young Italian, who entered the hospital with angina tonsillaris. On the third day the abscess broke, and immediately half a litre of bright red blood poured from the mouth. Three hours later the hemorrhage recurred, but in less quantity. No pulsation could be felt in the tonsillar swelling. A third hemor- rhage, more severe than both the preceding put together, caused the common carotid artery to be ligatured. The bleeding then permanently ceased. There was aphonia, which, however, disappeared in four days; no cerebral disturbance occurred. In six weeks the patient was discharged cured. The rational treatment of such hemorrhages consists in tying the carotid; and inasmuch as the source of the bleeding in such cases, whether it proceed from the internal carotid or from branches of the external carotid, cannot be determined during life, deligation of the common carotid must be preferred. 1 Medical and Surgical History of the War of the Rebellion, First Surgical Volume, p. 355. 2 Op. cit., p. 200; foot-note. 3 Gaz. des Hopitaux, Mai 7, 1874. 4 Centralblatt fur Chirurgie, No. 34, 1879. 721 SECONDARY HEMORRHAGE. (3) Secondary hemorrhages are often developed in consequence of the extension of a sloughing process, especially in unhealthy constitutions, from the adjacent tissues to the coats of the arteries themselves, when they are not primarily injured. The bleeding in such instances occurs on the separation or breaking down of the slough. The next two abstracts, together with the wood-cuts accompanying them (Tigs. 457 and 458), most excellently illus- trate this topic:— A Confederate soldier, aged 27,1 was struck by a musket-ball and captured, June 1G, 1864. The missile entered three inches below the left clavicle and emerged at the pos- terior border of the left axilla. Nothing of importance occurred until July 10, when profuse arterial bleeding from the exit orifice supervened ; it was stanched by plugging the tract of the ball with pledgets of charpie dipped in a solution of persulphate of iron, and applying com- presses tightly bandaged in the . armpit. Bleeding recurred, and the patient died on the 12th. Necroscopy revealed a phage- daenic condition of the posterior part of the wound, and the subscapular artery had sloughed completely through, or off, at its origin. The accompanying wood-cut (Fig. 457) represents the specimen. In the next case, also, the subscapular artery was invaded by the extension to it of a sloughing process, in consequence of which there occurred a secon- dary hemorrhage that proved fatal, notwithstanding deligation of the sub- clavian artery in the third part of its course:— A soldier, aged 21,2 was wounded May 9, 1864, by a conoidal musket-ball, which entered the right axilla, two and one-half inches above the lower border of the pectoralis major, and emerged two inches above the posterior fold of the arm-pit. On the 31st the right subclavian artery was tied at its outer third, for secondary hemorrhage from the in- jured parts, which were swollen, sloughy, and painful. The patient was feeble from Fig. 457. Hemorrhage from the sloughing off of the left subscap- ular artery at its origin. Spec. 2835, Sect. I., A. M. M. (Posterior view.) Fig. 458. Ligature of the right subclavian artery for secondary hemorrhage; the suhscapular artery had been opened by sloughing, and the ulcerous state of this vessel is shown in the cut. Spec. 4331, Sect. I., A. M. M. (Posterior view.) loss of blood ; pulse 130 ; skin hot. The hemorrhage, however, was not suppressed by the operation, for it recurred three times within forty-eight hours; and, on June 2, a branch of the axillary plexus of veins was tied, under chloroform, after cutting through 1 Medical and Surgical History of the War of the Rebellion, First Surgical Volume, p. 556. * Ibid., p. 539. 722 INJURIES OF BLOODVESSELS. the pectoralis major muscle. But death followed three hours after the last, and fifty hours after the first operation. Autopsy—The subscapular artery, three-fourths of an inch from its origin, had sloughed; the axillary, and an adjacent vein, had also sloughed. The specimen is represented in the accompanying wood-cut (Fig. 458). There are anomalies in the origin of the vertebral and thyroid axis ; and the axillary divides into the brachial and ulnar arteries. We should also state that this form of after-bleeding is not unfrequently met with in parts that are involved in, and undergoing destruction from, *hospital gangrene, and that some of the most striking instances of it ever witnessed by surgeons have occurred during the progress of that affection. The following abstract and wood-cut (Fig. 459),furnish tolerable illustrations of this point:— Fig. 459. Showing ligations of the radial and brachial arteries for secondary hemorrhage cansed by gangrene. Spec. 3645, Sect. I., A. M. M. A corporal, aged 37,* received, June 18, 1864, a gunshot flesh-wound of the upper third of the right forearm. On the 28th he was transferred to Satterlee Hospital. The wound was sloughing; the patient ana?mic and despondent. Nitric acid was ap- plied to the wound, and followed by flaxseed poultices; extra diet was prescribed. By July 20, the gangrene having ceased, healthy granulations had arisen, but the patient’s despondency continued. On the 23d profuse hemorrhage from the radial artery oc- curred, and that vessel was ligated. The surrounding tissues being much disorganized and the hemorrhage continuing, a ligature was put around the brachial just above the bifurcation. Next day several minor hemorrhages occurred, and on the 25th the patient died, apparently of anaemic exhaustion. The specimen is represented in the accompanying wood-cut (Fig. 459), and shows the radial artery ligated just below, and the brachial artery just above, the bifurcation. In all the cases belonging to this category, the bleeding occurs from parts of the arteries where the tunics have not been primarily injured by the mis- siles, as already stated. The solutions of continuity are entirely due to morbid processes of a peculiarly destructive character. These processes ate much more rapid in their progress than simple ulceration. The term slough- ing ulceration is sometimes employed to represent the less severe, and that of sloughing phagedcena the worst instances. But the secondary hemorrhages which result from sloughing are specially prone to be followed by pyaemia. The accompanying abstract and wood-cut (Fig. 460) will serve to illustrate this point:— A corporal, aged 30,2 received, September 19, 1864, a gunshot flesh-wound of the middle and outer side of the left arm and left side of the back, and entered a general hospital on the 27th. The wound was then sloughing. On October 4, 5, 6, and 7, hemorrhages occurred. The first three were controlled by a saturated solution of alum and persulphate of iron, and compresses of lint. The last hemorrhage required the application of a tourniquet to restrain it; during the day the entire hand and arm became excessively congested and inflamed ; the axillary artery Cleft) was then tied in its third part. The patient’s general condition was bad; he was much debilitated, having lost in all some thirty-six ounces of blood, and was subject to intermittent 1 Med. and Surg. Hist, of the War of the Rebellion, Second Surg. Yol., p. 450. 2 Ibid., p. 442. SECONDARY HEMORRHAGE. 723 fever. He improved for a week, and the wound began to look healthy, when pysemia set in. On the 22d he died, fifteen days after the operation. Necroscopy proved that pyaemia caused death. The right lung contained secondary abscesses, and the right Fig. 460. Showing the left axillary artery a fortnight after ligation for secondary hemorrhage from the brachial. Death resulted from pysemia. Spec. 3679, A. M. M. pleural cavity was full of pus. The specimen is represented in the accompanying wood- cut (Fig. 460). The axillary artery has been opened transversely, seemingly to show the distal coagulum. (4) Secondary hemorrhages are not unfrequently prpdueed by the sloughing of the coats of arteries at the points where they have been secured by liga- tures. The following abstract and wood-cut (Fig. 461) will serve to illustrate this topic:— A sergeant, aged 22,1 received a shot wound at the upper third of the right arm June 4, 1864, the ball passing antero-posteriorly ; the wound sloughed, and secondary hemor- rhage ensued on the 25th ; the axillary artery was ligated under chloroform. On July 1, hemorrhage arose from the axillary, the artery having sloughed at the point of liga- tion. The artery was then tied again high up in the axilla, by enlarging the previous wound of operation, and without anaesthesia. The patient was exsanguinated, having lost about thirty ounces of blood, and died one hour after the operation. Only the ter- minal subclavian and upper axillary portions of the vessel, with their branches, are repre- sented in the accompanying wood-cut (Fig. 461). Fig. 461. Showing ligation of the right axillary artery in the first part of its course, for secondary hemorrhage caused by sloughing of the artery at the point where it had been ligatured for a previous hemorrhage. Spec. 2545, A. M. M. view.) (5) Secondary hemorrhages are sometimes produced by the liquefaction and breaking down of the coagula and adhesions which have been formed at the mouths of wounded arteries, and by which they have been more or less firmly occluded. When this retrograde metamorphosis of the fibrinous material by which the apertures in wounded vessels are, in general, perma- nently closed, takes place, it denotes a more or less rapidly deteriorating con- dition of the general health of the patient, since its occurrence is due to constitutional rather than to local causes. 1 Med. and Surg. Hist, of the War of the Rebellion, Second Surg. Vol., p. 441. 724 INJURIES OF BLOODVESSELS. The following example occurred in my own practice A soldier, aged 27, was admitted to the Stanton Military General Hospital June 4, 1864, for a gunshot wound of the right leg, complicated with a badly comminuted fracture of the fibula, which had been received at Cold Harbor, on May 31. The effort to save the limb was continued. On June 14, secondary hemorrhage (arterial) occurred from the wound, and about ten ounces of blood were lost. The leg was then greatly swelled and inflamed all the way up to the knee. The pulse was small and frequent, and there were other signs indicating the approach of irritative fever; wherefore, the limb was amputated without delay, at the lower third of the thigh, by the circular method, under ether, as affording the patient the best chance of his life. Examination of the amputated leg showed that the muscles were extensively infiltrated with purulent matter, that the peroneal artery was severed, and that the hemorrhage had proceeded from its proximal end, which had been re-opened through liquefaction of the occluding clot and fibrinous exudation at the mouth of the vessel. The patient did well for a few days ; but unhappily he was then seized with pyaemia, and died from that disease, eleven days after the operation. The following abstract and wood-cut (Fig. 462) will serve to still further illustrate this subject in a useful manner:— A soldier was wounded1 Sept. 20, 1863, by a conoidal ball, which entered below the left zygomatic arch, passed transversely through, and escaped from the right side of the neck below the angle of the lower jaw. On Oct. 2, secondary hemorrhage from the mouth and wound of exit occurred. On the 4th the external carotid was ligated. The patient did well and appeared to be safe until the 12th, when hemorrhage recurred, but was again checked by compression. The wounds were nearly healed ; but the patient was greatly enfeebled by repeated losses of blood. On the 23d profuse hemorrhage from the wound of exit again set in, and the right common carotid was ligated, about an inch and a half above its origin ; but the patient sank and died on the 25th. The specimen was sent to the Army Medical Museum, and is represented in the accompanying wood-cut (Fig. 462), which shows a ligature on the common trunk, that was applied two days before death, a large coagulum at the bifurcation, but imperfectly indicated, the origins of . the occipital and facial arteries from the external carotid, and the rugose, ulcerated extremity of the external carotid that had been wounded. (6) Secondary hemorrhages are occasionally produced in the stumps of amputated limbs by the non-closure or non- obliteration of the main arteries, even when they have been properly secured by ligatures. In such cases, when a ligature separates and comes away, the blood usually flows out from the unclosed and patulous mouth of the artery in a great stream. The following very striking example occurred in my own practice:— A Confederate soldier, aged 27, received a gunshot wound of the right knee-joint at the Rappahannock Station November 7, 1863, and was captured. On the 9th, he was admitted to Stanton Hospital, where the attempt to save his limb was still pursued. On the 18th, however, amputation of the member become necessary, and accordingly was performed at the inferior third of the thigh, by the double-flap method, under ether. After that the patient did well in every respect until December 1, when he began to complain of great pain in the stump, and became agitated and restless. On the 2d, the pain, agitation, and restlessness were Fig. 4(52. Showing ligation of right carotid ar- tery, and rugose, ulcerated section of external carotid. Spec. 2133, Sect. I., A. M. M. 1 Med. and Surg. Hist, of the War of the Rebellion, First Surg. Yol., p. 393. SECONDARY HEMORRHAGE. 725 increased, and his countenance indicated great suffering. He referred the pain to the stump-bone, particularly the end of it; but he was not feverish, and the stump itself was not swelled nor hot. On the morning of the 3d, at an early hour, the ligature separated from the femoral artery, and secondary bleeding in a great stream immedi- ately ensued. It was soon arrested by digital compression, and did not recur ; but, meanwhile, the patient had lost so much blood that he could not be made to rally, and he died, eight hours after the separation of the ligature and the occurrence of the hemorrhage. Autopsy.—All of the stump had firmly united by adhesion, excepting a small part around and in front of the end of the stump-bone. The end of the femoral artery was patulous, not contracted, and without evidence of any effort on the part of the repara- tive processes of nature to occlude it. It was embraced by the forked extremity of an osteophyte which, springing from the linea aspera, extended horizontally inward along the angle of junction of the flaps. The femoral vein was well sealed up. The medullary tissue of the stump-bone was inflamed, being dark-red in color and of firm consistence, or hepatized, and contained a great number of abscesses which varied in size from that of a pin-head to that of a split pea. This case is fully reported in the volume of U. S. Sanitary Commission Surgical Memoirs, which was prepared by the author, pp. 358, 359. (7) Secondary hemorrhages very often occur from the distal orifices of severed or ligated arteries, and they result from the imperfect closure of these orifices, the proximal orifices being at the same time well sealed up. During our late civil war many examples of injured arteries were observed, in which there occurred during the secondary period a fatal hemorrhage from the distal end of the divided or ligated vessel. There was an occlusive coagulum on the cardiac side of the ligature; a non-occlusive coagulum, or, in some in- stances, even no clot at all, on the distal side. Several cases have already been mentioned in which secondary hemorrhage occurred from the distal portion of wounded or ligatured arteries. In the following example, which occurred during the late civil war, there was no clot whatever in the distal portion of the carotid artery, while the cardiac portion was securely plugged:—■ Pri vate H. Hutchins, aged 25, was wounded on December 9, 1864, by a conoidal ball, which entered the chin, fractured the lower jaw, and emerged at the back of the neck. On the 18th, violent hemorrhage occurred from the mouth ; it was supposed to proceed from the lingual artery, and left the patient almost pulseless. The common carotid was ligatured just above the omo-hyoid muscle. The patient did very well until the 27th, when hemorrhage occurred in the wound of operation, from the distal portion of the artery and the deep jugular vein, and he died on the same day. Necro- scopy showed an organized clot below the ligature; no clot had formed above the liga- ture, and the internal jugular vein was opened from sloughing of its tunics.1 Tlie clot which forms on the cardiac side of a ligature is usually much larger than that clot which forms on the distal side, and sometimes the distal clot is wholly wanting, as happened in the instance just related. When arteries of some magnitude are wounded, and the distal ends are not tied, hemorrhage by regurgitation is very apt to occur, as was .observed in the following instance of gunshot lesion of the brachial artery A soldier was wounded at Fair Oaks May 31, 1862, by a ball which passed through the posterior part of the upper arm without injury to the bone, but caused an extensive ecchymosis. On June 4, he was admitted to general hospital. On the 10th, free arterial hemorrhage occurred; on removing the clots, the wounded parts were found extensively disorganized, and the brachial artery not accessible. The axillary was then tied high up, and the subscapular also, to prevent subsequent trouble. On the 21st both ligatures came away ; feeble pulsations in the radial artery were observed. On the 23d very profuse hemorrhage from the brachial again occurred, which was stopped by compres- 1 Medical and Surgical History of the War of the Rebellion, First Surg. Vol., p. 420. 726 INJURIES OF BLOODVESSELS. sion applied with a pad in the axilla. On July 12 and 13, troublesome hemorrhage? still again occurred, and on the 14th the patient died.1 The return of pulsation at the wrist showed how completely the circulation in the arm had been restored; two days afterwards, that is, as soon as the tension in the brachial artery was sufficiently strong to expel the clots at the wound, they were pushed out, and then the blood regurgitated freely through the distal portion of the artery into the wound, and a very profuse hemor- rhage ensued. The following example serves well to illustrate the difficulties in treating hemorrhage from wounds of the shoulder, which are sometimes encountered in practice:— Lieutenant-Colonel Dawson, aged 38, received, June 17, 1864, a gunshot flesh-wound of the left shoulder. The bullet was extracted, and on the 19th he was sent to general hospital at Washington. On the 27th, secondary hemorrhage to the amount of thirty ounces supervened. The operation of tying the axillary artery was resorted to, but the bleeding still continued. The distal extremity was then secured by tying the brachial artery. A few hours later, however, the hemorrhage burst forth afresh, and finally the patient died.2 In this case the ligature of the brachial stopped the bleeding for a time by arresting the regurgitation of blood in the brachial artery. From what vessels did the blood escape which finally destroyed this patient? Clearly not from the axillary artery above, nor from the brachial artery below, the points where the ligatures were applied. But a long stretch of the main artery, embracing its wounded part, lay between these two points, and from this some five or six important branches were sent oft‘, namely, several of the thoracic branches, the subscapular, the two circumflex arteries, and the superior profunda; and the hemorrhage which destroyed this patient was doubtless caused by regurgitation of blood through these branches into the main trunk, whence it readily escaped by means of the wound. This result could have been obviated by tying the main artery at the spot where it was injured, with two ligatures, one of them being applied on each side of the aperture in its walls. The axillary artery, therefore, whenever it is the source of secondary hemorrhage, must always be tied in the wound with ligatures placed on each side of the breach in its walls, and in close proximity thereto. When promptly treated in this manner, these hemorrhages give no further trouble. Treatment of Secondary Hemorrhage.—The 'prophylaxis of secondary hemorrhage demands that all wounds, whether the result of accident or of surgical operations, but more particularly those which involve bloodvessels, shall be kept free from purulent matter, by antiseptic treatment and thorough drainage, especially the latter. Otherwise, ulceration and sloughing of the arterial and venous tunics, together with softening and disintegration of the occluding coagula, are very liable to supervene, and secondary hemorrhage to ensue. The following abstract and the wood-cut accompanying it (Fig. 463) illustrate in a useful manner the disastrous consequences which may follow the retention and burrowing of pus in wounds made for the deligation of the common carotid artery :— A sergeant, aged 21,3 was wounded Aug. 25, 1864, on the field, by a musket-ball, which entered over the right mastoid process, injured the external ear, and lodged under the 1 Med. and Surg. Hist, of the War of the Rebellion, Second Surg. Vol., p. 443. 2 Ibid., Second Surgical Vol., p. 442. 3 Ibid., First Surg. Vol., p. 393. SECONDARY HEMORRHAGE. 727 skin, a little in front of the auditory foramen. On the 28th he entered the Lincoln Hos- pital at Washington. The ball had not been extracted, but no symptoms demanded special attention until Sept. 7, when it was observed that the right parotid gland was so greatly inflamed that the patient could with diffi- culty separate his teeth more than one-fourth of an inch. In the course of the day, an alarming hemorrhage, supposed to proceed from the posterior auricular artery, occurred; it was stopped by compres- sion with lint steeped in a solution of persulphate of iron. On the 9th, an alarming hemorrhage again occurred, which was temporarily arrested, with difficulty, by compression with lint and styptics, until the patient could be taken to the operating room, where, under ether, the right common carotid artery was tied. Coagula were removed, and the missile was extracted from near the angle of the jaw. The bleeding recurred on the lltli and 12th, but ceased spontaneously. On the 18th, there were several recurrences of hemorrhage. On the 19th, the ligature was removed; the face and neck were much swollen. On the 20th, the patient died from hemorrhage. Autopsy— Submaxillary gland suppurating; an abscess extended about three- fourths of an inch above and below the place of ligation, and the ends of the artery were covered with pus. The artery from which the he- morrhage issued was not found. The specimen was sent to the Army Medical Museum, and is represented in the accompanying wood-cut (Fig. 463) which shows the termination of the innominate, the com- mencement of the right subclavian, the trunk of the right common carotid, severed by ulceration at the site of the ligature, and the bifur- cation into the external and internal carotid, the calibre represented being one-third of the normal. The ligature on the internal carotid was applied during an experiment upon the cadaver. It is not improbable that, in cases like the above, the pa- tient might often, perhaps generally, be saved by the employ- ment from the very outset of antiseptic dressings and thorough drainage. The use of carbolized catgut, or other appropriate antiseptic animal ligature, for the deligation of arteries and veins, will likewise aid much in producing good results, because it does not, in general, cause ulceration, but more or less slowly disappears by absorption, without inducing suppuration; and for this reason such ligatures should be applied in all deliga- tions, whether performed in the primary, intermediary, or secondary period. When suitable animal ligatures are not at hand, those of carbolized silk should be employed, as has already been stated. Many of the examples presented in the foregoing pages, with a view to illustrate the pathogenesis of secondary hemorrhage, also very clearly show- some things which should not be done for that affection. (1) The wound should not be plugged with lint soaked by acid ferric salts, or any other so-called styptics, for this treatment never permanently suppresses the bleeding where vessels of any magnitude are opened, and it often does much harm, by permitting the hemorrhage to return again and again in cases where the greatest promptitude of action on the surgeon’s part is necessary, in order to prevent the loss of so much blood that fatal amende exhaustion must ensue. (2) The main artery should not be tied at a distance from the bleeding wound, unless nothing else can be done, for in a large majority of cases where arteries are ligatured on the plans of Anel and Hunter, for secondary hemor- rhage from open wounds, the bleeding returns sooner or later, and proves fatal. Hut how should secondary hemorrhages be suppressed? In the lirst place, Fig. 463. Showing ulcera- tion of the common carotid attending- the separation of a ligature on the tenth day ; death from he- morrhage on the fol- lowing day. Spec. 3252, Sect. I., A.M.M. 728 INJURIES OF BLOODVESSELS. the wound must be opened, and the aperture whence the blood issues from the injured vessel must, if practicable, be exposed to view by enlarging the original wound or by making fresh incisions, if necessary, and by wiping out the coagula. Oftentimes the search can be materially aided by having an assistant control the How of blood in the main artery by digital compression, especially in the extremities, and sometimes, likewise, in the neck. “ Look your enemy fully in the face,” is a motto still more applicable to the manage- ment of external hemorrhages than to behavior in battle, for the surgeon has no long-range weapon with which to overcome his adversary. The bleeding vessel having been brought into view, it must be secured with two ligatures, one of them "being applied on each side of the aperture in its walls, or to each end of the vessel, if it be completely divided ; and the surgeon must sever the artery midway between the two ligatures, with a knife or scissors, in all cases where the original injury has not done so, in order that the two ends may retract, and thus lessen the tendency to a return of the hemorrhage. The bleeding vessel should likewise be sought for and found without any delay, to the end that infiltration of the surrounding textures with extrava- sated blood may be avoided, and that the hemorrhage itself may be permanently stopped, if possible, before the loss of blood becomes so great as to cause death by anaemic exhaustion, days and perhaps weeks afterward. The bleeding from small vessels will generally cease on exposing them to the air by wiping off the coagula, and applying cold water with moderate pressure. But to all vessels which continue to bleed, both proximal and distal ligatures must be applied. When the hemorrhage proceeds from an artery that is inaccessible, as, for instance, the internal maxillary, the main trunk should be tied as near the injured part of the vessel as practicable. In cases where the hemorrhage proceeds from branches of the external carotid which cannot be tied in the wound, the external carotid itself should be ligatured, rather than the com- mon carotid. But the superior thyroid, facial, temporal, and occipital, should always, if possible, be ligatured at the place of injury. Hemorrhage from wmunds of the tongue involving branches of the lingual artery should be com- bated by tying the trunk of that artery above the great cornu of the hyoid bone; and, owing to the great freedom of inosculation across the median plane, it will often be necessary to tie both linguals or both external carotids. When the vertebral artery is found to be the source of the bleeding, it should be secured by proximal and distal ligatures, if the seat of injury be below the foramina in the transverse processes of the cervical vertebrae; but if the artery be wounded above its passage into these foramina, it should be plugged with a piece of agaric, or a wad of lint, so fashioned as to completely fill the calibre of the artery, on the distal as well as on the proximal side of the breach in its walls. When an artery of the axilla is found to be the source of the hemorrhage, it should be borne in mind that there is scarcely any other region of the whole body where it is equally important to bring the bleeding vessel into view and to tie it on each side of the gap In its walls. If the axillary artery itself be found wounded, and the circulation be controlled by compressing the subcla- vian against the first rib, the distal ligature should always be applied first; otherwise, the profuseness of the distal bleeding will very much delay the completion of the operation, and perhaps place the patient's life in peril. In operating for secondary hemorrhage in the extremities, both lower and upper, it should never be forgotten that the application of a distal ligature is just as important as the application of a proximal ligature, because of the great freedom with which the terminal branches in the extremities inosculate together, as Dupuytren was the first to point out. 729 PARENCHYMATOUS HEMORRHAGE. Secondary hemorrhage from small arteries in deep cavities, where ligatures cannot readily be applied, may be suppressed by applying the actual cautery. The employment of carbolized catgut ligatures, antiseptic dressings, and thorough drainage by means of tubes of appropriate size, has already been insisted on with sufficient energy. Parenchymatous Hemorrhage. This form of bleeding did not receive mention until a very recent period. No account of it whatever is given by Guthrie, Ilennen, or their predeces- sors. Stromeyer appears to have been the tirst to call attention to it. In cases of parenchymatous hemorrhage, the blood does not issue from the wounded, granulating, or ulcerating part in distinct streams, but seems to escape by a general oozing through minute apertures. We therefore infer that the capillaries constitute its anatomical source, and that it is in reality a capillary hemorrhage. In such cases the blood flows in a steady stream. It does not in general possess the purple hue of venous, nor yet the bright- red color of arterial blood. It is in general not as dark as the former, nor as bright as the latter. It therefore usually has a distinct color of its own, and this, conjoined with the flow of the escaping blood in a steady stream, has led me to correctly surmise, in some instances where these phenomena were present, that the hemorrhage was parenchymatous in character, before the interior of the wound from which it issued had been exposed to view. Parenchymatous hemorrhage lias been met with in the ■primary, the inter- mediary, and the secondary periods in the history of wounds; but the causes or pathological conditions upon which its occurrence depends are, for the most part, widely different in each of these periods, especially in the primary and secondary periods. Parenchymatous hemorrhage has been encountered during the primary period in the stumps of limbs just amputated, where the operation has been performed through tissues that had previously been inflamed, and in which the inflammatory process had not yet entirely subsided. Such a hemorrhage is due to the fact that the dilated capillaries which have been severed by the knife in performing the operation, being still paralyzed from the inflamma- tory process, are unable to close their open mouths by the contraction of their muscular tunics, and that therefore the hemorrhage continues without impediment until it is suppressed by surgical art or by the occurrence of syncope, or until death occurs. Parenchymatous hemorrhage has been met with during the intermediary period in cases of amputation where the mouths of the capillaries have been but feebly or imperfectly closed in the primary period, so that when reaction has come on, with the vascular excitement and increased blood-pressure which attend it, the capillary orifices have been reopened, and capillary hemorrhage has ensued. In such cases, more or less parenchymatous bleeding usually attends the operation itself, and, occasionally, the capillary oozing continues in a minor degree until the advent of the intermediary period, when the capil- lary bleeding becomes more and more copious as the vascular excitement rises higher and higher. When parenchymatous hemorrhage occurs during the secondary period, it is generally associated with the symptoms of pysemia, or, at least, with pyse- moid phenomena, and is caused by obstruction of the veins which proceed from the seat of the hemorrhage toward the heart, with coagulated blood or thrombus, as was pointed out by Stromeyer. The state of affairs, as far as the circulation of blood is concerned, in a wounded limb, the principal veins of 730 INJURIES OF BLOODVESSELS. which are occluded by thrombosis, is as follows: The blood injected into the limb through its arteries, being not conducted away through its veins, stag- nates, and exhibits a more or less strong tendency to effuse itself from the parts whose capillaries are not strengthened and supported by tissues exte- rior to their walls. Thus it happens, in such cases, that the capillaries of wounded, granulating, and ulcerating surfaces, not unfrequently give way in consequence of the increased vascular tension, and parenchymatous hemor- rhage ensues. To illustrate primary parenchymatous hemorrhage, the following example, which occurred in my own practice, is presented:— Lieut. C. H. Doei-flinger, Co. K, 26th Wisconsin Vols., aged 20, and of excellent constitution, was wounded at Chancellorsville, May 2, 1863, by a conoidal musket-ball, which fractured his left leg, etc. On June 15, lie was brought to Stanton Hospital,, where the effort to save his limb was continued, although his condition was not favora- ble. On the 27th, amputation could no longer be delayed, and accordingly it was per- formed at the lower third of the thigh by the circular method. At the place of operation the tissues were considerably swelled and inflamed. A large number of ligatux-es were applied. There was also a troublesome oozing of blood, a parenchymatous hemor- rhage, from the face of the whole stump. After a time the wound of operation was closed and dressed; but the patient was still retained upon the operating table. In a little while, I was recalled because of a profuse flow of blood through the dress- ings. These were immediately removed, and the stump opened, in order to find the source of the hemorrhage. It was then seen that the blood did not issue in a dis- tinct sti-eam at any point, but escaped from the parenchyma over the raw sui'face of the whole stump, by a process of genei'al oozing, and that the hemonbage in all constituted a current of considerable size. The application of cold water, and even of ice, did not arrest this parenchymatous bleeding, and seemed to retard it but little. Finally, I covered the whole surface of the stump with lint soaked in liquor ferri persulph., and this proceeding speedily suppi-essed the bleeding. The stump was left open so as to granulate from the bottom, and pi-event any collection of purulent matter. The patient slowly recovered. Another example of primary parenchymatous hemorrhage, which occurred in my own practice, may be found reported in the volume of the U. S. Sani- tary Commission Surgical Memoirs, that has been already referred to.1 Dr. W. Clendenin has reported a case of primary parenchymatous hemor- rhage in a tliigh-stump, which proved fatal:— B. F. Black, Co. A, 6th Kentucky Infantry, aged 23, was wounded at Cliickamauga September 19, 1863, by a ball which passed obliquely through his right knee-joint. On October 30, amputation of the limb was performed. No tourniquet was used, and yet, after securing the artei’ies, profuse heinon-hage of a parenchymatous character took place. This hemorrhage was of the most persistent chai'acter ; it was, however, finally arrested by applying a strong solution of persulphate of iron, but not until such a quan- tity of blood had been lost that death ensued the same evening. Autopsy In the stump, a large abscess extended as high as the trochanter major, the intermuscular spaces being filled with a sei-o-purulent fluid. In the femoral vein, just below Poupai’t’s ligament, a fibrinous clot was found, which completely filled up the venous canal at that point. No pus was seen here, nor in any of the veins. The right side of the heart was entirely filled with a fibrinous clot. The liver, lungs, and all other organs were sound.3 The femoral vein, in this case, was occluded by a thrombus, whose forma- tion had resulted from the presence of an unhealthy femoral abscess. The parenchymatous bleeding which followed the amputation had, therefore, a twofold origin: First, the inflamed condition of the tissues divided by the i Op. cit., pp. 241, 413, 414. 2 Ibid., pp. 241, 242. PARENCHYMATOUS HEMORRHAGE. 731 operation, and the dilatation and paralysis of the capillaries which attend that condition; Secondly, the obstruction to the liow of blood from the stump toward the heart, which was caused by the fibrinous plugging or thrombosis of the femoral vein. We must, therefore, count thrombosis among the possible causes of primary parenchymatous hemorrhage; and its presence will always make the prognosis very unfavorable. To illustrate intermediary parenchymatous hemorrhage, I shall again call attention to the case of Lieut.-Colonel Maxwell, already presented under the head of Intermediary Hemorrhage. The bleeding occurred in a tliigh-stump on the second day after a secondary amputation. It was suppressed by open- ing the stump, and painting its raw surface all over with liquor ferri persulph. fortis, by means of a camel’s hair brush. The patient recovered. Another example of intermediary parenchymatous hemorrhage may be found in a case of secondary amputation of the left arm at the shoulder-joint, performed on August 5, 1864. Hemorrhage to the extent of eight ounces occurred on the 6th. The stump was then 'opened ; “ blood apparently oozing from the tis- sues, and was checked by pressure and Monsel’s salt.” The patient’s general condition was very low, and two days afterwards he died.1 To illustrate secondary parenchymatous hemorrhage, the following abstract of a case, which occurred in my own practice, is offered :— Private B. Romig, Co. F, 6th Michigan Cavalry, received on September 23, 1863, a gunshot flesh-wound of the right thigh, at the middle third, and on the inner side. The missile penetrated deeply, and lodged. On the 25th, he was admitted into Stanton Hos- pital. On October lltli, the symptoms of pyaemia appeared; and, on the 23d, the wounded limb was observed to be oedematous. On the 25th, while the patient was sitting on a chair to have his bed remade, hemorrhage from the wound suddenly occurred to the extent of four or five ounces, and ceased spontaneously. On the 26th, the hemorrhage recurred, and three or four ounces of blood were lost before it again ceased spontaneously. Meanwhile pyaemic rigors appeared, and frequently returned. The patient rapidly failed, and died about three o’clock P. M. on the 26th. Autopsy—Right lower extremity much swelled and oedematous ; on laying open the thigh and groin by incisions along the course of the femoral and iliac arteries, the chain of lymphatic ganglia was found to be very much enlarged in all its component parts. The femoral and other arteries were sound. But the right common iliac, ex- ternal iliac, common femoral, and deep femoral veins were filled with coagulum (thrombus), which in some parts exhibited a quite recent appearance, but in others was more or less disintegrated and softened by fatty transformation. The walls of the thrombosed veins were likewise very much thickened. The thrombosis had obviously caused the hemorrhage. Hot long afterward, another striking example of secondary parenchymatous hemorrhage came under my care at the same hospital;— Tobias Beaver, a prisoner of war, aged 30, was admitted on November 9, 1863, for a gunshot fracture pf the left femur in its lower third, which had been received on the 7th. After some time,- the fracture united and the wound of the soft parts healed. At a still later period, osteo-myelitis supervened, in consequence of the lodgment of a part of the missile in the medullary canal. The wound then reopened, and the general health became much impaired. On March 23, 1864, some hemorrhage from the wound occurred. The patient was weak, pale, and anmmic. On the 25th, he had a severe hemorrhage, which was controlled externally by injecting liquor ferri perchloridi; but the thigh swelled rapidly from internal effusion of blood. On the 27th, he died. Autopsy The thigh was swelled to twice the normal size. It contained a cavity which extended from the synovial pouches of the knee-joint to the trochanter major, and was full of blood and pus, the quantity being estimated at one quart; the external outlet of this cavity was plugged by a hard coagulum. The superficial femoral vein * Medical and Surgical History of the War of the Rebellion. Second Surgical Volume, p. 444. 732 INJURIES OF BLOODVESSELS. was filled with coagulated blood (thrombus) from the popliteal to the mouth of th« piofunda. The subcutaneous connective tissue was highly oedematous, this redema, as well as the hemorrhage, being obviously due to the obstruction of the venous circula- tion. Three additional examples of secondary parenchymatous hemorrhage, which came under my own observation, are reported in the volume of U. S. Sanitary Commission Surgical Memoirs, already referred to.1 We have thus mentioned five cases in which parenchymatous hemorrhage occurred during the secondary period. In all of them the bleeding was pre- ceded by general debility, pallor, and loss of llesli. All of them proved fatal. In three instances, the veins were examined after death, and their condition noted; in every instance, the principal veins leading from the seat of the parenchymatous bleeding were found perfectly occluded by coagulated blood, that is, they were plugged up by thrombosis. In the remaining two instances, doubtless, the veins were also plugged up by blood-clots. In every one of the five cases, likewise, there were more or less strongly marked symptoms of pyaemia. To the obstructive form of secondary parenchymatous hemorrhage, just described, there is another of some importance which must be added. Capil- lary hemorrhages may be produced on the surface of granulating wounds by powerful stimuli to the vascular and nervous systems of any kind, as, for instance, venereal excitement, and excess in drinking. The first-named is the common, and the latter an occasional, cause of this additional form of parenchymatous bleeding, which may occur during the secondary period in the history of wounds or surgical operations. Scorbutic Parenchymatous Hemorrhage.—Scurvy essentially consists of an alteration in the constitution of the blood, which leads to an effusion from the capillaries into the various tissues of a fibrinous liquid, usually deeply colored by red corpuscles. The passive hemorrhages which take place from the gums, nose and ears, stomach, and bowels, and occasionally from the lungs and bladder, in cases of scurvy, are usually capillary hemorrhages. The sanguinolent effusions on the free surfaces of sores or ulcers, which impart to them the peculiar aspect termed “ scorbutic,” are also poured out from the capillaries, and therefore they appear to ooze out from the paren- chyma at the base and margins of these sores or ulcers. When scorbutic persons are wounded, the more or less copious oozing of a sanguinolent liquid from their wounds, or parenchymatous hemorrhage, is not uncommon in the primary, the intermediary, and the secondary periods, but •especially in the first two of these. Boyer relates a case where it occurred in the secondary period:— I amputated (he says) the middle finger of a man, aged 50, for caries in consequence of whitlow. The collateral arteries were tied ; the ligatures came away on the seventh day; no hemorrhage followed. Shortly afterward, however, the lips of the wound became bloated, black, soft, and spongy, and bled freely on the slightest touch. From this time the patient experienced every day considerable hemorrhage, to which the ligature and compression were opposed in vain. The bloated-appearance of the wound, the spongy state of the gums, the violet spots which appeared on several parts of the body, especially the legs, left no doubt of the existence of scurvy. The patient was then placed upon a strongly antiscorbutic plan of treatment; the hemorrhage soon ceased, and he rapidly recovered. \ 1 Op. cit., 245-248. DELIGATION OF ARTERIES. 733 Treatment of Parenchymatous Hemorrhage.—The primary and inter- mediary forms of parenchymatous hemorrhage can almost always be promptly suppressed by applying the solution of the persulphate or the perchloride of iron to the bleeding surface, by means of a camel’s hair brush, or a piece of lint, as already shown above. In the absence of these styptics, it is highly probable that the primary and intermediary forms of parenchymatous hemor- rhage, in open wounds, may be arrested by the application of hot water to the bleeding surface. To be of use the water must be hot enough to coagu- late albumen, that is, its temperature must be not less than 160° Fahr. Should this proceeding fail, the actual cautery may be necessary. When parenchymatous hemorrhage occurs in the secondary period, in con- sequence of thrombosis and pyaemia, there is but little .hope of saving the patient. If the application of styptics and pressure does not stop the hemor- rhage, the surgeon may amputate the bleeding member, or tie its main artery.. Upon this point Stromeyer says: “A single amputation, practised on this, account, proved rapidly fatal; the ligature of the chief artery had but tem- porary success; the extraction of extensive loosened sequestra sometimes- effected a temporary stoppage of the hemorrhage, but death followed from pyaemia.”1 The results of my own experience in this regard are no better. In some cases, doubtless, it is preferable to amputate; in others, to tie the main artery. If the patient be not already much reduced by systemic dis- ease, and especially if pyaemia has not yet appeared, it is better to amputate;, but if the patient be very low, or affected with pyaemia, it is better to liga- ture the main artery. When parenchymatous hemorrhage results from venereal excitation or excess in drinking, the bleeding may be promptly suppressed by the applica- tion of iced water or of the acid salts of iron, in solution, to the part whence it proceeds. The main point, however, in the treatment of such cases, is to prevent a recurrence of the hemorrhage by meeting the causal indication, that is, by removing or making inoperative the causes which produce it. Scorbutic parenchymatous hemorrhage must be treated by freely adminis- tering antiscorbutic remedies, such as the juice of scurvy-grass, limes, and lemons, together with acidulous fruits and fresh vegetables for food, as well as milk and the juice of raw beef. Deligation of Arteries. The instruments required for the ligation of arteries or veins, in their con- tinuity, are a scalpel, forceps, grooved director, silver probes, artery-needles, and ligatures. The ordinary scalpel (Fig. 464) is best adapted to the dissection, and the Fig. 464. Scalpel. broad, thin, end of its handle can he employed to separate the connective tissue, the layers of fascia, and other parts, where it is not desirable to use the cutting edge. The forceps (Fig. 465) should have delicate, accurately-fitting teeth, and the blades, while not too broad, should be so stiff as not to bend when closed and locked, on making traction. Not unfrequently, a second 1 Gunshot Fractures, p. 35, Am. ed., 1862. 734 INJURIES OF BLOODVESSELS. Fig. 465. Liston’s artery forceps. pair of forceps is also required. One, at least, of the silver probes (Fig. 466) should have a flattened and eyed extremity. Fig. 466. Silver probes. Of artery-needles, among the best is Mott’s “American aneurism needle” Fig. 441, p. 690), especially for ligaturing deeply seated arteries. It consists of two sections, namely, a straight handle and a curved extremity, the latter of which is screwed on to the former. The curved extremity, or point of the needle, has two eyes; when used, the second eye is threaded with the ligature; the point of the needle is then gently passed under the artery, and, as it emerges on the opposite side, the blunt hook is inserted into the first eye, whereby the point is securely held until the handle is unscrewed, when the point is drawn through with the ligature. There are, however, several forms of artery-needle which may be reckoned as useful instruments; three of them are represented by the accompanying wood-cuts (Figs. 467, 468, 469). Fig. 467. Plain American aneurism needlo. Fig. 468. Syme’s aneurism needle. The curved point of Mott’s artery-needle is sometimes liable to become loosened, and may then turn in the wound while it is being passed around the artery. To obviate this difficulty the instrument represented by Fig. 469 has been devised. The shaft is' hollow, and receives a steel rod, having a button-shaped head for convenience in turning it. The lower end of the rod terminates in a male screw, destined to work in a female screw in the upper end of the curved point. The shaft is provided at its lower end with two triangular teeth, and the upper end of the curved-point with two correspond- DELIGATION OF ARTERIES. 735 ing triangular depressions, as shown in the drawing. The two parts of the instrument being placed in relation with each other, the screw is projected, Fig. 469. Improved American aneurism needle. and two or three turns effectually lock the parts together. After the point of the needle has been passed under the artery, and while it is held by the hook, two or three reversed turns of the screw disengage the curved extremity containing the ligature, with which it is then drawn through. For ligatures, carholized catgut, prepared by Mr. Lister’s improved method, is preferable to every other kind of thread. When from want of suitable animal ligatures it is necessary to use silk ones, they should be carbolized by soaking them for half an hour in a mixture of melted wax and carbolic acid. The patient must be placed upon a firm bed or upon a table, and the sur- geon takes a position usually on the outer side of the limb or part to be operated on; one assistant administers the anaesthetic, a second assistant takes a position where he can compress the artery on the proximal side, if by any accident it should be wounded, or if the ligature should cut through its tunic; a third uses the sponges, and a fourth manages the retractors. It is important to guard against wounding the superficial veins; wherefore their position should be defined before commencing the operation, which can readily be done by applying pressure on the cardiac side of the point at which the incision is to be made. General Rules for Exposing and Ligating the Principal Arteries in their Continuity.—I. The operator must, before commencing the opera- tion, call to mind the exact anatomical relations of the parts involved in the operation. II. The direction and length of the cutaneous incision is then to be deter- mined. It is expedient to mark this out upon the skin with ink or chalk. III. The body is brought into the position most advantageous for the ope- ration, and into the best light. IV. The cutaneous incision is made by keeping the skin upon a stretch with the fingers of the left hand, while the scalpel cuts through the whole thickness of the skin from one end of the incision to the other; or, if the artery lie immediately under the skin, by pinching up a transverse fold thereof with the fingers, and cutting it through with one stroke of the knife, either from without inward, or by transfixion from within outward. V. Pinch up the fascia carefully with the forceps, nick it with the scalpel applied horizontally, and incise it freely on a grooved director introduced beneath. VI. After the edge of the muscle is laid bare, which is the anatomical guide to the artery, very little use should be made of the knife. With his fingers, or the handle of the scalpel, the surgeon can readily separate the connective tissue so as to fully expose the sheath of the artery; and by so doing he will be much less troubled with oozing of blood or hemorrhage from small vessels, and be enabled to see the principal artery much more distinctly, than if he should use the knife in the deep parts of the wound. (Mott.) VII. As soon as the sheath of the artery is exposed, the operator seizes it with his forceps and raises it into a small cone. He lowers the handle of his 736 INJURIES OF BLOODVESSELS. knife so far sidewise and outward that the flat surface of the blade is turned toward the artery, and then divides the cone, flatwise, just beneath the for- ceps, thus opening the sheath of the vessel. By repeating this procedure, he can open the arterial sheath to any desirable extent. But denuding the artery to any considerable extent of its filamentous structure, must, by rob- bing the vessel of its connecting media, always be adverse to reparative changes. In fact, if the artery be detached too far from its sheath, it will be liable to slough, and secondary hemorrhage to ensue at the seat of ligation. The sheath should, therefore, be opened no further than is necessary to permit the needle to enter it and pass around the vessel. VIII. As soon as the sheath is sufficiently opened, Mott’s or the improved American aneurism needle is introduced, and carefully passed around the artery, but always from the side where the vein lies ; the handle is then de- tached by unscrewing it, and the curved point together with the ligature is drawn through. Or, a bent probe is carefully passed around the vessel whilst a pair of forceps keeps the sheath upon the stretch (Fig. 470). Fig. 470. Fig. 471. Introducing the probe. (Esmarch.) Introducing the aneurism needle. (Esmarch.)' IX. By means of the probe, a track is made, through which a narrow aneurism needle (Syme’s or the plain American needle), with an eye at the point, is passed in an opposite direction (Fig. 471). X. The probe is then removed; the eye of the needle being threaded with a strong ligature of carbolized catgut or carbolized silk, the needle itself is withdrawn, and the middle of the ligature remains lying beneath the artery, XT. The ends of the ligature are tied together with a square or reef knot,, and without pulling on the artery. The knot must be drawn together with, the tips of both index fingers at the bottom of the wound (Fig. 472). Fig. 472. Tying the knot. (Esmarch.) XII. It is advisable to tie the larger arteries with two ligatures, and to divide the vessel itself midway between them, so that both ends may retract within the sheath. DELiGATlON of arteries. 737 Ligation of the Innominate Artery.—Surgical Anatomy.—The innominate is the first and largest of the great branches which issue from the arch of the aorta. In length it varies from one inch and a half to one inch and three-fourths. It arises from the right superior portion of the arch of the aorta, in front of the left carotid, and passes in an oblique direction upward, outward, and backward, to the superior margin of the right sterno-clavicular articulation, where it divides into the right common carotid and right sub- clavian. By extending the neck, the innominate can be drawn up and made more superficial. It is in relation on its right side with the right vena innominata, right pneumogastric nerve, and the summit of the right pleura; on its left side, with the left carotid artery and a remnant of the thymus gland; behind, with the trachea; in front, with the inferior thyroid vein and the left vena innominata, a remnant of the thymus gland, the origins of the sterno-thyroid and sterno-hyoid muscles, and the sternum. Mott’s Operation.—Place the patient on his back, with his shoulders slightly raised, his head well thrown back, and his face turned to the left side. The operator, standing on the patient’s right side, makes an incision two and one-half or three inches long, half an inch above and parallel to the top of the sternum and the inner part of the right clavicle, through the skin, superficial fascia, and platysma myoides, commencing over the trachea, and ending over the sterno-cleido-mastoid muscle. Another incision of the same length is then to be made along the anterior border of the sterno-mas- toid muscle, until it joins the first where it began over the trachea, at the middle line. The sternal root and most of the clavicular root of the sterno- cleido-mastoid muscle are next separated by a director from the underlying fascia, and then divided by cutting in the line of the first incision, using a finger passed under the muscle as a guide. The angular flap must be turned outward. Pushing the thyroid veins aside, the sterno-hyoid and sterno-thy- roid muscles are now to be carefully raised on a director, cut across, and drawn inward. A little scratching with a probe or handle of the scalpel will disclose the sheath of the common carotid artery, pneumogastric nerve, and internal jugular vein. Next open the sheath of the carotid, and trace the artery downward to the innominate. Separate the pneumogastric nerve from the carotid, draw it with the internal jugular vein outward, and the carotid inward, toward the trachea, and expose the subclavian artery. In uncovering the innominate, the utmost pains must be taken to avoid injuring the right and left innominate veins. Pass the needle from below upward and inward, taking especial care to avoid wounding the pleura. Dr. Valentine Mott, of New York, who was the first to ligature the inno- minate, operated by the method just described, in May, 1818. The patient, however, died on the twenty-sixth day from secondary hemorrhage. SMillot’s Operation.—The brachio-cephalic trunk (says Sedillot) can very easily be reached by following another procedure which I have applied to that artery (Pig. 473), to the primitive carotid, to the commencement of the subclavian, and to the principal branches which issue from it, such as the inferior thyroid and the vertebral. To execute this procedure, make an incision two inches and a half or three inches in length through the integu- ments, along the interval which separates the sternal and clavicular attach- ments of the sterno-cleido-mastoid muscle. This interval is distinctly marked by a depression above the sterno-clavicular articulation. Separate the internal from the external portion, while the head is slightly flexed in order to relax the muscle ; then, by turning over the sterno-hyoid and sterno-thyroid muscles inside, or by dividing them on a grooved director, which is preferable, one can perceive at the bottom of the wound 738 INJURIES OF BLOODVESSELS. the innominate, the common carotid, the pneumogastric nerve, and its branch the recurrent laryngeal; and more externally and above, the phrenic nerve, Fig. 473.1 Showing Sedillot’s method of tying the innominate artery. (Sddillot.) the internal jugular vein, the trunk of the subclavian, and the origins of the vertebral, inferior thyroid, and internal mammary arteries.2 This procedure enables the surgeon to judge of the condition of the vessels on which he operates, to modify his manoeuvres according to their pathological state, and to expose, ligate, and divide between the two ligatures one or several arteries, to assure the success of his ope- ration. Manec’s Transverse Operation. — Make an incision 9 centimetres (3J inches) in length, extending from a point midway between the two sterno-mastoid muscles, toward the right shoulder, 1 \ centimetres, (about | inch) above the clavicle (Fig. 474), through the skin and platysma myoides; then, on a grooved director, divide the stern o-mastoid as far as the incision ex- tends, and likewise, successively, the ster- no-hyoid and sterno-tliyroid. Isolate the innominate artery with the handle of the scalpel and the director, taking care to avoid the internal jugular vein, and the pneumogastric and phrenic nerves.3 Appreciation.—The procedures of Sedillot and Manec may appear to be more bril- liant ; but when we consider the difficulty of performing such an operation during life, and the obstacles caused by the effusion of blood at the bottom of a narrow wound, into which the instruments are with difficulty introduced, we shall recognize, I believe, that Mott’s operation is the most prudent and Fig. 474. ■Showing Manec’s plan of tying the innominate artery. (S6dillot.) 1 Permission to copy this wood-cut and many others that follow it, to which his name is attached, has been generously given to the writer by Professor S6dillot, Member of the Insti- tute, etc., for which courtesy it is but just to make this acknowledgment. 2 Medecine Operatoire, t. i. pp. 240, 241. Paris, 1865. 3 Ibid., pp. 241, 242. 739 deligation of arteries. the most sure, and that it should therefore be preferred. This, too, is -Se- dillot’s opinion. [The innominate artery appears to have been tied in 25 cases, including that recently recorded by Durante. The result of this has not been determined, but the rest, with two exceptions (the cases operated upon by Dr. Smyth and Mr. Banks),all proved fatal. Banks’s patient died after subsequent ligation of the subclavian.] Dr. Smyth ligatured the innominate one-fourth of an inch below its bifur- cation, for traumatic aneurism of the subclavian, tying also the common caro- tid one inch above its origin. Hemorrhage occurred on the fifteenth, thirty- third, and fifty-first day, and was controlled in each instance by filling the wound with shot. On the fifty-fourth day the bleeding again recurred, and then the vertebral was tied; after that, the case progressed, without inter- ruption, to complete recovery. [The patient survived ten years, ultimately dying of hemorrhage from the aneurismal sac, into which the blood had made its way through the subscapular artery.] Ligation of the Common Carotid Artery.— This artery was first tied for aneurism by Sir Astley Cooper, in a woman, aged 44, at Guy’s Hospital, in 1805.1 The patient died, however, on the nineteenth day. The same surgeon repeated the operation, in 1808, with success. Surgical Anatomy.—The right common carotid artery extends from the innominate, that is, from the right sterno-clavicular articulation, to the upper edge of the thyroid cartilage; the left common carotid extends from the highest point of the aortic arch, also to the upper edge of the thyroid carti- lage; the left is therefore longer than the right. The relations of both, in the neck, are identical; the direction of each is oblique from before backward, and from within outward, along the external side of the trachea and larynx, in a line drawn from the sterno-clavicular articulation to a point midway between the mastoid process and the angle of the jaw. The sheath of each is derived from the deep cervical fascia, and contains also the internal jugular vein and the pneumogastric nerve, the artery being on the inner side, the vein on the outer side, and the nerve between them. At the root of the neck, the artery lies deeply, and it should not be ligatured at this point, unless absolutely necessary. It is covered, in this part, by the skin and platysma myoides, the superficial and deep fasche, the sterno-mastoid, sterno-hyoid, and sterno-thyroid muscles, in front; externally, it is in relation with the pneu- mogastric nerve and internal jugular vein; internally, with the trachea; behind, with the longus colli and rectus anticus major muscles, together with the transverse processes of the cervical vertebras. On the right side, the internal jugular vein recedes from the artery; but, on the left, it approaches and often overlaps the artery. The carotid tubercle of Chassaignac, which is the anterior projection of the transverse process of the sixth cervical verte- bra, is a precise guide to the artery when the neck is straight. It is from two to three inches above the clavicle (Holmes), and the artery lies in front and a little to the inner side of it. At the root of the neck the operation may be done in the following man- ner (Fig. 476):— 1 Mr. Abernethy, however, in 1798, had tied the primitive carotid, in the case of a man gored in the neck by a cow, the primary branches of the external carotid being torn off, and the inter- nal carotid opened. Finding that he could stop the bleeding by compressing the common trunk between his thumb and a finger within the wound, he placed a ligature around the vessel. The bleeding was suppressed, but the patient died about thirty hours after the operation (Surg. Observations, vol. ii. p. 72, Am. ed.). Mr. Fleming, in 1803, successfully ligatured the primi- tive carotid for hemorrhage from a self-inflicted wound of the neck (Medico-Chirurgical Journal, vol. iii. p. 50). But, to Sir Astley Cooper the credit is unquestionably due of having first planned and executed this operation, in 1805, for the relief of aneurism. 740 INJURIES OF BLOODVESSELS, (1) Place the patient on liis back, with his head extended and inclined to the opposite side. Fig. 475. (2) Make a cutaneous incision, two and a half inches in length, between the two heads of the sterno-cleido-mastoid muscle downward to the clavicle, Surgical anatomy of the neck. (S6dillot.) Fig. 476. Ligation of the right common carotid artery between the two heads of the sterno-cloido^mastoid muscle. (S6dillot.) and ending seven-eighths of an inch to the outer side of the sternoclavicular articulation. DELIGATION OF ARTERIES. 741 (3) Divide the platysma and deep fascia; widen the interspace between the sternal and clavicular portions of the sterno-eleido-mastoid muscle with the fingers, until the internal jugular vein is visible. (4) By means of retractors, draw the vein with the clavicular portion of the sterno-eleido-mastoid carefully outward, and the sternal portion, together with the sterno-hyoid and sterno-thyroid muscles, inward; the pneumogastric nerve appears to the inner side of the vein, and the artery lies somewhat further inward and still deeper; the omo-hyoid muscle is seen crossing the vessels at the upper part of the wound. (5) Open the arterial sheath, and pass the needle from without inward, carefully avoiding the internal jugular vein and the pneumogastric nerve by keeping the point of the needle close to the artery; compressing the vein with a finger at the upper part of the wound will cause it to collapse. Just below the omo-hyoid muscle the common carotid is much more acces- sible, and at this point it is not unfrequently ligatured. It is here covered by the skin, the platysma myoides, the superficial and deep fasciae, the sternal part of the sterno-eleido-mastoid, the sterno-hyoid, and sterno-thyroid muscles; it is obliquely crossed, from within outward, by the sterno-mastoid artery, likewise by the superior and middle thyroid veins, and, lower down, by the anterior jugular; on its external side are the pneumogastric nerve and the internal jugular vein; and on the inner side are the inferior thyroid artery and recurrent laryngeal nerve, which separate it from the trachea and thyroid gland; the descendens noni nerve lies on the sheath of the artery. (Fig. 475.) To tie the common carotid below the omo-hyoid muscle, proceed thus (Fig. 477):—Place the patient on his back, with his head extended; make an Fig. 477. Ligation of the left common carotid artery below the omo-hyoid muscle. (S6dillot.) ’incision three inches in length along the inner border of the sterno-mastoid muscle, in the line above described, commencing on a level with the cricoid ■cartilage, and successively dividing the skin, superficial fascia, platysma myoides, and deep fascia, so as to expose the inner border of the sterno- mastoid muscle; carefully avoid the sterno-mastoid artery and the middle thyroid vein; bend the head forward, draw the sterno-mastoid muscle out- ward, and the sterno-hyoid and sterno-thyroid muscles inward, by retractors; 742 INJURIES OF BLOODVESSELS. expose the anterior belly of the omo-hyoid muscle, and draw it upward; divide the deep fascia, and expose the sheath of the vessels ; open it directly over the artery, carfully avoiding the descendens noni nerve, which runs along its tracheal side; press the pneumogastric nerve and the internal jugular vein away from the artery, that is, outward, and pass the needle from without inward, being careful not to include within the ligature the inferior thyroid artery and recurrent laryngeal nerve, which lie behind and on the inner side of the vessel. If the omo-hyoid muscle interfere with the opera- tion, it may be turned aside, or even divided. Above the omo-hyoid muscle the common carotid artery is still more accessible, and at this point it is very often ligatured. It is covered only by the skin, superficial fascia, platysma rnyoides, deep fascia, and anterior border of the sterno-mastoid; it is in relation internally with the larynx and pharynx, and, externally, with the pneumogastric nerve and internal jugular vein. To tie the common carotid above the omo-hyoid, proceed thus:—Place the patient on his back, with his shoulders raised by a pillow, and his head turned to the opposite side; make an incision, three inches in length, com- mencing a little below the angle of the jaw, in the line above described, along the anterior border of the sterno-mastoid, dividing the skin, superficial fascia, and platysma rnyoides; then carefully raise the deep fascia on a grooved director, and incise it; avoid injuring the small underling veins ; fiex the head to relax the muscles, and draw the margins of the wound apart with retractors; avoid the descendens noni nerve and the superior thyroid artery; open the sheath directly over the carotid; if the internal jugular vein swell up into the incision, compress it in the upper and lower parts of the wound, and draw it outward; pass the ligature from without inward, the point of the needle being kept close to the artery, in order to avoid wounding the internal jugular vein or including the pneumogastric nerve. The point of election for deligating the common carotid artery is opposite to, or on a level with, the crico-thyroid membrane, and, in performing this operation, the omo-hyoid muscle is often drawn downward ; otherwise the steps are identical with those just given. Ligation of the External and Internal Carotid Arteries.—These vessels arise from the common carotid by its bifurcation at the upper edge of the thyroid cartilage, and at their origin the external carotid is more superficial and internal than the other. External Carotid.—The external carotid, artery ascends almost perpendicu- larly from its origin to the deep sulcus behind the angle of the lower jaw, occupied by the parotid gland, underneath or through which it passes up to a point between the neck of the lower jaw and the meatus auditorius, where it divides into the temporal and internal maxillary arteries (Fig. 478). Relations.—In front, the external carotid is crossed by the posterior belly of the digastric, stylo-hyoid, and platysma myoid muscles; by the hypo- glossal nerve, near its origin; higher up it is situated in the substance of the parotid gland, and is crossed by the facial nerve. Behind, it is separated from the internal carotid by the stylo-pharyngeus and stylo-glossus muscles, the glosso-pharyngeal nerve, and a portion of the parotid gland. Operation.—Place the patient in the position directed for ligating the common carotid. Make an incision from a point midway between the angle of the jaw and the anterior border of the sterno-mastoid muscle, parallel to and three-eighths of an inch in front of the latter, to a point half an inch below the upper border of the thyroid cartilage. The skin, superficial fascia, DELIGATION OF ARTERIES. 743 Fig. 478. Showing the surgical anatomy of the anterior superior cervical triangle. platysma, and deep fascia, having been carefully divided, the last three laminae on a grooved director, the operator encounters the facial and lingual veins, and not unfrequently one or two lymphatic ganglia. If these veins- cannot be readily drawn aside, each of them is to be tied with two ligatures, and divided midway between these. The external carotid artery may now be found, crossed by the hypoglossal nerve, and by the stylo-hyoid and posterior belly of the digastric muscle. It should next be cautiously separated, by means of a director, from the internal carotid artery and internal jugular vein, both of which run closely along its outer side. Pass the needle from without inward between the two carotids, carefully avoiding the internal jugular vein and the hypoglossal nerve. The operation of tying the external carotid artery has proved to be a very successful procedure, for of nineteen cases collected by Professor Agnew, “only one proved fatal from hemorrhage, and none from causes which could properly be attributed to the operation.”1 The terminal branches of the external carotid arteries freely inosculate toge- ther across the median plane. When, therefore, the external carotid lias been tied for hemorrhage from a wound of its branches, should the hemor- rhage return, it is proper to tie the other external carotid. This procedure has, thus far, been uniformly successful.2 Internal Carotid.—The internal carotid artery curves slightly outward from its origin, and then ascends nearly perpendicularly through the maxillo- pharyngeal space to the carotid foramen in the petrous bone. Its cervical portion is in relation, in front, with the stylo-glossus and stylo-pharyngeus muscles, the glosso-pharyngeal nerve and the parotid gland ; externally, with the internal jugular vein, the glosso-pharyngeal, pneumogastric, and hypoglossal nerves; internally, it is in relation with the side of the pharynx, 1 Principles and Practice of Surgery, vol. i. p. 636. 2 American Journal of the Medical Sciences, October, 1873. 744 INJURIES OF BLOODVESSELS. the tonsil, and the ascending pharyngeal artery; and, posteriorly, with, the rectus anticus major, the sympathetic nerve, the pharyngeal arid laryngeal nerves, which cross behind it, and, near the carotid foramen, with the glosso- pharyngeal, pneumogastric, and lingual nerves, and partially with the internal jugular vein. Operation.—The internal carotid artery may he ligatured through the inci- sions just directed for tying the external carotid; the latter vessel being drawn forward, and the internal jugular vein being drawn backward, the point of the needle is cautiously insinuated underneath the artery from with- out inward, its movements being directed by the index finger of the free hand, and extreme care being taken that no structure besides the artery is em- braced within the ligature. Or, make an incision along the inner edge of the sterno-mastoid, three inches in length, from the angle of the jaw to the cricoid cartilage, through the skin, platysma, superficial and deep fasciae ; the inner border of the ster- no-mastoid muscle now appears; cautiously separate the connective tissue, draw the sides of the wound apart, and the artery is exposed ; draw the di- gastric muscle and hypoglossal nerve upward, and the internal jugular vein outward; the external and internal carotid arteries may now be ligatured both together, or either of them separately (Fig. 478). In 1851, Keith, of Aberdeen, Scotland, tied the internal carotid with one ligature, on Hunter’s plan. In July, 1869, Hr. A. T. Lee, of Kingston, Tenn., successfully secured the internal carotid artery by two ligatures, one being applied on each side of an aperture in its walls made by a stab-wound of the neck. This case has already been mentioned in the section on punctured wounds of arteries. In February, 1871, Hr. W. T. Briggs, of Kashville, Tenn., tied the internal carotid above and below with success.1 In 1874,2 a case was recorded by Hr. II. B. Sands, of New York, in which he successfully ligatured the internal carotid artery above and below the bleeding point, for secondary hemorrhage occurring ten days after an opera- tion for the removal of the lower jaw, performed in October, 1872. Ligation of the Superior Thyroid Artery.—This vessel is the first branch of the external carotid, and issues from it one-fourth of an inch below the great cornu of the hyoid bone. It curves downward and inward to the thyroid gland, in a tortuous course. At first, it is superficial, lying in the triangle formed by the sterno-mastoid, digastric, and omo-hyoid muscles. Before entering the thyroid gland, it divides into several branches which pass beneath the omo-hyoid, sterno-hyoid, and sterno-thyroid muscles. Operation.—Place the patient’s head in an extended position. Make an incision two inches in length along the inner border of the sterno-mastoid, the centre of which corresponds to the great cornu of the thyroid cartilage. Having divided the skin, superficial fascia, platysma myoides, and deep fascia, draw the sterno-mastoid outward and expose the omo-hyoid muscle, the internal jugular vein, and the common carotid artery. Then search with the director, or with the handle of a scalpel, for the superior thyroid artery, in the deep sulcus between the upper end of the larynx and the great vessels of the neck, where it is easily found and readily ligated. The needle should be passed from above downward. Ligation of the Lingual Artery.—Surgical Anatomy.—This artery is the second branch which issues from the front of the external carotid. It 1 American Journal of the Medical Sciences, January, 1879, pp. 142, 143. * New York Medical Journal, Jan-uary, 1874. DELIGATION OF ARTERIES. 745 .-arises about one-fourth of an inch above the superior thyroid, almost facing the great cornu of the hyoid bone. It ascends obliquely above the level of the latter, then curves abruptly downward and inward, and, passing under- neath the outer margin of the hyoglossus muscle, runs parallel with and near to the great cornu of the os hyoides; finally, ascending to the under surface of the tongue, it runs forward in a serpentine course to the tip, under the name of the ranine artery, and terminates by inosculating with its fellow of the opposite side. The hyoglossus muscle, underneath which the lingual artery passes, sepa- rates it into three portions or surgical divisions, the first being posterior to that muscle, the beneath it, and the third anterior to it—that is, ex- tending from the anterior margin of the hyoglossus to the tip of the tongue. All its branches, the hyoid, the dorsalis linguse, and the sublingual, are given off in the second part of its course. The second part or division of the artery, that is, the portion under the hyoglossus muscle, is the part which has uni- formly been chosen for deligation. It is covered by the skin, superficial fascia, platysma myoides, deep fascia, the inferior border of the submaxillary gland, a second fold of the deep fascia which extends beneath the gland and completes its capsule, the facial, superficial lingual, and pharyngeal veins, the stylo-hyoid and digastric mus- -cles, the hypoglossal nerve, and the hyoglossus muscle. It rests upon the middle constrictor of the pharynx, and runs along about one line above and parallel to the great cornu of the hyoid bone. To expose this portion (that is, the second) of the lingual artery, there are three important guides, namely, the glistening pulley of the digastric tendon, the great cornu of the os hy- oides, and the hypoglossal nerve; the first two lie immediately below and in front of the artery, the last, immediately above and in front of it, and all three are separated from it by the hyoglossus muscle. Operation.—Place the patient on his back, with his head turned a little to the opposite side and well extended, so as to amplify the space between the hyoid bone and the base of the jaw. Ascertain the position of the great oornu of the os hyoides ; then begin the tegumentary incision at the anterior border of the sterno-mastoid muscle, half an inch above a point opposite to the extremity of the great cornu of the hyoid, and, continuing it forward and somewhat downward so as to give it a slight curve with the convexity below, terminate it three-fourths of an inch short of the median line, and half an inch below the base of the jaw (Fig. 479). The head must be rigidly main- tained in the same position throughout the operation. Any material change of position, especially flexion, will alter every detail of the procedure. The incisions should all be made in a forward direction, that is, away from the great bloodvessels of the neck, which lie near the posterior end of the wound. The skin, platysma myoides, and the connective and adipose tissue being divided, the first layer of the deep fascia, or the anterior part of the capsule of the submaxillary gland, will appear. Divide it on a grooved director, and the gland will be exposed. With a finger, or the handle of a scalpel, detach the gland from its deep connections, and draw it upward over the jaw with a blunt hook, taking great care that the facial artery and vein, which pass through its substance, are not injured. Divide the portion of the deep fascia constituting the posterior part of the capsule of the gland, and the white shining aponeurosis which loops the digastric tendon to the great cornu of the os "hyoides will be exposed, and, likewise, the insertion of the stylo-hyoid muscle. Immediately below them the hypoglossal nerve, accompanied by the lingual vein, will appear, three lines above the cornu of the hyoid, and run- ning across the hyoglossus muscle, forward and upward, toward the middle £>f the jaw. Detach the nerve somewhat from the hyoglossus muscle by 746 injuries of bloodvessels. scratching through the connective tissue which surrounds it, and push it upward out of the way. Fix the os hyoides by inserting a tenaculum into the digastric aponeurosis, then carefully insinuate the point of a director underneath the posterior margin of the hyoglossus muscle, and gently push Fig. 479. Ligation of the lingual artery. (S6dillot.) it along close to the upper border of the great cornu of the hyoid hone, so as- to separate the hyoglossus from the middle constrictor of the pharynx which lies behind. Now divide the fibres of the hyoglossus muscle on the director, and the lingual artery accompanied by a vein will be brought into view. Pass the needle from above downward in order to avoid the hypoglossal nerve. Occasionally a few fibres of the stylo-hyoid muscle must also be divided. Some surgeons gradually uncover this artery from before back- wards, by raising the fibres of the hyoglossus with a forceps, and incising them with a knife. But at every step of the operation, after opening the superficial fascia, the operator should shape his course by feeling for the "great cornu of the os hyoides with a finger in the wound. Esmarch’s Operation.—(1) The cutaneous incision is 4 centimetres (about If inches) in length, along the upper border of the great cornu of the hyoid bone. (2) The platysma is divided ; the posterior facial vein is drawn out- ward. (3) The posterior belly of the digastric muscle is exposed ; behind and below it, appears the hypoglossal nerve; the submaxillary gland is drawn upward. (4) The hypoglossal nerve runs in front over the hyoglossus mus- cle, accompanied by the lingual vein; below the nerve and behind the hyo- glossus muscle passes the lingual artery. (5) Between the hypoglossal nerve and the great cornu of the hyoid bone the fibres of the hyoglossus are cau- tiously divided; immediately beneath this muscle lies the lingual artery, accompanied by a vein. . . Ligation of the lingual artery is one of the most difficult of all ligations; and, therefore, I have very attentively considered it. Esmarch lays down the steps with clearness and brevity. From the great freedom of inosculation,, which exists between the two lingual arteries, it is often necessary to tie both of them to suppress hemorrhage from wounds of the tongue. Ligation of the Facial Artery.—Surgical Anatomy.—The facial artery is the third branch which issues from the front of the external carotid. It 747 DELIGATION OF ARTERIES. arises a little above the great cornu of the os hyoides, and passes obliquely to the submaxillary gland, in which it lies embedded. It then curves over the body of the lower jaw, close to the anterior inferior angle of the masseter muscle, ascends to the angle of the mouth, and thence to the inner canthus of the eye, where it is named the angular artery. Over the buccinator muscle its course is tortuous to accommodate itself to the movements of the jaw. Below the jaw, it passes under the digastric and stylo-hyoid muscles; on the body of the jaw it is covered by the skin, superficial fascia, and platysma myoides, and lies on the periosteum in a groove which is found at the junc- tion of the posterior third with the anterior two-thirds of the body of the bone. The facial vein runs on its outer side. The groove just mentioned is the point usually selected for the deligation of the artery. Operation.—Having recognized the pulsations of the artery, make an in- cision one inch in length, along its course over the body of the lower jaw, as just described (Fig. 480), through the skin, superficial fascia, and platysma Fig. 480. Ligation of the facial and temporal arteries. (Sedillot.) myoides; separate the lips of the incision, and detach the connective tissue from the artery, which is thus exposed ; draw the facial vein and masseter muscle outward, and pass the needle between the two vessels. Ligation of the Temporal Artery.—This artery is the more superficial of the two terminal branches of the external carotid. It commences in the substance of the parotid gland, opposite the meatus auditorius externus, ascends almost longitudinally over the root of the zygoma, and, at one inch and a half or two inches above the zygomatic arch, divides into the anterior and posterior temporal branches. Operation.—Having-determined the position of the artery by its pulsations, make an incision through the skin, one inch in length, at a point above the zygoma and in front of the ear, then divide the dense connective tissue on a director, and the artery will be exposed. Pass the needle from behind forward, in order to avoid the temporal vein and the auriculo-temporal nerve (Fig. 480). Ligation op the Occipital Artery.—The occipital artery arises from the external carotid, opposite the facial, passes backward beneath the posterior belly of the digastric, stylo-hyoid, trachelo-mastoid, and sterno-mastoid 748 INJURIES OF BLOODVESSELS. muscles, to the occipital groove in the mastoid portion of the temporal bone. It then ascends between the splenius and complexus muscles, and divides into two branches, which are distri- buted upon the occiput. The hypo- glossal nerve curves around this artery near its origin, from behind forward. Operation.—To tie the artery near its origin, make an incision along the inner border of the sterno-mastoid muscle, two inches in length, and at the angle formed by this muscle and the digastric. Having carefully di- vided the deep fascia, expose and iso- late the artery, carefully protecting the hypoglossal nerve. To tie the artery behind the mastoid process, make an incision two inches long, half an inch behind and a little beneath the mastoid process, obliquely upward and backward (Fig. 481). Divide the skin and aponeurosis of the sterno-mastoid muscle, likewise the splenius muscle, to the limits of the wound. The pulsations of the artery are recognized by the finger. It should then be separated from the occipital vein and tied. If the artery be denuded near the mastoid process, much care must be used not to damage the large mastoid tributaries which hereabout enter the occi- pital vein, and establish a communication between it and the lateral sinus of the dura mater. Fig. 481. Ligation of the occipital artery. (Sedillot.) Ligation of the Vertebral Artery.—Surgical Anatomy. — This vessel is the first and largest of the branches of the subclavian artery. It ascends through the foramina in the transverse processes of all the cervical vertebra?, excepting the last; then winds backward around the articulating process of the atlas ; and, piercing the dura mater, enters the skull through the foramen magnum. The two vertebral arteries unite at the lower border of the pons Varolii to form the basilar artery. Each vertebral artery, with the vertebral vein, lies in front of the cervical nerves in the foramina of the transverse processes of the six upper cervical vertebrae. Before entering the so-called vertebral canal in the transverse processes just mentioned, the artery passes behind the internal jugular vein and the inferior thyroid artery, to the trans- verse process of the sixth cervical vertebra, ascending between the scalenus anticus and longus colli muscles, in a line drawn from the posterior part of the mastoid process to the junction of the inner fourth of the clavicle with the outer three-fourtlis of the same. Operation.—Place the patient on his back, with his shoulders depressed and his face turned to the opposite side, and make incisions like those employed in Mott’s operation for tying the innominate, that is, make one cut through the skin, superficial fascia, and platysma myoides, or 3 inches in length, along the anterior border of the sterno-mastoid muscle, and terminating half an inch above the sternum, and another cut of the same depth and length above the clavicle, parallel therewith and half an inch therefrom, to meet the termina- tion of the first cut. Carefully raise and divide the sternal root, together with the anterior part of the clavicular root, of the sterno-cleido-mastoid muscle. Reflect the angular flap, so as to bring into view the common sheath of the DELIGATION OF ARTERIES. 749 primitive carotid artery, tlie internal jugular vein, and the pneumogastric- nerve. Separate with a linger the cellular connection of the common sheath to the sterno-thyroid muscle, and finally to the longus colli. The head is. now to be raised, though still turned to the opposite side, and the common sheath, etc., drawn outward, the sterno-thyroid muscle, etc., being drawn inward, by retractors ; separate the connective tissue at the bottom of the wound, and expose the aponeurosis which passes from the scalenus anticus to- the longus colli, and the anterior part of the transverse process of the sixth cervical vertebra, that is, “ the carotid tubercle of Chassaignac.” Then cau- tiously open the aponeurosis an inch below this point, and the artery is found- lying very deep. Pass the needle from without inward. Take especial care to avoid injuring the phrenic and the sympathetic nerves; the “ thyroid ganglion” of the latter, and its communicating branches being considerably exposed. Should difficulty be experienced in finding the artery, a finger must be inserted to the bottom of the wound, and search made with it for the- “ carotid tubercle of Chassaignac,” at the extremity of the transverse process of the sixth cervical vertebra, below which the pulsations of the artery may be felt. From the peculiarity of termination of the vertebral artery, above men- tioned, the blood may flow backward, or regurgitate, in it, with almost the same freedom, as it flows forward, or toward the brain ; wherefore, this artery,, when wounded before it reaches the carotid tubercle, must always be ligatured at the injured part, and with a distal, as well as a proximal, thread, the ex- posure of the vessel being made by cautiously dilating the original wound. But, in cases of subclavian aneurism, deligation of this artery in its con- tinuity is not unfrequently necessary because of the great freedom, just men- tioned, with which the blood regurgitates in it when the innominate- is tied,, or the subclavian on the cardiac side of its origin. Thus, Dr. Smyth, in the only successful case of ligation of the innominate, was. compelled to tie the vertebral artery as well as the common carotid. Professor Willard of Yew York, has tied this artery simultaneously with the common carotid and the subclavian arteries, in a case of subclavian aneurism. Maisonneuve ligatured the vertebral and inferior thyroid arteries for hemorrhage from a shot-wound of the neck, and extracted the missile; the bleeding ceased, but death ensued from purulent infiltration of the spinal canal. Two additional cases in which this artery was ligated have been reported by an Italian surgeon. Distal ligature of the vertebral artery between the atlas and the axis, as well as between the occipital bone and the atlas, as suggested by Dietrich,, would be both difficult in performance and uncertain in result. Ligation of the Inferior Thyroid Artery.—This vessel arises from the- thyroid axis, and ascends obliquely, in a tortuous course, behind the common sheath of the primitive carotid artery, the internal jugular vein, and the- pneumogastric nerve, to the inferior part of the thyroid gland, to which it is distributed. It is in relation with the middle cervical ganglion of the sym- pathetic, the “ thyroid ganglion” of Haller, and the communicating branches- thereof; they lie in front of it. Operation.—Proceed as for ligation of the primitive carotid artery between the two heads of the sterno-cleido-mastoid muscle (Pig. 416), until the com- mon sheath of the carotid, the internal jugular vein, and the pneumogastric nerve, are brought into view. Then draw the common sheath of these vessels, etc., outward, that is, away from the thyroid gland, and search, just below that body, with a finger in the deep fissure between the common sheath of the great vessels and the oesophagus, for the artery as it ascends behind the* 750 INJURIES of bloodvessels. common sheath, obliquely inward, where it should be tied. Pains should be taken to avoid injuring the middle cervical ganglion of the sympathetic, and its communicating branches. The needle should be passed from without inward. Deligation of both inferior thyroid arteries has been performed a number of times for vascular enlargements of the thyroid gland, but the results have not been of such a character as to warrant a repetition. However, for hemorrhages from wounds of the neck, as in Maisonneuve’s case mentioned above, in which the vertebral was also tied, the operation must be resorted to whenever it appears expedient. Ligation of the Internal Mammary Artery.—The internal mammary artery is the first branch which issues from the lower side of the subclavian artery. It runs directly downward behind the clavicle, on the posterior sur- face of the costal cartilages, and near the edge of the sternum, until it reaches the sixth intercostal space; there it divides into the musculo-phrenic and superior epigastric arteries. It is accompanied by two veins. The in- ternal mammary artery is crossed in the first part of its course by the internal jugular and subclavian veins, and by the phrenic nerve; in the chest, it lies at first on the costal cartilages and intercostal muscles, and is covered by the pleura behind, but lower it is covered also by the triangularis sterni muscle. Ligation of the external mammary is esteemed easy of performance in the first three intercostal spaces, difficult in the fourth, very difficult in the fifth, and almost impossible in the sixth. Goyrand’s Operation.—An incision two inches in length is to be made near the edge of the sternum obliquely from above downward and from without inward, forming with the axis of the body an angle of forty-five degrees. The middle part of this incision should be three or four lines distant from the margin of the sternum, and in the centre of the sternal extremity of the intercostal space. Dividing successively the skin, the cellulo-adipose subcu- taneous tissue, and the great pectoral muscle, the intercostal space is exposed. An incision is then to be made in the same direction and over the entire width of the space of the aponeurotic layer which continues the external intercostal muscle and the superficial fasciculi of the internal intercostal. With a grooved director the fibres of the latter muscle are to be separated and torn through, and the artery and its two vense comites are then laid bare at three lines from the edge of the sternum, separating those fibres from the pleura. Then nothing is easier than to isolate the artery, and pass the needle beneath it. Goyrand’s operation is recommended by Guthrie, and I have no doubt that it constitutes the best method of ligating the internal mammary artery in its continuity. When, however, traumatic hemorrhage occurs from this artery, it should always be secured at the place of injury by a distal ligature as well as by a proximal ligature; and when the arterial lesion is situated in the fourth, fifth, or sixth intercostal spaces, it will often be advisable to cut out one of the costal cartilages with bone-forceps, either wholly or in part, in order to obtain room for passing a distal and proximal ligature. During the late civil war, the internal mammary artery was tied for secondary hemorrhage by Judson and by Bontecou, but in neither instance was the operation successful. Ligation of the Subclavian Artery.—Surgical Anatomy.—On the right side, the subclavian artery issues from the innominate artery; on the left, from the arch of the aorta. The right is, therefore, shorter than the left, DELIGATION OF ARTERIES. 751 and lies nearer to the anterior wall of the chest; it is also somewhat larger, that is, greater in circumference, because it is a branch of a branch, instead of being a direct offshoot from the main trunk. The course of each subclavian artery is divisible, for surgical as well as for anatomical purposes, into three parts marked by the scalenus anticus muscle behind which the vessel passes, namely, the first part, extending from its origin to the inner margin of the scalenus anticus, the second, part, lying directly behind the scalenus anticus, and the third part, extending from the outer border of the scalenus anticus to the inferior margin of the first rib. On the right side, the first part ascends obliquely outward to the inner border Fig. 482. Surgical relations ot the subclavian artery and subclavian vein. (S6dillot.) A portion of the clavicle has been removed. ■of tlie scalenus anticus; on the left side, it ascends longitudinally to the inner border of that muscle. On both sides, the second part curves outward behind the scalenus anticus. On both sides also, the third part passes down- ward and outward beneath the clavicle, to the inferior margin of the first rib, where it becomes the axillary artery. Relations.—On the right side, the first part is in relation, in front, with the internal jugular and subclavian veins at their point of junction, and is crossed by the pneumogastric nerve, cardiac nerves, and phrenic nerve. Behind and beneath, it is invested by the pleura; it is also crossed by the right recurrent laryngeal nerve, and by the vertebral vein, and is in relation with the trans- verse process of the seventh cervical vertebra. On the left side, the first part is in relation in front with the pleura, the vena innominata, the pneumogastric and phrenic nerves (they run parallel to it), and the left carotid artery. To its inner side lies the oesophagus ; to its outer side, the pleura; and, behind, the thoracic duct, longus colli, and vertebral column. The second part, on both sides alike, lies between the two scaleni muscles, •and is supported by the first rib. The scalenus anticus separates the artery from the subclavian vein and the phrenic nerve. Behind, it is in relation with the brachial plexus of nerves. The third part, on both sides alike also, is in relation, in front, with the subclavian vein and subclavian muscle; behind, with the brachial plexus of nerves and scalenus posticus muscle ; above, with the supra-scapular artery and platysma myoides; and below, with the first rib. 752 INJURIES OF BLOODVESSELS. Operation at the First Part.—To tie the right subclavian on the tracheal side of; the scaleni, place the patient on his hack, with his shoulders raised and his head turned to the opposite side. Make two incisions, one parallel to the inner por- tion of the clavicle, and the other along the inner border of the sterno-cleido- mastoid muscle, each three inches in length, and joining at an acute angle. Pass a director behind the sternal attachment of the sterno-cleido-mastoid, and divide it as well as the connective tissue; avoid small arteries and veins in this place, especially the anterior jugular vein. Divide, likewise, the sterno-hyoid and sterno-thyroid muscles on a director. Open the deep cervi- cal fascia by scratching it with a finger nail or end of the director, and expose the internal jugular vein, which being pressed aside (inward), pass the needle around the artery from below upward to avoid the pleura. To tie the left subclavian on the tracheal side of the scaleni, place the patient in a position corresponding to that above described. Make an incision three and one-half inches long, through the skin and platysma myoides, on the inner edge of the- sterno-cleido-mastoid muscle, terminating at the sternum ; this is to be met by another incision along the sternal part of the clavicle, two and one-half inches- in length. Divide the sternal and half of the clavicular origin of the sterno- cleido-mastoid muscle on a director, and raise the angular flap. Penetrate- the deep fascia with the handle of the scalpel and the fingers. Continue the- dissection along the outer side of the internal jugular vein to the inner edge of the scalenus anticus muscle, half an inch above the first rib, to avoid the thoracic duct. The phrenic nerve must be recognized and avoided; and the fingers pressed to the bottom of the wound will discover the rib, and then the artery. Pass the needle from below upward. (J. Kearney Rodgers.) Operation at the Second Part.—The portion of the artery embraced between the scaleni muscles is very short. It is covered by the skin, the platysma myoides, the sterno-cleido-mastoid muscle, and the scalenus anticus, upon which rests the phrenic nerve ; below, lies the pleura; and above, the brachial plexus of nerves. Lay bare the deep cervical fascia by an incision three and one-half inches in length, parallel to and half an inch above the clavicle, com- mencing at the inner edge of the trapezius muscle. Penetrate this fascia by tearing it with the handle of the scalpel and with the fingers. Divide the outer part of the clavicular origin of the sterno-cleido-mastoid muscle. Find the tubercle of the first rib, and the insertion into it of the scalenus anticus. Bring into view the phrenic nerve as it passes over this muscle, in order to avoid it. Begin at the outer edge of the muscle, some distance from the rib, and cautiously divide its fibres from before backward, and from without inward ; the retraction of the severed fibres will expose the artery. The por- tion of the muscle upon which rests the phrenic nerve must not be disturbed. If the muscle be incised too near the rib, the internal mammary artery may be wounded. Pass the needle from without inward. Operation at the Third Part, or the Point of Election.—To tie the subclavian artery external to the scaleni muscles, place the patient on his back with the shoulders moderately raised, the head extended, the face turned somewhat to the opposite side, and the arm drawn downward. Make an incision through the skin, two and one-half or three inches in length, about half an inch above and parallel to the clavicle, from the anterior border of the trapezius to the posterior border of the sterno-cleido-mastoid muscle. Divide the platysma, with the superficial fascia, and the border of the sterno-cleido-mastoid muscle will be exposed; the external jugular vein must not be injured. With the fingers and the handle of the scalpel divide the connective and adipose tissue. The omo-hyoid muscle and supra-scapular artery are to be drawn upward. Continue the dissection, by means of the fingers and the handle of the scalpel only, through the adipose and connective tissue with its veins, to the scalenus Leligation of arteries. 753 anticus muscle, tlie outer edge of which can be distinctly felt extending upward from the tubercle of the first rib; behind and just external to the outer edge of this muscle, the pulsations of the artery can be felt. The inner border of the brachial plexus of nerves now appears, and is to be drawn upward and outward. Between the scalenus anticus and the brachial plexus, but somewhat deeper than the latter, lies the artery. Divide the deep layer of the cervical fascia with the fingers and the handle of the scalpel, or the point of the director, and the artery then comes into view. The subclavian vein lies in front of and below the tendon of the scalenus anticus, and close to the clavicle. Open the sheath of the artery by tearing it with the finger nail, and gently insinuate the point of the needle, from before backward and slightly from within outward, keeping it close to the artery. Also guide the point of the needle by the end of the finger, and prevent it, when emerg- ing on the opposite side, from including a branch of the brachial plexus. Injury of the external jugular vein (at the outer border of the sterno-cleido- mastoid), of the supra-scapular artery (above the clavicle), and of the phrenic nerve (running downward upon the scalenus anticus), must be avoided. Sometimes the clavicular portion of. the sterno-cleido-mastoid muscle has an unusually broad attachment to the clavicle, as has also the trapezius, in which case the clavicular attachment of the former must likewise be divided until sufficient room is obtained. Sometimes, too, the external jugular vein enters the supra-clavicular fossa at such a point that it cannot be drawn into either angle of the incision, in which case it must be tied with two ligatures and divided between them. The cutaneous incision directed above is substantially that recommended by Hodgson (Fig. 483). Roux, however, advised a longitudinal incision, the Fig. 483. Hodgson’s operation for tying the snbclavian artery external to the scalenus anticus. (S6dil'lot.) lower end of which should rest on the clavicle; Marjolin advocated an inci- sion shaped like an inverted X; and Physick preferred one fashioned like the letter V- But, as Sedillot justly observes, the procedure of Hodgson is the simplest and the best, and ought to be generally adopted. It has been sanc- tioned by Lisfranc, Sanson, Velpeau, Sedillot, etc., in France, and, I believe, is generally preferred by the surgeons of Great Britain and America. I also know from experience that the artery can be exposed with great facility by this method. But the ease and celerity with which the operation is performed will very much depend upon keeping the surface of the dissection unstained with blood, which can be done, as I likewise know from experience, by not using the cutting edge of the knife at all, in ordinary cases, after dividing the 754 injuries of bloodvessels. platysma myoides, the dissection being prosecuted with the fingers, etc., in the manner above described, and the landmarks of the operation being con- stantly kept in view or felt for: these are the omo-liyoid muscle and the brachial plexus of nerves, above; the first rib, below; the tense, sharp, outer edge of the scalenus antieus, together with the tubercle of the first rib, inter- nally; and the pulsations of the artery itself just behind and external to the outer edge of the scalenus antieus muscle. The operation of ligating the subclavian artery on the outer side of the scaleni muscles was attempted, for the first time, in 1809, by Sir Astley Cooper. In the same year a ligature was passed around the artery for axillary aneurism, by Ramsden,at St. Bartholomew’s Hospital,and the patient survived five days. Between that date and 1816, the operation was repeated by Sir William Bliz- zard, by Thomas Blizard, and by Dr. Codes, but all three of the patients died. The first successful deligation of the subclavian artery was performed, in 1817, by Dr. Wright Post, of New York; and in 1820, Liston obtained an equally happy result from the same operation. The operation of tying the subclavian on the tracheal side of the scaleni was performed, for the first time, in 1818, by Dr. Colies, and with a fatal result. Including Banks’s case, it has been practised twenty times, death following in every instance. Five of these operations have been performed in America: by J. Kearney Rodgers, in 1845 ; by Valentine Mott, in 1851 j by Willard Parker, in 1863; and by S. C. Ayres and C. II. Bullen, in 1864. The two last-mentioned cases occurred during the late civil war. The operation of ligating the subclavian artery between the scaleni muscles, that is, in the second part of its course, was likewise twice performed during the late civil war, namely, by Surg. J. II. Grove, U. S. Vols., at Rome, Ga., in 1864; and by Surg. B. B. Breed, U. S. Vols., at Nashville, Tenn., in 1865. Both operations were unsuccessful.1 Ligation of the Axillary Artery.—Surgical Anatomy.—The axillary artery gently curves outward and somewhat downward, through the middle of the axillary space, from the inferior margin of the first rib to the inferior border of the latissimus dorsi muscle, where it becomes the brachial artery. (Figs. 482, 484.) It is crossed by the pectoralis minor muscle, which divides its course into three unequal parts, namely : (1) the part internal to or above the pectoralis minor; (2) the part behind or covered by that muscle; and (3) the part external to or below it (Fig. 482). Relations.—Having emerged underneath the costo-coracoid membrane, the artery is in immediate relation with the axillary vein, which lies at first to the inner side, and then in front of it. Near the middle of the axilla, the artery is embraced by the two heads of the median nerve, and is crossed in front by the pectoralis minor muscle. Internally, that is, on the thoracic side, it is in relation above with the first intercostal muscle ; it next rests upon the first serration of the serratus magnus; and below, it is separated from the chest by the brachial plexus of nerves. Externally, that is, on the humeral side, it is separated at first from the brachial plexus by a triangular cellular interval; it next rests against the tendon of the subscapularis muscle; and, finally, is in contact with the coraco-brachialis muscle. Seven important branches issue from it. Rogdson’s Operation. (Fig. 485.)—The patient having been placed on his back, the operator makes a semilunar incision through the integuments, just below the clavicle, three or four inches in length, commencing about 1 Medical and Surgical History, etc., First Surgical Volume, pp. 546, 547. deligation: of arteries. 755 Fig. 484. Surgical anatomy of the axillary region (Sedillot.) an inch from the sternal end of the clavicle, and terminating near the anterior margin of the deltoid muscle’s attachment to that bone, taking care not to cut the cephalic vein. The tibres of the pectoralis major are to be divided in the same direction and to the same extent. The semilunar flap thus formed is then raised, when the pectoralis mi- nor will be seen crossing the inferior part of the wound. The pulsa- tions of the artery can be distinctly felt between the superior margin ot this muscle and the clavicle. The axillary vein lies below the artery, but if swollen it may overlap it. One trunk of the brachial plexus of nerves lies above, and in contact with the artery, but the other trunks thereof run behind it. The artery is isolated by scratching with the finger nail, and passing the needle under it from before backward, and slightly from within outward, avoiding the vein. The point of the needle is guided with the point of the index finger, as it emerges, and is thus kept from taking up any branch of the brachial plexus of nerves. Chamberlaine’s Operation.—Make a transverse incision, three inches in length, through the skin and platysma, along and upon the lower edge of the clavicle, commencing three fingers’ breadth from the sternal end of that bone, and ending about an inch from the acromion process of the scapula. Make a second incision, three inches in length, obliquely through the integuments, over the deltoid and pectoral muscles, meeting the first nearly in the centre. Remove the cellular membrane and fat. Detach the clavicular portion of the Fig. 485. Hodgson’s operation for tying the axillary artery immedi- ately under the clavicle. (S6dillot.) 756 IXJUKIES OF BLOODVESSELS. pectoralis major, and remove the cellular tissue overlying the axillary vessels. The artery is now brought into view, and its pulsations make it clearly dis- tinguishable from the contiguous parts. The pectoralis minor and the margin of the deltoid are also brought into view (Fig. 486). Separate the artery from the axillary vein lying in front, and from the brachial plexus of nerves behind. Cautiously pass a ligature with the improved American or with Mott’s artery needle, keeping the point of the instrument close to the artery so as not to embrace any other part. The cephalic vein must not be injured by the incisions. Fig. 486. Fig. 487. Chamberlaine’s operation for tying the axillary artery, (sedillot.) Belpech’s operation for tying the axillary artery. (Sedillot.) Delpech’s Operation.—Make a slightly oblique incision downward from the junction of the outer third with the inner third of the clavicle, along the interstice between the pectoralis major and deltoid muscles (Fig. 487). Strongly separate or retract these muscles, and divide the pectoralis minor on a grooved director. Then introduce the left index finger to the bottom of the wound, and, bending it like a hook under the mass of vessels and nerves, draw them outward. Tie the artery at the point where it is embraced between the two heads of the median nerve, carefully avoiding the axillary vein, which lies below and internally, and the trunks of the brachial plexus of nerves, which are found above and external to it. This procedure has the serious fault of requiring the nerves and vessels to be pulled or dragged with more or less of violence, and to be isolated by lacerating the cellular tissue which surrounds them. The operations of Hodgson and Chamberlaine are therefore to be preferred. In performing each of these three operations, especially the last, care must be taken that the cephalic vein be not wounded. Operation in the Axillary Hollow or Armpit.—Below the pectoralis minor,, that is, in the third part of its course, the artery is quite superficial, being covered only by the integuments and deep fascia. Place the patient on his back, with the arm extended and rotated outward (Fig. 488). The operator should stand on the outer side, if it be the right arm, and on the inner side if it be the left arm. Having found the inner border of the coraeo-brachialis mus- cle, and the place where the artery pulsates, make an incision two or three inches 757 LKTHOATION of arteries, in length, along the line indicated in the accompanying wood-cut (Fig. 488), divid- ing the skin only. Incise the fascia on a director. Then the axillary vein is to be pushed backward with the end of the director, and next the brachial plexus of nerves. The median nerve is now recog- nized, and, being drawn forward, while the internal cutaneous and ulnar nerves are pushed backward, the artery is ex- posed. Cautiously separate the artery from the vein, which is pushed backward, and the nerves that surround it. Pass the needle from behind forward. The axillary artery was ligatured, for the tirst time, on January 17, 1815, by Mr. R. Chamberlaine, of Kingston, Jamaica, for an aneurism of the left axilla, occasioned by a wound with a cutlass, received October 5, 1814. The operation proved successful. Fig. 488. Ligation of the axillary artery, in the armpit. (Sedillot.) Ligation of the Brachial Artery.—The brachial artery passes down the inner side of the arm, from the lower border of the latissimus dorsi to a point about an inch below the bend at the elbow, where it divides into the radial and ulnar arteries. Its course is indicated by a line drawn from the junction of the anterior and middle thirds of the axilla to the middle of the bend at the elbow. Operation in the Upper Third, of the Arm.—Having placed the patient on his back, with the arm extended ajid rotated outward, make an incision, two inches in length, along the inner border of the coraco-brachialis. The artery is readily exposed. It lies between and behind the median and ulnar nerves, the former to the outer and the latter to the inner side. It has two venae comites. Operation in the Middle Third.—The brachial artery in the middle of the arm descends on the inner side, first of the coraco-brachialis, and afterward of the biceps. It is covered by the integuments and fascia, and is slightly over- lapped by the biceps. The internal cutaneous nerve lies superficial to the artery. The median nerve obliquely crosses it. The ulnar nerve is internal to it. The arm being extended at right angles to the trunk, and held supine, the course of the artery may be ascertained by its pulsations; by the internal margin of the biceps and coraco-brachialis ; by the median nerve; and by the line above described. The steps of the operation are as follows: (1) The cutaneous incision is 4 centimetres (about 1J inches) in length along the inner border of the biceps. (2) The biceps is drawn outward with a retractor. The median nerve is seen lying immediately upon the artery. (3) The median nerve is detached from the sheath and drawn outward by a strabismus hook (Fig. 489); the sheath of the artery is then opened ; it lies between two veins (venfe comites). The arm is now flexed, the artery isolated, and the ligature passed from without inward. Sometimes the brachial artery divides into the ulnar and radial arteries in the upper third of the arm; the radial, in that case, commonly runs more superficially and externally (upon the biceps), while the ulnar appears conspicuously small (Esmarch). Operation at the Elbow.—The brachial artery, at the elbow, lies in the cen- tre of a triangular space, formed externally bv the supinator longus, and in- ternally by the pronator radii teres. (1) The cutaneous incision is made 4 758 INJURIES OF BLOODVESSELS. centimetres (about 1J inches) in length, and 5 millimetres (a fifth of an inch) to the inner side of the tendon of the biceps; carefully, so as not to injure the median vein, which is drawn downward (Fig. 490). The bicipital fascia Fig. 489. Fig. 490. Ligation of the brachial artery in the middle of the arm. (Sedillot.) Ligation of the brachial artery at the elbow. (Sedillot.) is divided. Immediately beneath it is the artery, lying on the brachialis anticus muscle, and between the venae comites. The median nerve lies a few millimetres inward, and passes beneath the pronator radii teres (Esmarch). Ligation of the Radial Artery.—Although the radial artery is smaller than the ulnar, it directly continues the course of the brachial artery, and runs in a line drawn from the middle of the bend at the elbow to the inner side of the styloid process of the radius. It is superficial in nearly all its course. The radial nerve lies on its outer or radial side. It has two venae comites. Operation in the Upper Third.—Having extended the arm in a supine position, and having raised the superficial veins by compressing them above, make an incision through the skin and superficial fascia, two inches in length, along the inner margin of the supinator longus, if this is recognized, or in the line just indicated. Raise the deep fascia on a grooved director, and divide it. Flex the forearm somewhat, to relax the muscles; then, drawing the supinator longus aside, the sheath of the artery is exposed. Pass the needle from with- out inward (Fig. 491). Fig. 491. Ligation of the radial artery in its upper third. (Sedillot.) Operation in the Lower Third.—Here the artery lies very superficial, be- tween the tendons of the supinator longus and flexor carpi radial is, and its pulsations are very distinct. The forearm being supine and the hand forcibly extended, to show the flexor tendon, make a light incision, two inches in length, on the radial side of the flexor carpi radialis tendon. Cautiously DELIGATION OF ARTERIES. 759 raise the deep fascia on a director, and divide it. This brings into view the artery with its venae comites, and the radial nerve lying on its outer or radial side (Fig. 492). The needle may be passed in either direction. Fig. 492. Ligation of the radial artery in its lower third. (S6dillot) Operation on the Dorsum of the Wrist.—Below the styloid process of the radius, the artery runs in the groove between the upper extremities of the first metacarpal bones, and a fibrous band separates it from the tendons of the thumb (Fig. 493). It may be ligatured just before it forms the deep Fig. 493. palmar arch ; or a little below and behind the extremity of the styloid process of the radius, as it passes under the extensor muscles of the thumb, between the extensor primi internodii and the extensor secundi internodii pollicis. To tie the artery at the commencement of the deep palmar arch, make an in- cision, one inch in length, along the ulnar border of the extensor secundi internodii pollicis, at the angle formed by the first two metacarpal bones, taking care not to wound the superficial veins, and the artery is readily exposed. To tie the artery below and behind the styloid process of the radius, place the hand between pronation and supination, the thumb strongly abductedL so as to render its extensors prominent. Then make a light incision, one inch in length, between the tendons of the two extensors, commencing at the lower extremity of the radius, and continued in a line with the axis of the first metacarpal bone. Avoid the superficial vein of the thumb. Draw the ex- tensor ossis metacarpi pollicis outward, and the extensor secundi internodii pollicis inward, thus bringing into view the artery and its accompanying veins (Fig. 493). Ligation of the radial artery on the dorsum of the wrist. (Sedillot.) Ligation of the Ulnar Artery.—The ulnar artery is the larger of the two -terminal branches of the brachial. It crosses the forearm obliquely to the commencement of its middle third; it then descends on the ulnar side of the limb to the wrist, crosses over the annular ligament, and forms the super- ficial palmar arch, which terminates by inosculating with the superficialia 760 INJURIES OF BLOODVESSELS. volse. Its course, in its lower part, is indicated by a line drawn from the inner condyle of the humerus to the external side of the pisiform hone. Operation in the Upper Third.—The forearm should be in a supine position, with the hand strongly extended and inclined to the radial side. (1) The cutaneous incision commences 3 centimetres (about lb inches) below the fold of the elbow, and runs 4 centimetres (about 1| inches) along a line, which, in the supine position, separates the ulnar from the central third of the anterior surface of the forearm (Fig. 494). (2) After dividing the fascia of the forearm, the interval between the bellies of the flexor carpi ulnaris and flexor sublimis digitorum is to be sought for, and enlarged with the tip of the index finger and a blunt hook. (3) At the bottom lies the artery, with its venae comites; on its ulnar side lies the ulnar nerve (Esmarch). Isolate the artery by flexing the forearm slightly, and the hand strongly. Pass the needle from within outward. Operation in the Tower Third.—The ulnar artery, in the lower third, is cov- ered by the deep fascia, and has upon its inner or ulnar side the flexor carpi ulnaris and ulnar nerve, and upon its outer side the flexor sublimis digitorum. Place the forearm supine, and extend the hand so as to make prominent the tendon of the flexor carpi ulnaris. (1) The cutaneous incision is made 3 centimetres (about 1| inches) in length, on the radial side of the tendon of the flexor carpi ulnaris, which is inserted into the pisiform bone (Fig. 495). Fig. 494. Ligation of the ulnar artery at the junc- tion of the upper and middle thirds of the forearm. (Sedillot.) Fig. 495. Ligation of the ulnar artery above the wrist. (Sfedillot.) (2) The superficial layer of the fascia of the forearm is to be cautiously divided; in like manner the deep layer. (3) The artery, accompanied by two veins (venae comites), lies between the tendons of the flexor carpi ulnaris and the innermost tendon of the flexor sub- limis digitorum. On its ulnar side lies the ulnar nerve (Esmarch). Operation below the Os Pisiforme.— At the wrist, the artery runs on the radial side of the pisiform bone. The hand being turned backward, make a slightly curved incision about two inches in length and with concavity looking inward, on the radial side of the pisiform bone, through the skin and adipose tissue. The artery is Fig. 496. Ligation of the ulnar artery below the pisiform bone. (SSdillot.) DELIGATION of arteries. 761 seated deeply in a groove, and the dissection should be continued along the side of the os pisiforme until the vessel is brought into view. The latter part of the dissection will be facilitated by slightly flexing the hand (Fig. 496). Pass the needle under the artery from within outward. Ligation of the Abdominal Aorta.—The abdominal aorta lies in front, and rather to the left side, of the bodies of the vertebrae, having the vena cava ascendens on its right side, the sympathetic nerve on its left, and the left lumbar veins behind. It may be ligatured rabout one inch above its bifurcation at the fourth lumbar vertebra. Cooper's Operation (Fig. 497).—Place the patient ■on his back, with knees drawn up and legs Hexed. Make an incision, three inches in length, along the linea alba, the middle of it being on a level with the umbilicus, but a little to the left thereof, and ■open the peritoneum. Push the intestines aside, find the-artery by its pulsations, and with a finger nail scratch through the peritoneum covering it on the left side. Pass the needle from left to right, taking care not to embrace the sympathetic nerve, and not to injure the vena cava. Murray's Operation.—Murray made an elliptical incision on the left side, six inches in length, from the cartilage of the tenth rib downward, and with its concavity forward, to within an inch of the an- terior superior spinous process of the ilium. The tissues were then carefully divided to the perito- neum, which was raised from the iliac fossa and psoas muscle, when, with great, difficulty, and by scratching with the end of a director as well as with the finger nails, room was made to pass the ligature around the artery, which was tied three or four lines above its bifurcation. The patient died in twenty- three hours. The abdominal aorta was ligatured for the first time in 1817 by Sir Astley Cooper. FText it was ligatured by James, of Exeter, in 1829 ; by Murray, at the Cape of Good Hope, in 1834; by Monteiro, at Rio Janeiro, in 1842; by South, in 1856 ; and since that time by Hunter McGuire, of Richmond (1868), by Stokes, by Watson, and by both Czerny of Vienna and Czerny of Heidelberg, making in all ten operations with ten deaths. The most interesting of these cases was Monteiro’s, in which the aorta was tied for a large false aneurism on the lower and right side of the abdomen. The incisions were made much as in Murray’s case, and the artery was ligatured with great difficulty. The patient died from secondary hemorrhage on the tenth day. Fig. 497. To illustrate Cooper’s method of tying the abdominal aorta. (Se- dillot.) Ligation of the Common Iliac Artery.—Surgical Anatomy.—The com- mon iliac arteries begin at the bifurcation of the abdominal aorta on the left side of the body of the fourth lumbar vertebra, a point directly behind the left side of the umbilicus. They vary in length from three-fourths of an inch to three inches, averaging about two inches (L. Ilolden). They diverge from each other, and run downward and outward on each side to the margin of the pelvis opposite the sacro-iliac synchondrosis, where they in turn each divide into the external and internal iliac arteries. The artery on the right side has on an average the same length as the artery on the left side (L. Ilolden). But the surgical relations of the two arteries are not identical. 762 INJURIES OF BLOODVESSELS. The right common iliac artery is covered in front by the peritoneum, the ileum, and, at its termination, by the ureter. The two common iliac veins pass behind it, and< near its origin, the inferior vena cava and the right common iliac vein lie on its outer side. The left common iliac artery is covered ante- riorly by the peritoneum, the rectum, and the superior hemorrhoidal artery, and, at its termi- nation, by the ureter. The left common iliac vein is on the inner s\de and also behind the artery (Fig. 498). Operation.—Place the patient on his back, but inclining to the opposite side. The course of the vessel can be ascertained by drawing a line from the umbilicus to the middle of Poupart’s liga- ment. Make an incision through the integu- ments and superficial fascia, commencing just anterior to the end of the eleventh rib, downward, one inch and a half within the anterior superior spinous process of the ilium, and terminating just above: the internal abdominal ring by a sharp curve upward and inward (Fig. 499). Fig. 498. Showing the relation of the common, external, and internal iliac arteries to their accompanying veins. (Sedillot.) Fig. 499. Sbowing an operation performed by Surgeon J. Cooper McKee, IT. S. Army, for tying the left Internal and com. mon iliac arteries. From a photograph of the cadaver. The wound of operation was seven inches in length. For an account of the case, see Medical and Surgical History, etc. Second Surgical Volume, p. 334. The entire length of the incision is about seven inches. Next divide the three abdominal muscles, and cautiously separate the fascia transversalis from the peritoneum, beginning at the upper part of the wound where the adhesion is slightest. Now gently raise the peritoneum from the iliac fossa, and press it inward toward the pelvis. Find the external iliac artery by its pulsa- tions, and carry the finger along that vessel, still detaching the peritoneum, until the common trunk is reached. Then the ureter, in front, is carefully pushed aside, and the needle is passed from within outward. There is great danger of tearing the peritoneum while effecting the detacli- 763 deligation of ARTERIES. ment of it from the fascia trailsversalis; and, in order to avoid this accident, the work of separating the fascia transversalis from it should be begun high up in the wound of operation, where the attachments are the weakest. Again, there is great danger of rupturing the peritoneum while separating it from the iliac fossa; and, in order to avoid this accident, the peritoneum, with the intestines inclosed therein, should be cautiously raised up on the palms of an assistant standing on the other side of the patient, while the operator, with his fingers, gently severs the attachments. The common iliac artery was ligatured for the first time in 1812, by Pro- fessor William Gibson, of Philadelphia, for hemorrhage from a gunshot wound ; but the patient died, thirteen days after the operation, from a renewal of the bleeding. This artery was ligatured for aneurism for the first time in 1827, by Dr. Valentine Mott, of Yew York; the patient recovered. The statistics which have been collected show that the common iliac artery has been ligatured about sixty-eight times, with only sixteen recoveries. Ligation of the Internal Iliac Artery.—Surgical Anatomy.—The internal iliac artery issues from the common iliac at the sacro-iliac synchondrosis. It runs downward and forward to the upper margin of the great sacro-sciatic foramen. It usually is about one inch and a half in length. It is in rela- tion, anteriorly, with the ureter, which separates it from the peritoneum; posteriorly, with the internal iliac vein and the lumbo-sacral nerve ; it rests on the sacral plexus of nerves and the pyriformis muscle; on the left side it is overlapped by the rectum. Operation.—The steps of the procedure required to expose the internal iliac artery are identical with those employed to expose the common iliac artery (Fig. 479). The needle should be passed from within outward, keeping its point close to the artery, to avoid injuring the internal iliac vein, which lies behind and to the inner side of it. The internal iliac artery may also be ligatured by making an incision five inches in length, half an inch outside of, and parallel to, the epigastric artery, as was practised by Stevens. Finally, it may be ligatured by making an elliptical incision seven inches in length, commencing two inches to the right or left of the umbilicus, according to the case, and ending near the external abdominal ring, with its convexity toward the ilium (White). The internal iliac artery was ligatured for the first time in 1812, by Stevens, of Santa Cruz ; the opera- tion proved successful. Since his time, the opera- tion has been frequently repeated, the whole num- ber of cases being about twenty-seven, with eight recoveries. Fig. 500. Ligation of the Gluteal Artery. — Surgical Anatomy.—The gluteal artery emerges from the pelvis, through the upper margin of the great sacro- ischiatic foramen, and at the upper border of the pyriformis muscle. It is covered hy the gluteus maximus muscle. It is accompanied by two veins, and by the gluteal nerve. Operation.—A line drawn from the posterior superior spinous process of the ilium to the apex of the trochanter major indicates the course of the artery. Place the patient on his belly, with his thigh extended. Make an incision four or five inches in length, on the line just mentioned, through Ligation of the left gluteal ar- tery. (Follin.) A. Gluteus maxi- mus. B. Gluteal artery. C. Glu- teal veins. 764 INJURIES OF BLOODVESSELS. the skin and subcutaneous adipose tissue (Fig. 500). It will run parallel with the fibres of the gluteus maximus muscle, which should be separated, and a finger introduced, in order to find the artery by its pulsations. Then sepa- rate the pyriformis and gluteus medius muscles, between which it lies, and the borders of which cover it. Isolate the artery from its venae comites, and pass the ligature around it, taking care not to include the gluteal nerve. The gluteal artery was tied in 1808 by Bell,and in 1883 by R. Carmichael; since that time the procedure has been repeated by several others, and may now be considered an established operation. Ligation of the Isciiiatic Artery (Fig. 501).—Surgical Anatomy.—The isehiatic artery escapes from the pelvis through the great sacro-ischiatie foramen, between the pyriformis and coccygeus muscles, and descends in the interval between the trochanter major and the tuberosity of the ischium. It is separated from the gluteal artery by the pyriformis muscle, and is covered by the gluteus maximus. It is accompanied by the isehiatic nerves, and by a vein which lies at its posterior and inner side. Operation.—The centre of a line drawn from the posterior superior spinous process of the ilium to the tuberosity of the ischium, indicates the point where the artery passes out from the pelvic cavity. Place the patient upon his belly. Make a longitudinal incision two inches long, the centre of which corresponds to the point of emergence of the artery, as just described. Divide successively the skin, the cellulo-adipose tissue, and the fibres of the gluteus maximus muscle. The artery is to be found on the inner side of the nerves, and must be carefully separated from the vein. The position of the artery is to be ascertained by inserting a finger into the wound and feeling its pulsations. Fig. 501. Ligation of the ischiatic artery. Ligation of the Internal Pudic Artery (Fig. 502).—Surgical Anatomy.— The internal pudic artery is the smaller of the two terminal branches of the anterior trunk of the in- ternal iliac. It descends in front of the ischiatic -artery to the lower border of the great sacro-ischia- tic foramen. It emerges from the pelvis through the great sacro-ischiatic foramen, below the pyri- form is muscle, crosses the spine of the ischium, and re-enters the pelvis through the lesser sacro-ischiatic foramen; it then crosses the internal obturator muscle to the ramus of the ischium, being situated about an inch from the margin of the tuberosity, and bound down by the obturator fascia; it next ascends the ramus of the ischium, enters between the two layers of the deep perineal fascia, and rises along the ramus of the os pubis. At the sym- physis it pierces the anterior layer of the deep perineal fascia ; and, very much lessened in size, it reaches the dorsum of the penis, along which it runs to supply that organ, under the name of the arteria dorsalis 'penis. Fig. 502. Ligation of the internal pudic artery. 765 Operation.-—(1) The artery may he ligatured on its emergence from the great sacro-ischiatic foramen by making the same incisions as those employed for exposing the iscliiatic artery ; the pudic artery is found a little internal thereto, accompanied by its venre comites and by the internal pudic nerve. (2) The artery may be ligatured, in the perineum, as it ascends the ramus of the ischium and os pubis. Draw a line from the middle of the pubes to the inner border of the tuber iscliii. Place the patient in the position for lithotomy; make an incision two inches in length along the ramus of the pubis, near the arch ; by careful dissection the artery is found running along the inner border of the ramus, where it may be separated from its veme comites and the internal pudic nerve, and where a ligature may be applied. Care must be taken not to wound the corpus cavernosum. DELIGATION OF ARTERIES, Ligation of the Arteria Dorsalis Penis.—This artery attains the dorsum of the penis by ascending between the two crura and the symphysis pubis, and runs forward, through the suspensory ligament, in the groove of the corpus cavernosum to the glans, distributing branches in its course to the body of the organ and to the integuments. It is enveloped in the subcuta- neous fascia; and is accompanied by the dorsalis penis nerve and vein, which structures must not be injured in exposing and ligaturing the artery. Operation.—Make an incision three-fourths of an inch in length, commenc- ing two inches in front of the pubes, and exactly in the median line, through the skin and the superficial lamina of the subcutaneous layer. Thereby the artery is fully exposed. Pass a small artery needle around it, carefully avoid- ing the vein and the nerve which accompany it. Ligation of the External Iliac Artery.—Surgical Anatomy.—The exter- nal iliac artery, on each side, runs obliquely downward along the inner border of the psoas muscle, from a point opposite the sacro-iliac synchondrosis to the femoral arch, where it becomes the femoral artery. In front it is in relation with the spermatic vessels, the peritoneum, and a thin layer of fascia, derived from the iliac fascia, which envelops the artery and the accompanying vein. At its commencement it is crossed by the ureter; and, near its termination, by the crural branch of the genito crural nerve, and the circumflex iliac vein. Posteriorly, it is in relation with the external iliac vein, which gradually passes to its inner side, where it is found at the femoral arch. Externally, it lies against the psoas muscle, from which it is separated by the iliac fascia. Internally, below, passes the vein, as just stated; and, curving along its side,, the vas deferens. It is surrounded throughout its entire course by lymphatic vessels and ganglia. Hear its termination it sends off two branches, the epi- gastric and the circumflex iliac arteries. It is about four inches in length,, and its course corresponds to a line drawn from the left side of the umbilicus to a point midway between the anterior superior spinous process of the ilium and the symphysis pubis. It may be ligatured in any part of its course, ex- cepting at its upper and lower extremities. Abernethy’s Operation.—An incision about three inches in length was made- through the integuments, in the direction of the artery, beginning a little above Poupart’s ligament, and more than half an inch on the outside of the upper part of the abdominal ring, to avoid the epigastric artery. The apon- eurosis of the external oblique muscle being exposed, was next divided in the direction of the external wound. The lower part of the internal oblique muscle was thus uncovered, and the finger being introduced below the infe- rior margin of it and of the transversalis muscle, they were divided with the- crooked bistoury for about one inch and a half. Mr. Abernethy now intro- duced his finger beneath the bag of the peritoneum, and carried it upward 766 INJURIES OF BLOODVESSELS. by the side of the psoas muscle, so as to touch the artery about two inches above Poupart’s ligament. He took care to disturb the peritoneum as little as possible, detaching it to no greater extent than was requisite to admit his two fingers to touch the vessel. The pulsations of the artery made it clearly distinguishable. By means of an eyed probe two ligatures were conveyed under the vessel; one of them was carried upward as far as the artery had been detached, and the other downward; they were firmly tied, and the vessel was divided in the interspace between them.1 Stevens, of Santa Cruz, tied the internal iliac by an operation which was substantially the same as that of Abernethy. Sir Astley Cooper7s Operation.—A semilunar incision is to be made through the integuments in the direction of the fibres of the aponeurosis of the ex- ternal oblique muscle (Fig. 503). One extremity of this incision will be situated near the anterior superior spinous process of the ilium; the other will termi- nate a little above the inner margin of the abdominal ring. The aponeurosis of the external oblique muscle will be exposed, and is to be divided throughout the extent and in the direction of the external wound. The flap which is thus formed being raised, the spermatic cord will be seen passing under the margin of the internal oblique and transverse muscles. The opening in the fascia which lines the transverse muscle, through which the spermatic cord passes, is situated in the mid-space between the anterior superior spinous process of the ilium and the symphysis pubis. The epi- gastric artery runs precisely along the inner margin of this opening, beneath which the external iliac artery is situated. If, there- fore, the finger be passed under the spermatic cord through this opening in the fascia which lines the transverse muscle, it will come into immediate contact with the artery, which here lies on the outside of the external iliac vein. The artery and vein are connected together by dense cellular tissue, which must be separated to enable the operator to pass a ligature, by means of an aneurism needle, between them and around the artery.2 Care must be taken to avoid the epigastric artery, which runs near the inner part of the incision. Dupuytren, while performing this operation at the IIotel-Dieu, in the autumn of 1821, wounded the epigastric artery. The hemorrhage was so copious that two ligatures were required. Death from peritonitis ensued. Appreciation.—Mr. Norman, of Bath, after trying both modes of operating, found that employed by Sir Astley Cooper a more easy way of finding the artery than the longitudinal incision practised by Mr. Abernethy. Samuel Cooper and M. Roux both came to the same conclusion. Mr. Todd, also, after repeated trials of Mr. Abernethy’s and Sir A. Cooper’s methods on the cadaver, concluded that the plan recommended by the latter afforded the greater facility of applying the ligature to the artery, because more room was obtained by it, and with less disturbance of the peritoneum. For these reasons Cooper’s method of ligaturing the external iliac artery, or some slight modification of his method, has almost universally been preferred by sur- Fig. 503. Sir A. Cooper’s operation for tying the external iliac artery. (Sedillot.) * Surgical Observations, 1804. 2 Hodgson, Diseases of Arteries, etc., pp. 421, 422. London, 1815. 767 DELIGATION OF ARTERIES. geons of the past and present generations.1 One of the best of these modifi- cations is very clearly and tersely described as follows:— Esmarch's Operation.—(1) The cutaneous incision, which is 1 centimetre (about | of an inch) above and parallel to Poupart’s ligament, 8 to 10 centimetres (from 3| to 4 inches) in length, and slightly convex, begins 3 centimetres (about 1|- inches) to the inner side of the anterior superior iliac spine, and ends opposite the internal inguinal ring (without exposing the ring or the spermatic cord). (2) The subcutaneous tissue, the thin superficial fascia, the strong tendinous aponeurosis of the external oblique, and the muscular fibres of the internal oblique are divided ; then the horizontal muscular fibres of the transversalis in the outer angle of the wound. (3) The thin subjacent fascia transversalis must be carefully divided. (In fat subjects there is still a thin layer of fat). (4) The peritoneum is carefully pressed toward the umbilicus with the fingers bent like a hook (taking care not to strip up the iliac fascia from the pelvic wall and with it the artery). (5) The artery lies in contact with the inner border of the psoas muscle ; to its inner side is the vein; to the outer side the anterior crural nerve covered by the iliac fascia; the genital branch of the genito-crural nerve crosses the artery obliquely.2 Open the sheath cautiously and insinuate the needle beneath the artery, from within outward, to avoid the vein. The external iliac artery was ligatured for the first time, in 1796, by Mr. Abernethy, for inguinal aneurism, a disorder which previously had always been deemed incurable. lie lost his first two cases, but saved the third and fourth. The operation was first performed in America by Dr. Dorsey, of Philadelphia. During our civil war this artery was ligatured 16 times with only two successes, but this enormous fatality was due not as much to the hazards attending the operation itself, as to the inutility of tying main arterial trunks for shot-lesions of their branches, instead of securing the injured vessels themselves with both proximal and distal ligatures at the seat of the injury; for nearly two-thirds recover when the external iliac artery is ligatured for other causes, 169 recorded cases having given in all but 61 deaths. Ligation of the Epigastric Artery.—The epigastric artery arises from the anterior face of the external iliac three or four lines above Poupart’s ligament. At first it descends; then, passing forward between the peritoneum and the transversalis fascia, it ascends obliquely in a line drawn from the middle of Poupart’s ligament to the umbilicus, to the border of the sheath of the rectus. This sheath it enters near the lower third thereof, passes up- ward behind the rectus muscle, to which it is distributed; and in the sub- stance of that muscle ends by inosculating, near the ensiform cartilage, with the termination of the internal mammary artery. It lies behind the inguinal canal, to the inner side of the internal abdominal ring, and immediately above the femoral ring. It is crossed near its origin by the vas deferens in the male, and by the round ligament in the female. It is accompanied by two veins, almost to its origin. Operation.—Make an incision through the integuments, two and a half or three inches in length, and halt an inch above arid parallel to Poupart’s liga- 1 In one instance, however, where I tied the right external iliac artery for inguinal aneurism in a woman, aged about 30, I uncovered the artery, and brought it fully into view by Liston’s modification of Abernethy’s method, without any difficulty whatever. The wound healed kindly, although the ligature was rather late in coming away ; but, after a time, pulsation unhappily reappeared in the tumor, and a relapse occurred. Stephen Smith, I believe, tied the common iliac in this case afterwards, with a fatal result from secondary hemorrhage. Still, I think Cooper’s operation is to be preferred. 2 Esmarch’s Handbook, p. 155. 768 INJURIES OF BLOODVESSELS. merit, to the middle whereof the middle of the wound should exactly corre- spond ; one or two vessels in the superficial fascia will probably require ligation. Next, the tendinous aponeurosis of the external oblique should be raised and divided on a director, and then the lower border of the internal oblique and transversalis muscles raised, when, on tearing through the fascia transversalis, the artery will be exposed near its origin. In passing the needle around the artery, be careful not to include its vense comites. The circumflex iliac artery may be exposed and tied by the same incisions. After tearing through the transversalis fascia, it will be found running paral- lel with, and close to, Poupart’s ligament. Ligation of the Femoral Artery.— Surgical Anatomy.—The femoral artery descends the inner side of the thigh from the termination of the external iliac behind Poupart’s ligament, at a point mid- way between the anterior superior spinous process of the ilium, and the symphysis pubis, to the opening in the adductor mag- nus, at the junction of the middle with the inferior third of the thigh, where it be- comes the popliteal artery. The femoral artery and vein are inclosed in a strong sheath, the femoral or crural canal, which is formed to a great extent by aponeurotic and areolar tissue, and by a process of fascia, sent inward from the fas- cia lata. Near Poupart’s ligament, this sheath is much larger than the vessels it contains, and is continuous with the fascia transversalis and the iliac fascia. If the sheath be opened at this point, the artery will be seen to be situated in contact with the outer wall of the sheath. The femoral vein lies next the artery, but separated from it by a fibrous septum. Between the vein and the inner wall of the sheath, but sepa- rated from the vein by another thin fibrous sheath, there is a triangular space into which the sac is protruded in femoral her- nia. This space is occupied, in the normal state of the parts, by loose connective tis- sue and by lymphatic vessels, which pierce the inner wall of the sheath, to proceed to a gland situated in the femoral ring. Relations.—The upper third of the femo- ral artery is superficial, being covered oidy by the skin, the inguinal glands, and the superficial and deep fasciae. The lower two- thirds is covered by the sartorius muscle. To its outer side, the artery is first in rela- tion with the psoas and iliacus, and then with the vastus internus. Behind, it rests upon the inner border of the psoas muscle ; it is next separated from the pectineus by the femoral vein, and pro- funda vein and artery, and then lies on the adductor longus as far as its termi- nation. Near the lower border of the adductor longus it enters an aponeu Fig. 504. I'.’iiK Showing the surgical anatomy of the femoral region. (S6dillot.) DELIGATION OF ARTERIES. 769 rotic canal, formed by an arch of tendinous fibres, thrown from the border of the adductor longus and the border of the opening in the adductor magnus, across to the side of the vastus interims. To its inner side, it is in relation at its upper part with the femoral vein, and, lower down, with the peetineus, adductor longus, and sartorius. The immediate relations of the artery are the femoral vein and two saphenous nerves. The vein at Poupart’s ligament lies to the inner side of the artery; but, lower down, it gets altogether behind, and inclines to its outer side. The short saphenous nerve lies at the outer side, and somewhat upon the sheath for the lower two-thirds of its extent. The long saphenous nerve is situated within the sheath, and in front of the artery to the same extent. The course of the femoral artery is indicated by a line drawn from a point midway between the anterior superior spinous process of the ilium, downward and inward to the inner side of the internal condyle of the femur. Operation on the Common Femoral Artery.—(1) The cutaneous incision com- mences at a point midway between the anterior superior spine of the ilium and the symphysis pubis, two millimetres (one line) above Poupart’s ligament, and is carried downward for five centimetres (about two inches). (2) The super- ficial fascia is divided. (3) The subcutaneous tissue is divided; the lymphatic ganglia are avoided by drawing them aside or by removing them. (4) Divi- sion of the fascia lata. (5) The sheath of the vessels is opened one centimetre (about three-eighths of an inch) below Poupart’s ligament, because immedi- ately below this point the superficial epigastric and superficial circumflex iliac arteries are given off* (Fig. 505). (6) The femoral vein lies on the inner side of the artery, and the anterior crural nerve on the outer side (Fsmarch). Pass the needle from within outward. Fig. 506. Ligation of the common femoral artery. (Sedillot.) Ligation of the superficial femoral artery at the apex of Scarpa’s triangle. (Sedillot.) Operation on the Superficial Femoral Artery at the Apex of Scarpa’s Triangle (Fig. 506).—(1) The cutaneous incision, live centimetres (about two inches) in length, at the inner border of the sartorius, commences six finger-breadths (eight to ten centimetres, or from three to four inches) below Poupart’s liga- 770 injuries of bloodvessels. ment. (2) The border of the sartorius is exposed and drawn outward. (3) The sheath is opened. The femoral vein lies to the inner side and somewhat be- hind the artery; the anterior crural nerve is on the outer side (Esmarch). Pass the needle from within outward, keeping its point close to the artery to avoid the femoral vein. Should the saphenous vein be wounded, it must he liga- tured, since the use of pressure to stop the bleeding might interfere with the collateral circulation. Operation on the Superficial Femoral at its Lower Third.—Here the artery enters a fibrous sheath formed by bands which extend from the vastus interims to the adductor magnus and adductor longus, being covered by the sartorius muscle, fas cue, and integuments. Flex the thigh on the pelvis, and the leg on the thigh, and place the limb on its outer side (Fig. 507). (1) The cutane- ous incision, 8-10 centimetres (from 3 to 4 inches) in length, is made over the sartorius, in the middle of a line drawn from the anterior superior spi- nous process of the ilium to the in- ternal condyle of the femur. (2) The sheath of the sartorius is opened, the muscle liberated and drawn outward until the posterior wall of the mus- cular sheath, which covers the canal of Hunter, is exposed. (3) After opening the canal, the artery is brought into view; upon it runs the saphenous nerve, and behind it the femoral vein (Esmarqh). The vessels are united by very dense connective tissue, and much caution must be used in isolating the artery. Fig. 507. Ligation of the femoral artery in the tendinous canal of the adductor muscles. (Sedillot.) Ligation of the Popliteal Artery.—The popliteal artery commences at the opening in the adductor magnus muscle, and passes obliquely downward and outward, through the middle of the popliteal space, to the lower border of the popliteus muscle, where it divides into the anterior and posterior tibial arteries (Fig. 508). Operations.—(1) To ligature the artery in the upper part of its course, make an incision three inches in length, beginning at the inferior third of the thigh, and continuing along the external margin of the semi-membranosus muscle. Divide the skin and fasciae. Separate the connec- tive tissue with the finger and director. Now flex the leg, and first the popliteal nerve appears; next the popliteal vein, to its inner side, and, lastly, the artery itself. Pass the needle from within outward. (2) To ligature the artery in the lower part of its course (Fig. 508), place the patient on his belly with the leg extended. Make an incision through the skin, three inches long, somewhat to the outer side of the median line. The external saphenous nerve which lies under the skin must be avoided. Cautiously divide the fascia, and then the cellulo-adipose tissue between the heads of the gas- trocnemius is to be separated with the finger, so as to expose the popliteal Fig. 508. Ligation of the popliteal artery in the lower part of the popliteal space. (Sedillot.) 771 DELIGATION OF ARTERIES. nerve, tlie popliteal vein, and the artery. The nerve and vein are to be drawn inward, and the needle passed from within outward. (3) To ligature the popliteal artery below the internal condyle of the tibia, semiflex the leg, and lay it upon the outer side. The operator, standing on the external side of the limb, should feel for the internal side of the muscular mass which bounds the popliteal space internally and below. He makes an incision, two and a halt inches in length, from above down- ward, from without inward, and from behind forward, along the edge of the internal head of the gastrocnemius muscle, within half an inch of the in- ternal border of the tibia (Fig. 509), taking care to avoid the internal saphenous vein. He then divides the •crural aponeurosis a little further back than the skin, and introduces a finger to break down the intermuscular septum, the leg being flexed on the thigh to relax the muscles. Fig. 509 represents the nerve as seen at the bottom of the wound, the artery to the inner side, and the accompanying vein drawn outward. Fig. 509. Ligation of the popliteal artery below the inner con* dyie of the tibia. (Sedillot.) Ligation of the Posterior Tibial Artery.—The posterior tibial artery passes obliquely downward along the tibial side of the leg, from the bifurca- tion of the popliteal artery at the lower border of the popliteus muscle to the •concavity of the os calcis, where it divides into the internal and external plantar arteries. Its course is indicated by a line drawn from the centre of the popliteal space to a point just behind the inner malleolus. In the upper third of the leg, the artery lies very deep, being covered by the tibialis posticus, the deep fascia, the soleus, and the gastrocnemius, as well as by the skin and superficial fascia. Operation.—At a distance of two-thirds of an inch from the inner edge of the tibia, make an incision not less than four inches in length, through the integu- ments and deep fascia; with the index finger in the wound, detach and push outward the inner head of the gastrocnemius, and likewise separate the attachments of the soleus, thus exposed, from the-posterior surface of the tibia; next, whilst an assistant draws this mus- cle backward and outward with a blunt hook, divide the deep layer of the crural fascia upon a director, and search for the artery immediately underneath; separate the artery from its venae comites and from the poste- rior tibial nerve, and be careful not to include either ■of them while passing the needle around the artery. In the middle third of the leg, the artery lies more superficial, running parallel to the inner edge of the tibia, from which it is separated by the flexor longus digitorum muscle. It is covered by the internal border of the soleus. It is accompanied by two veins, and the posterior tibial nerve here lies on its inner side. Operation.—Three-fourths of an inch behind the inner edge of the tibia, make an incision parallel Fig. 510. Ligation of the posterior tibial artery at the middle third of the leg. (Sedillot.) 772 injuries of bloodvessels. thereto, three inches in length, through the integuments and deep fascia. The border of the gastrocnemius is to be drawn backward, so as to expose the soleus (Fig. 510). Divide the fibres of the soleus on a director; the artery is now felt pulsating about an inch from the edge of the tibia. [Next, divide the pearl-colored deep aponeurosis which covers it, and then relax the muscles by changing the position of the leg. Separate the artery from its venae comites, and press the nerve to the outer side. Pass the needle from without inward, carefully avoiding the veins and the nerve. In the lower third of the leg, the artery descends behind the inner malleolus, running at first parallel to the tendo Aehillis, and then midway between the inner malleolus and the tuberosity of the os calcis. It is quite superficial, and in relation anteriorly with the tendons of the tibialis posticus and fiexor longus digitorum, and, posteriorly, with the posterior tibia! nerve. On each side of it lies one of the venae comites. Operation.—Having placed the leg on its outer side, and extended the foot,, make an incision two inches in length, a finger’s breadth behind the inner edge of the tibia, and parallel to it, through the skin and superficial fascia. liaise the deep fascia on a grooved director and divide it. Flow, turn aside some adipose tissue, and the artery with its venae comites and the posterior tibial nerve will be brought into view (Fig, 511). The sheaths of tendons must he carefully avoided. It is to be observed that sometimes- the artery lies anterior to the cutaneous incision above directed. At the inner side of the ankle, the artery may be ligatured by making a curved incision one inch and a half in length, midway between the inner malleolus and the tendo Aehillis. Having divided the skin and superficial fascia, the deep- fascia must be raised on a grooved director and freely opened. Immediately underneath should be found the artery, together with the tendons of the tibialis posticus and flexor longus digito- rum muscles on the inner side, and the posterior tibial nerve, together with the tendon of the flexor longus pollieis muscle, on the outer side of the vessel. Separate the artery from its venre comites, etc., and pass the needle around it from without inward, tak- ing care to embrace nothing else. In the lower third of the leg, there are numerous anastomoses formed by large branches of the internal saphenous vein, which in general run trans- versely ; these may he revealed by compressing the trunk of the vein above them, so that injury to them may as much as possible be avoided. Fig. 511. Ligation of the posterior tibial artery at the lower third of the leg. (Sedillot.) Ligation of the Peroneal Artery.—The peroneal artery arises from the posterior tibial, from one to two inches below the inferior border of the popli- teus muscle; it is nearly as large as the anterior tibial artery, and descends obliquely outward to the tibula. It then runs downward along the inner border of the fibula to its lower third, where it divides into the anterior and posterior peroneal artery. As it descends, however, it diminishes in size so rapidly that, below the middle of the leg, it is too small to require a formal deligation. DELIGATION of arteries. 773 Operation.—Make an incision two and a half inches long over the external border of the fibula, terminating opposite its middle. Divide consecutively the skin, superficial fascia, and deep fascia, whereby the origin of the soleus muscle will be brought into view. This must be detached and drawn in- ward, when the border of the fibula will be distinctly exposed. The operator now divides the fibres of the flexor longus pollicis, and separates them from the posterior surface of the fibula, at the inner surface of which will be found the artery, at the point where the interosseus membrane joins the bone. Ligation of the Anterior Tibial Artery.—Tlie anterior tibial artery passes forward between the two heads of the tibialis posticus muscle, and through the opening in the upper part of the interosseous membrane, to the .anterior tibial region. It then descends the anterior aspect of the leg to the ankle-joint, where it becomes the arteria dorsalis pedis. Relations.—In its downward course it rests upon the interosseous membrane —to which it is connected by a small tendinous arch that is thrown over it— upon the lower part of the tibia, and upon the anterior ligament of the joint. In the upper third of its course it is situated between the tibialis anticus and extensor longus digitorum; lower down between the tibialis anticus and ex- tensor proprius pollicis; and just before it reaches the ankle-joint, it is crossed by the tendon of the extensor proprius pollicis, and becomes placed between that tendon and the tendons of the extensor longus digitorum. Its immediate relations are with the venae comites and the anterior tibial nerve, the latter of which lies at first to its outer side, and, about the middle of the leg, becomes placed superficially to the artery. The course of the artery is indicated by a line drawn from the inner border of the fibula, above, to a point midway between the two malleoli, below. Operation at the Upper Third.—Having turned the limb inward, and extended the foot, take as a guide the line just mentioned, or a point ten lines to the outer side of the spine of the tibia, and make an incision four inches in length through the in- teguments. Divide the deep fascia by a cruciform incision to allow its complete separation. The in- termuscular septum is now to be sought for, and may be recognized (a) as the first intermuscular space from the tibia; (h) on pressure from within outward, by the resistance of the other muscles; ( m 9 to Side. As to life. Local condition. Cause of death, date after oper’n. 1 Arendt, 1821 M. 35 R. Aneurism anast. Nov. 18, 6 17 Recov- Cured. The secondary hemorrhage lasted for several days, of face. 1821 weeks. ered. but was slight; 12 ligatures were applied du- ring the operation. 2 23 L. 23 1839 20 1839. of head. years. ered. rapid. 3 F. y’g R. Some Tumor began to decline ; pain in head ; Lemi- Moscow. of ear. days. tion brain. plegia; death. 4 F. 39 R. 8 No cerebral symptoms. 1833. near ear. years 1833 ered. 5 F. 44 L. 44 External carotid tied first; as tumor was not. ] 860. mos. temporal region. mos. ered. affected, common carotid was tied and first liga- ture removed. No cerebral symptoms followed. 6 M. 34 L. 12 Im- of head and face. 1819 ered. proved. 7 Bushe, M. 19 L. Erectile tumor of 19 Jan. 15, 29 Recov- Cured. . . 1830. cheek. years. 1830 ered. 8 Blackman, M. 30 R. 2 % 1843. neck. years. 1843 (exhaust.) 9 Blackman, M. 15 R. Fungus haematod. do. 1848 13 Recov- 1848. 3 weeks ered. after, 2d operat’n. 10 Blackman, M. 15 L. do. do. do. 1848 14 Recov- (Uncer- Same case as No. 9. 1848 ered. tain). 11 Chelius, M. 19 R. Aneur. varix. of 1 Jan. 18, 21 Recov- Cured. 1836. temporal region. year. 1836 ered. 12 Cherry, F. 12 Erectile tumor. Recov- Cured. 1858. ered. 13 Deguise, F. 1827. J4 Dewar, F. 27 R. 14 Syphilitic diathesis. I860.' tumor of tonsil. 1859 ered. 15 Detmold, F. 26 R. 1840 16 Prof. Wm., right side head. ered. provem’t months afterwards of phthisis. 1840. CASES OF CAROTID LIGATION. 809 6 Name of opera- tor. PATIENT. Nature of disease. Duration of disease. Date of operation. I Hemorrhage occurred after oper- ation. Lig. came away No. days after operation. RESULT. REMARKS. X 0) GQ S) < | Side. As to life. Local condition. Cause of death, date after oper’n. 16 M. L. 1842 10 Cured. 1842. chin. ered. plied. 17 Detmold, 8 L. Aneurism anast. 1845 10- Recov- Cured. ✓ 1845. mos. of left ear. ered. 18 Dupuytren, M. 20 R. 12 ear and temple. 1818 ered. 19 Gunderlach, ... H R. Aneurism anast. H Sept. 13, 13 Recov- Not Same case as No. 20. 1831. of frontal and years. 1831 ered. cured. nasal regions. 20 L. 53 28 ? Patient died subsequently of variola. 1832.' years. 1832 ' ered. 21 Grandchamp, F. 50 R. Pulsating tumor 2 1839 Recov- During previous year, the two facials, the trans- 1839. of face. years. ered. verse facial, infra-orbital, and temporal artery of the affected side were tied, with no effect upon tumor. No cerebral symptoms followed ligature of common trunk. 22 F. H. Hamil- M. 2 R. 6 Feb.12, ton, 1860. outer angle of weeks. 1860 ered. fit. and destroyed it; soft, elastic, with distinct right eye. bruit’ tumor returned subsequently, and pa- tient died from it. 23 Hart, 1861. M. 11 L. 1861? 8 Cured. No symptoms of cerebral disturbance. of upper lid and ered. orbit. 24 Heine, 1869. M. 21 5 1869 cirsoid aneurism days. ered. five days after, hemorrhage and ligature of com- of ear and scalp. mon carotid. 25 Jobert, M. R. 4 Died. No cerebral symptoms. 1836.' temporal region. mos. 1836 day. 26 Jiingken. M. 19 R. 16 Not by anastomosis. ered. cured. 27 Kerr, 1840. F. 67 R. Vascular tumor; April 30, 26 supposed aneur. 1840 ered. monia. 28 Kuhl, 1843. M. 53 L. Aneurism anast. 24 May 24, Sev. 27 Recov- Not One year after a fall from a horse on occiput; occip. traum. years. 1843 times. ered. cured. hemorrhage 72 days after first operation. 29 Kubl, 1843. M. 53 R. do. do. Aug. 4, 3d 27 Recov- Cured. The second carotid tied; no marked cerebral 1843 day. ered. symptoms followed the second operation, although convulsions occurred after the first. Cases In which the Common Carotid Artery has been tied.—Continued. 810 PATIENT. O d © a O © to * 2-a S 'S ® . 1^1| RESULT. Name of opera- Nature of disease. *2 c3 © U £ ° a © a ££ Cause of tor. M * 6 u .2 ® P< = g ©5 * p. As to Local REMARKS. © © in 00 < m d r3 ft e8 O ft © © «4-. c3 35 © d life. condition. death, date after oper’n. 30 Kuhl, 1836. F 43 R. Vascular tumor of frontal region. . 4 Sept. 16, 1836 Died. Second day. Cerebral symptoms followed ; unconscious four hours. Autopsy : Tuberculosis of lungs ; pneu- mos. mogastric nerve injured by inflammation of sur- 31 Lenoir, 1851. F. y’g Erectile tumor of temporal region. 15 Died. rounding structures ; right subclavian included in ligature by mistake. After. 32 Lisfranc, 1827. F 18 R. Fungus hsematod. (supposed aneu- Died. 8th day. Hemor- Fungus of left cerebral fossa; petrous portion temporal hone carious; internal jugular vein 33 Liston, 1841. M. 20 L. ism). Vascular tumor of neck. After. Died. rhage. 10th day. Hemorr’ge. obliterated. 34 Liicke, 1866. M. 66 L. Spontaneous pul- sating tumor of 7 Aug. 9, 1866 14, 16, Died. 19th day. Hemorr’ge, Delirious after operation. Autopsy: Ulcerated hole in carotid at ligature. years. 17th' 35 Maisonneuve. F. 30 R. forehead. 2 day. Died. delirium. Third day. External carotid was tied first; this lig. fell 16th day. The sup. thyroid was tied at this time. ism of parietal reg., traumatic. mos. Hemorrhage again occurring, the internal and common carotids were tied, followed by com- plete left hemiplegia. Autopsy: Right hemi- sphere softened, the sympathetic nerve included in both the internal and common carotid liga- tures (Pilz). 36 Maunoir. M. 30 L. Cirsoid aneurism. Recov- ered. No im- provem’t .. 1821 37 Mayo, 1833. M. 5 L. 5 1833 8 Recov- ered. Im- proved. mos. 9 face. Erectile tumor of mos. 38 McClellan, 1825. F. L. 1825 14 Recov- ered. Cured. cheek. Aneurism anast. ; Seve- 12 days. Paralysis (right) 24 hours after operation ; 8th 39 McClellan, M. 43 L. May 12, Died. 1829. antrum of nose. ral 1829 Cerebral day coma ; death in convulsions. years. complica- tions. 40 F. 23 L. Aneurism anast. 2 Mar. 12, 30 Recov- ered. Cured. Patient was 3 months pregnant at time of opera- tion ; did well. 1835. Millies. of face and occi- put. Aneurism, fusi- years. 1835 Four days. 41 Died. Died suddenly ; no autopsy. form; superior thyroid. SURGICAL DISEASES OF THE VASCULAR SYSTEM. Cases in which the Common Carotid Artery has been tied.—Continued. CASES OF CAROTID LIGATION. 811 PATIENT, O d ©* d © O' so • _ £ JS "V ® L « ft . o ® d RESULT. © Name of opera- tor. © dq © be < ©’ m Nature of disease. •ri s .a d 'rs P o St d © P £ ° a ® 3 t. O ® « c: os 35 © £ d d © •J-T W 'O o p As to life. Local condition. Cause of death, date after oper’n. REMARKS. 42 Mussev, 1827, New M. 20 R. Erectile tumor of Sept. 20, 1827 Recov- ered. Not im- proved. Tumor afterwards removed, patient lost 2 quarts blood, and more than 20 ligatures were required scalp. Hampshire. Same case as No. 42. Tumor had crossed bridge of nose and invaded portion of opposite eye. 43 Mussey. M. 20 L. do. Nov. 2, Recov- ered. Im- proved. 1827 44 C’d Aneurism anast. Recov- ered. Valentine, New York. of orbit and nose. 45 Mott. 3 Recov- ered. mos. C’d of neck and jaw. 1830 15 Im- proved. 46 Mott, 1830. Recov- ered. of temple. 47 Mott, Prof. A. B., 1854. F. 64 L. Aneurism anast. of left side of Feb. 1, 1854 17 Recov- ered. Cured. mos. face. 48 Mott, A. B. F. 7 R. Fungus hsematod. at orbit. April 10, 1854 Recov- ered. Cured. Eye was extirpated at same time ; no return after two years. y’rs 49 F. 23 L. Aneurism anast. Oct. 30, 1856 21 Recov- ered. Cured. 1856. 50 Mott, A. B., F. 9 R. Large aneurism anast. over paro- 14 Recov- ered. Cured. 1859. mos. 1859 • tid gland. 51 Willard Par- F. 45 L. Erectile tumor of 45 April 6, 1857 18th 21 Recov- ered. 1 Hemorrhage on 18th day controlled by moderate pressure. ker, 1857. y’rs face. years. day. 52 Parker, 1861. F. 10 R. Extensive vascu- 10 April 29, 1861 None. 12 Recov- ered. Cured. Three years after operation, patient was perfectly well. mos. lar tumor of face. mos. 53 Pirogoff, 1843. M. 20 L. Hem. ; aneurism 5 Im- At six years of age, small tumor of scalp. In 1843, attempt to remove it resulted in such alarming anastomosis of 1843 ered. proved. occipital and hemorrhage, that Pirogoff tied carotid. Tumor temporal region. not entirely disappearing by following year, re- maining carotid tied. Tumor was then treated - by compress, and cured. 54 Pirogoff, 1844. M. 20 R. do. 16 Recov- ered. Cured ? Same case as No. 53. 1844 55 Pirogoff, 1837. 9 L. Erectile tumor, 9 Jan. 26, Occur- 117th day. Hemor’ge. mos. occiput. mos. 1837 ' red. 56 Pirogoff. M. Mid. L. ? age. anast, ereff. Cases in which the Common Carotid Artery has been tied.—Continued. 812 SURGICAL DISEASES OF THE VASCULAR SYSTEM. i Name of opera- tor. PATIENT. Nature of disease. Duration of disease. Date of operation. Hemorrhage occurred 1 after oper- ation. Dig. came away No. days after operation. RESULT. REMARKS. >< © CO © &0 < | Side. As to life. Local condition. Cause of death, date after oper’n. 57 Pirogoff. C’d L. After. Died. Hemorr’ge anast. reach of surgical interference when hemorrhage occurred, causing death. 58 Post, Prof. M. 27 R. Telangectasis Many April, 1, Died. Phlebitis ; Autopsy : Two phlebolithes were found in tumor. A. C., N. Y., right cheek. years. 1845 pyaemia; Phlebitis of int. jugular, although vein was 1845. delirium. not wounded in the operation ; pus in vein. 59 Randolph, M. 25 R. Aneurism varix . 1836 Died. Next day. Coma soon after operation. 1833. Cerebral complica- tions. 60 Robert, 1846. F. 19 L. 19 June 5, 19 frontal region. years. 1846 ' ered. but passed away. 61 Robert, 1847. F. 19 R. 194 Feb. 22, 18 years. 1847 ' ered. benefit. tumor. Same case as No. 60. 62 M L 1857 A few days 63 F. 11 R. 1844 Not Temporal artery was also tied. (See No. 70.) 1844. head. ered. cured. 64 8 R. 8 Cured. 1832. mos. face. mos. 1832 ered. 65 Southam, F. 28 R. 8 May 20, 14 1864. ' head. years. 1864 ' ered. fore operation. 66 6 10 Not, 1865. mos. of face and eve. ered. cur’d but benefited 67 M. 19 L. 1823 Not Same case as No. 68. 1823. region of left ear. ered. cured. 68 M. 20 R. do. 1824 Died. 3d day. Exhaust’n 1824. to be applied lower down. 69 M. 20 Im- Hotel Dieu. of scalp. ered. proved. time. 70 F. 17 L. 1850 14 Not 1850. ered. cured. years previously by Dr. J. K. Rodgers. No cerebral symptoms followed. (See No. 63.) 71 M. 16 L. 1835 Internal carotid was also tied. 1835. temporal region. Hemorr’ge. Cases in which the Common Carotid Artery has been tied.—Continued. 813 o Name of opera- tor. PATIENT. Nature of disease. Duration of disease. Date of operation. Hemorrhage occurred after oper- ation. Lig. came away No. days after ' operation. RESULT. REMARKS. M 9 m d be < 53 As to life. Local condition. Cause of death, date after oper’n. 72 M. 23 L. 1845. face and neck. 1845 ered. ter. ture, but there was no positive improvement. 73 M. 23 R. 1845. face and neck. 1845 ered. proved. plunging needles into remaining parts. Cured. 74 Wardrop, 6 L. Erectile tumor of 6 1818 Died. 14th day. Tumor ulcerated freely after operation. 1818. w’ks cheek. weeks. Exhaust’ll 75 F. 5 L. 11 Cured. 1826. mos. face. 1826 ered. 76 Wardrop, M. 22 L. Erectile tumor of 12 Oct.(?) 25 Recov- Im- Died 103 days after operation ; psoas abscess. 1827. face and head. years. 1827 ered. proved. 77 Wardrop, M. 6 R. Aneurism anast. 6 Mar. 2, 9 Not 1842/ ' mos. of cheek. mos. 1842 ' ered.‘ cured. tumor. 78 F. 6 L. 4th day. A. T., I860'. mos. of left external time. carotid. 79 M 25 Aneurism anast. 18 Cured. 1847.' external carotid. ered. mor, deemed impracticable to tie ext. carotid. 80 Zeiss. 15 L. 15 8 mos. face. mos. Cere. com. 81 F. 28 R. July 29 15 Cured. 1830. above ear. 1830 ered. 82 Bradley, E., M. 20 L. Hemorrhage dur- 19* Dec. 6, None. 3d Recov- Cured. Tumor grew rapidly within the last year. In New York, ing removal of years. 1877 week. ered. operation for removal, while dissecting with the 1877. vascular tumor handle of the scalpel, the tumor gave way, and of parotid and a frightful hemorrhage occurred. The common submaxillary carotid was tied immediately above the clavicle, regions (Angei- the incision being made behind the posterior oma). border of the mastoid muscle. Hemorrhage . ceased instantly. The recovery was prompt, and the tumor has entirely disappeared. After ligature of the common trunk the tumor was not removed, but the wound was packed with lint soaked in Monsel’s solution. No symp- toms of cerebral disturbance. The internal carotid has never been tied for any of the lesions given in the preceding Table,except in the pases reported by Maisonneuve and Velpeau, cases of carotid ligation. Cases in which the Common Carotid Artery has been tied.—Continued. 814 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Table of Oases in which the External Carotid Artery has been tied on account of the lesions mentioned in the preceding Table. 6 PATIENT. <4-. o lvi n anti /LeejvdyJd66ued ( tftmrva j Ligature of vessel in orbit 1 1 1 Op. cit. 2 Gazette Medicate, 1866, p. 321. 8 Warren, loc. cit., first case. 4 Rivington gives two idiopathic cases thus treated, as cured, but in one of these vision was lost; in the other noises in the head continued. * The cause of death is not stated in one ; it was secondary hemorrhage in two ; pysemia in two ; cerebral disturbance in one. * Three of these were cured : 1 by injection of the lactate of iron, 2 by deligation of the other carotid; 1 died after galvano-puncture. 946 ANEURISM. I have not wished to alter these numbers, gathered from Mr. Rivington’s paper, by the addition of the only case published since it was written. This was Von Leiden’s1 case; pressure, continued for ten weeks, failed; ligature of the carotid cured. Relapse occurred, or threatened, on the other side, in one case; the condi- tion was successfully treated by the administration of digitalis, local com- pression, and the application of ice. Relapse on the same side occurred eight times, six of the cases being trau- matic ; subsidence took place in one idiopathic case, and in two of the draumatic cases. In two American cases, both carotids were tied, and in a third (Frothingham), after partial relapse, the spongy remains of the tumor were dissected out. Since relapse is most frequent in traumatic cases, it is probable that the condition arises from arterio-venous aneurism ; or, perhaps, that both carotids, or one carotid and a branch from the other, communicate with the sac of an aneurism behind the orbit. Ligature in the orbit of an artery feeding an orbital aneurism can only be 'employed in very exceptional circumstances. The case so treated by Mr. Lans- downe resulted from a wound of the upper eyelid, which was followed by a consecutive traumatic aneurism of the injured vessel. Carotid Aneurism.—Carotid aneurism has been said to be more common in women than in men; but this is an error. I find in Pilz’s tables, to be quoted immediately, 88 cases of this disease; of these, 55 were in men and 28 in women, the sex in 5 not being stated. The external branch is affected in 7 per cent, of the cases of carotid aneurism; the internal in about 5.75 per cent. The very large proportion of 87.25 per cent, belongs to the primitive trunk. The most usual point for the appearance of the tumor is the bifurcation, but it may also have its seat quite at the lower part of the neck, immediately above the clavicle. For reasons which will appear shortly, I prefer to divide these cases into those of high carotid aneurism, to be now investigated, and of low carotid aneurism, which can be better discussed with subclavian, innominate, and aortic aneurisms, under the category of aneurism at the root of the neck. Aneurism of the carotid artery, at or near the bifurcation, lies between the trachea and the sterno-mastoid muscle, and is so easy of diagnosis that nothing on that subject need be said here;2 but the surgeon should be aware that a certain normal increase in the size of the artery, just at its division, is, especially in women, not very unusual, and that this expansion may, as age advances, become more conspicuous, either from the loss of subcutaneous fat, frequent in elderly females, or from real enlargement, which may not, how- ever, pass the limits dividing disease from mere peculiarity of form. Hence, a pulsating tumor at this part of the female neck should not be at once considered, still less treated, as aneurismal, more especially if it have been discovered through accident, by touch or sight, or have been merely observed fey some third person, the patient experiencing no painful or obstructive symptoms. The rule, in such a case, is to carefully watch the tumor, and to measure it by compasses or other means, from day to day, or week by week. If it be stationary, and no pressure symptoms arise, surgical interference is unnecessary, or may at least be postponed. Case XVII.—I was consulted in November, 1878, by Mrs. G., aged 62, on account of a pulsating tumor on the right side of her neck, which gave her no inconvenience, and had first been observed by her husband. There was no history of injury, and the • Zeitschrift flir praktisch. Medizin, No. 47. 2 Certain points of differential diagnosis between this disease and certain cysts of the neck, are given at p. 845. CAROTID ANEURISM. 947 lady was in perfect health, but of late had grown considerably thinner. There was very visible pulsation on a level with the thyroid cartilage ; at each systole the tumor looked nearly the size of a pigeon’s egg; the pulsation, which was markedly expansile, ceased on compressing the carotid below. To the touch, a rather considerable dilatation of the artery was evident, but not as great as it appeared to sight—some of the expansion being certainly venous, probably from pressure of the dilated part of the artery on the jugular vein. I carefully measured the limits of expansile pulsation, and watched the case closely during a fortnight, and in that time found no change whatever. Relaxing my vigilance, I saw the patient then only from time to time. In February, 1879,1 happened to meet at her house her younger sister, who told me that previous to her marriage, which happened just before she was twenty, my patient had been very thin, and she (the sister), with others, had often noticed a great beating on the right side of her neck, and that the spot looked then, as far as she could remember, exactly the same as it did at the time of speaking. After marriage, and until lately, the lady had been considerably stouter, and it is likely that the increased embonpoint overlay and concealed the pul- sation. While avoiding unnecessary interference, we are to remember that, if the tumor be increasing, no time should be uselessly lost; the growth is in this situation usually rapid; nor is there very much room to spare. Such aneur- isms tend, as a very general rule, upward, yet, combined with growth in that direction, a certain downward extension may also occur. If in growing the tumor come to cover the trunk of the artery, the difficulties and dangers of treatment are enormously increased. Many of the resources of surgery, useful in other situations, are inapplicable to carotid aneurism. Coagulating injections, and even galvano-puncture, would be dangerous in this place.1 The parenchymatous injection of ergot might be tried by one who had faith in it; and direct pressure by means of a truss-like instrument of a liorse-slioe shape—a somewhat modified Signoroni’s tourniquet—might be employed if the aneurism were small and firm. But, in truth, our means of attack are almost limited to proximal pressure and ligature. There is no doubt that indirect pressure, combined or alternated with the direct, may cure a certain class of aneurisms of the neck, as also of the orbit. The compression may be in part instrumental; thus, for instance, a Cole’s com- pressor may be used with the hand. Mechanisms carrying movable arms (adap- tations of Carte’s instrument to the neck) generally disappoint both surgeon and patient. Digital compression is much more bearable, and, in truth, if a sufficient staff can be mustered, is much more easily effected. The place where the least amount of force exerts the greatest influence, is the carotid (or Chas- saignac’s) tubercle, as the transverse process of the sixth cervical vertebra is called. Generally, pressure on any part of the vessel produces after a time vertigo, tinnitus aurium, faintness, and a sense of sickness. This is generally attributed to disturbance of the cerebral circulation, but I believe wrongfully. It seems to me that interference by compression with the sympathetic, perhaps also with the pneumogastric nerve, is more likely to be the cause of the un- pleasant sensations. After a certain number of sittings the parts become accustomed to the manipulation, and the unpleasant symptoms diminish. Another mode of compression, that of Rouge, may be substituted for, or may alternate with, that just described ; to effect this, the patient’s head must be so placed to relax the sterno-mastoid muscle, on one side of which the surgeon places his thumb, on the other his finger; then insinuating them behind the muscle, he, as it were, pinches the carotid between them. The manoeuvre is best and most easily carried out some distance above Chassaignac’s tubercle; 1 The gas-bubbles and tar-like tiuid, described at p.865, might act injuriously on the brain. 948 ANEURISM. it fatigues the hand rapidly, hut obviates the troubles which patients so often experience when the vessel is compressed against the spine. Even with the best precautions it will be impossible, while the patient is conscious, to prolong the sittings very much, or to let them follow each other rapidly. Thus, in orbital aneurism, the pressure in the three successful cases was used in one case (Gioppi) for a minute or two at a time; in another, for about five minutes; and in the third, from twenty to thirty minutes a day. In the very few cases of success in carotid aneurism, from ten to fifteen minutes’ pressure was (if I read the accounts correctly) the utmost that could be borne. The rapid method is, of course, open to the surgeon ; but he must remember that this method may require from one to many hours’ anaesthesia ; he may, during such treatment, have great difficulty in distinguishing between the causes of syncope or asphyxia that maybe due either to the direct effect of the anaesthetic, to cutting oft' a part of the blood-supply to the brain, or to failure of the heart or lungs through pressure upon the pneumogastric and sympathetic nerves. Such pressure, while the patient is under the influence of any anaesthetic, can hardly be free from danger. Pressure is reported to have been suc- cessful in six cases; of these, three were traumatic. Of the others, I may say that one occurring in a rather lean old lady (reported as greatly benefited, but afterwards relapsed), was, to my mind, not an aneurism, but one of those not abnormal enlargements at the bifurcation already mentioned. It is quite impossible to ascertain the number of cases in which pressure has been used and failed—and a proportion or percentage of its effects is there- fore unobtainable. The proximal ligature for high carotid aneurism is the form of operation to be chosen, and, when possible, one would elect to tie the vessel shortly below its fork; but in some cases the position of the sac leaves no choice— the vessel must be taken up, if at all, lower down in the neck ; the two forms of operation are termed respectively “above” and “below” the omo-hyoid. The former is the easier, and is thus performed. Ligation of Carotid above Omo-hyoid.—The patient, being etherized, should have a rather thick pillow placed under the shoulders, but none under the head, which, falling back, renders the middle part of the neck prominent; the face should be slightly turned towards the unaffected side.1 The sur- geon feels about midway between the clavicle and the ear for the edge of the sterno-mastoid muscle, and makes there an incision about two and one-half inches long, so placed that its middle shall be on a level with tne cricoid cartilage. This incision may go at once through the platysma and fascia, but if this latter structure be not then divided (the muscular fibres of the sterno-mastoid not being in view) the knife must be drawn down the track again. In doing this, it is well to spare any large vein (the external jugular sometimes crosses here), or to tie it, if divided, at both ends. The operator’s finger will, if the fascia have been sufficiently incised, very easily turn the sterno-mastoid outward, and then will be seen the omo-hyoid, which can generally be pressed inward without using the knife; or the fascia, on its outer edge, may require some dissection. These two muscles, with the other soft parts, are now to be held respectively inward and outward. On looking into the wound, the operator sees the yellow, fat-charged fascia, one 1 Once or twice I have found my assistants forcing the patient’s chin far over to the opposite shoulder ; this embarrasses, as it causes the sterno-mastoid to overlie the artery : the chin should be kept about midway between the acromion and the episternal notch of the opposite side. I may add here, that in certain aneurismal cases (aortic and innominate) the etherized patient cannot breathe while the head is thrown back ; the ansesthetizer is obliged to insist on bending it forward, and the operator has to get at the vessel under very trying circumstances, since in that posture it lies much deeper, and the ramus of the jaw is terribly in the way. 949 CAROTID ANEURISM. part of which covers the vessel (sheath), and, running obliquely through it, a quantity of veins, which should be avoided1 by placing the linger in the depth of the wound, and finding the pulse of the carotid at a place free from venous complication. Here a bit of the fascial sheath should be pinched up on the front, inner aspect of the vessel, a little hole made, the director passed in, the safety of the descendens noni nerve verified, the sheath slit far enough to let the naked artery be seen, and the needle passed from without inward. A few words about the nerves. The descendens noni lies at this place, on the outer aspect of the sheath, and will rarely be endangered if that structure be opened as above described ; but it is well to see that it is out of the line taken by the director; if its absence there be verified, it need not be hunted up elsewhere. The pneumogastric nerve lies in the interval between the artery and vein in the back part of, but not loose in, the sheath; each of the vessels, as well as the nerve, has a compartment, strongly walled, to itself, while the sympathetic, behind the sheath, is also separated by a thick fascia from the vessels. If these anatomical positions be maintained, both nerves are safe.2 Young operators are sometimes made anxious and embarrassed by unnecessary cautions, yet sometimes the parts do not quite maintain their proper positions; hence it is well, before tightening the ligature, to see that it includes the artery only. Ligation of Carotid below Omo-hyoid.—The low operation also requires an incision about two and a half or three inches in length, along the inner margin of the sterno-mastoid; it may extend from just below the level of the cricoid cartilage to an inch or half an inch above the sterno-clavicular joint.3 The fascia may be freely divided and the muscle turned outward ; judging from my own experience, it can very rarely be necessary to sever its sternal origin. When this has been done, much caution in the use of the knife is advisable. Many veins, much engorged if there be dyspnoea (sometimes the anterior jug- ular lies here), meander in this space ; they and the loose fascia can generally be pushed away with the finger until the omo-hyoid is seen. Along the inner border of this muscle, as it lies on the sterno-hyoid, a few touches of the knife are required in order to allow of its being drawn upward and outward ; the finger and a blunt hook will now turn and hold the outer edge of the sterno- hyoid inwards. The sheath, avoiding the descendens noni, is to be opened and the ligature passed as in the higher operation.4 The unaccustomed ope- rator should be prepared for having to go very deep, especially on the left side, where the vessel seems almost to lie in a pit. After deligation of the vessel, the size of the aneurism may not much decrease, and pulsation, although arrested, may return after a very short time. This results chiefly from the very free communication of the vessels of the two sides at the base of the brain. Blood finds its way through the circle of Willis into the internal carotid of the affected side, and to that part of the common trunk which lies above the ligature, thence into the external carotid, 1 I have generally seen here a very full, turgid vein, the superior thyroid, coming obliquely from the larynx to the internal jugular; it sometimes runs before, more often behind, the carotid. I suppose it is the effect of the anaesthetic, which causes this to swell to the size of a cedar pencil 2 Pilz (Zur Ligatur der Art. carot. comm., Langenbeck’s Archiv, Bd. ix. S. 399) says that the vagus has probably never been included in the ligature, but that a piece has been cut out of it; but that, on the other hand, the sympathetic nerve has been tied with the vessel. Neither of the cases to which he refers, was one of simple deligation—the former extirpation of a tumor, the latter a complicated deligation of several arteries for secondary hemorrhage. 3 The length of the patient’s neck and the position of the aneurism cause some slight variation in placing the incision. 4 It is well to say that, in operating on the right side, more especially if a ligature which divides the inner vascular coats be used, the artery should not be attacked too low. The only case of fatal secondary hemorrhage which I have ever had in this operation, followed the liga- tion of a carotid with catgut close above the sterno-clavicular joint. 950 ANEURISM. and so to the face and parts outside the skull. The operation, however, having relieved the blood-pressure, and the current being very indirect, coagulation, though slower than in arteries whose branches anastomose by less patent communication, nevertheless takes place. The nearer to the bifurcation is the opening between sac and artery, the slower cceteris paribus is solidification. I use the words “ other things equal,” because a large aneurism with a small mouth consolidates more quickly than a small one with a large orifice. Before going on to study the mortality of tying the common carotid artery, it is necessary to consider its effects upon the brain. On this subject we have a variety of tables, which vary considerably; I will place their results in their chronological order:— Whole number Cases attended with Per of cases. cerebral complications. cent. Norris1. # # . 138 30 21. Ehrmann2 # , . 213 47 22. Pilz8 . # . 482 154 32. Lefort4 . # . . 241 73 30. Wyeth5 . . . 789 53 6.7 The death-rate of those affected with such symptoms varies, in these several authorities, from 56 to 73 per cent. When we consider the marvellous freedom of circulation in the brain, and remember that its tissue must be saturated with nutritious fluid always migrating from the vessels, quite sufficient to last until the momentary local anaemia has passed away ; and when we reflect that in consequence of hemor- rhage at distant parts, or from other cause, complete syncope and coma often must render the brain all but bloodless for lengthened periods without per- manent ill results, it is, I submit, impossible to attribute these alleged cere- bral effects to the obstruction of one only out of four large streams that supply the organ. This view is greatly corroborated by certain cases in which, one carotid being already plugged, the other has been tied; and still more by 29 cases recorded'by Pilz, in which one carotid was tied a certain time after that on the other side had been ligatured. Of these patients 8 died, 21 recovered. Among the fatal cases is one (Longmore) of gunshot injury, which appears to have been, rather than the operation, the immediate cause of death. Cerebral disturbance occurred in but five of these cases. Wyeth records 33 cases in which both carotids were tied at intervals varying from three days to six years (in one case of gunshot injury both vessels were tied simultaneously). Of these cases 9 only died, five of the deaths occurring in cases of gunshot wound and hemorrhage, and the fatal result being due to the injury rather than to the operation. So low a death-rate shows that cerebral anaemia can hardly be produced by tying a single carotid. The same thing is shown by the case of Dr. Smyth, who, 54 days after tying the right carotid, ligatured the vertebral on the same side; yet no brain symptoms were observed. Rossi, too, tied the right carotid of a patient who after death was found to have the left carotid and right vertebral obliterated; during the six days of his survival, the brain was nourished through the left vertebral alone. In no instance of tying the innominate, which operation cuts off all the right blood-supply of the brain, have cerebral symptoms been observed. We must, therefore, seek some other cause for the large percentage of brain complica- tions ascribed by some authors to carotid deligation. I believe it may be 1 I exclude the distal method and deligations undertaken for the cure of cerebral affections. 2 Des effets produits sur l’encepliale par l’obliteration des vaisseaux qui s’y distribuent. Paris, 1860. 3 Arcliiv fiir klinische Chirurgie, Bd. ix. S. 257. 4 Gazette Hebdomadaire, 1864 and 1868. 5 Essays in Surgical Anatomy and Surgery, p. 120. This author speaks of delirium, convul. •ions, and other slight cerebral symptoms as occurring in 18 other cases. CAROTID ANEURISM. 951 accepted that a very large majority of the cases in which so-called cerebral symptoms have supervened from the seventh to the tenth day, or later, were cases of pytemia—a malady which twenty-live or thirty years ago was but little understood. Some of the deaths may have been due to detachment of minute portions of clot. Pilz infers from the small number of deaths when both carotids have been tied, that the brain trouble, when one only is ligatured, may be due to a want of balance in the circulation. However this may be, it cannot be denied that deligation of one carotid is sometimes followed by cere- bral disturbance, a tact whereon Le Fort founded his recommendation to tie, whenever possible, the external rather than the common carotid. No doubt this advice is in accordance with those sound surgical principles which would forbid a large operation when a smaller one would suffice, and a possible com- plication, however remote, might be avoided. Dr. Wyeth1 has, of late, even more strongly emphasized this view, and has supported it by numbers, finding that the death-rate of tying the external carotid is only four and a half per cent. It must, however, be pointed out that cases of aneurism suitable for this deligation must be very rare: in 91 cases of this procedure, aneurism (described as being in the parotid) is given but once as the cause of operation. The statistics of carotid deligation for aneurism, have been collated by Norris (38 cases), Pilz (86 cases), and Wyeth (106 cases); but, for the purpose in hand, none of these collections can be accepted without some examination and sifting of the materials, since many of the cases belong to a category already studied as orbital aneurism, or to that of cirsoid aneurism; and since some of them are examples of mistaken diagnosis. We will take carotid aneurism, properly recognized, excluding all other cases; nor will it be necessary to refer more particularly here2 to the work of older compilers, since their tables are included in the more modern record of Dr. Wyeth.3 I have separated exam- ples of aneurism from the rest, and have added one or two other cases. Thus are collated of deligations of the common carotid artery for aneurism of that vessel, or of a branch (exclusive of orbital or intra-cranial disease), cases, 107; recoveries, 77, or 71.96 per cent.; deaths, 27, or 25.23 per cent. ; deaths from independent causes, 3, or 2.8 per cent.4 The causes of death may be stated thus:— ( place not mentioned # . 6 Hemorrhage -< from sac .... 9 . 2 (from site of ligature . 1 Inflammation, suppuration, or rupture of sac . . 4 Exhaustion ....... Pyaemia ....... . 2 Inflammation of lung ..... . 1 Cerebral complications ..... . 8 Not stated5 ....... . 4 1 Op. cit., p. 132. 2 Subtracting 8 of the cases given by Pilz, we have 78, of which 55 ended in cure and 23 in death ; of these deaths, 2 are unrelated to either the aneurism or the operation (causes, cancer of rectum, and general atheroma). Thus the true life-rate and death-rate in the 78 cases are as follows : Recovered, 55, or 70.5 per cent.; died, 21, or 27 per cent.; died from independent causes, 2, or 2.5 per cent. 3 Dr. Wyeth’s collection of operations amounts to the astonishing number of 789. It is, I think, to be regretted that his table is arranged only according to the alphabetical sequence of the operator’s names. Form of disease or injury, mistaken diagnosis, and chronology, are thus neglected, and the cases, being lumped together, require much sifting and examination previous to being used. Of liis 789 cases, 328, or 41 per cent., proved fatal, a ratio much too high for aneurisms, and much too low for gunshot or other severe injuries. 4 These numbers include eight distal deligations for carotid aneurism, but none for innominate or aortic aneurism. 5 The number of deaths appears greater than that given above, because two cases appear under headings of both hemorrhage from sac and rupture of sac. Pilz records 12 deaths from hemorrhage, viz., 9 from the sac, 1 from point of ligature, 2 site not stated. 952 ANEURISM. In considering the deaths from hemorrhage, we must distinguish clearly between those bleedings which spring from the site of deligation and those which arise from the sac. It is a pity that this distinction is not made in Wyeth’s table. But I have been able to procure fuller information in many cases. Thus, in all the 107 deligations for carotid aneurism, bleeding occurred but twice from the site of ligature alone, and once from that place and from the sac simultaneously. This distinction is important, because, in a certain proportion of cases which must stand on the fatal side of the list, the operation affected the result neither one way nor the other: the sac continued to grow, and ultimately burst, just as though no operation had been per- formed. It appears, then, that we may accept a little over 25 per cent, as having been the mortality of this operation up to the present time, but it is probable that the immediate future will diminish this proportion very con- siderably. The old operation for carotid aneurism was advocated by Mr. Syme as even the best primary procedure; but the vessel is badly placed anatomically, since it is difficult or impossible to command the circulation; and any surgeon who reads the account which Mr. Syme gives of his operation (a traumatic case), will hardly be induced to follow that eminent surgeon’s example. If, how- ever, the Hunterian operation have failed, and the aneurism continue to in- crease, the old method may be practised with comparative facility, since the ligature obstructs the artery sufficiently to make it safe. This has been done twice in America, and quite lately in London, by Mr. Morris.1 No difficulty was experienced in the operation. Aneurism of the Vertebral Artery.—This is always traumatic, follow- ing punctured wounds (stabs) at the side or back of the neck, or more rarely bullet-wounds. No instance of spontaneous aneurism has been, as far as I know, recorded. Although rare, 22 wounds and aneurisms of the vertebral artery have been collected.2 The usual place of injury is between the first and second vertebrae, where the vessel makes its turn to pass outwards to the foramen in the wider transverse processes of the former hone ; but in two cases it was between the second and third vertebrae ; in one between the fourth and fifth; and in one (Kocher’s) between the fifth and sixth. Of great surgical interest is the diagnosis of these cases, the difficulties of ■which will be at once apparent when it is stated that, in more than half of the recorded cases, viz., in 12, the disease was mistaken for aneurism of some branch of the carotid; and that in 11 cases that vessel was tied, while in one the inferior thyroid was supposed' to be the wounded vessel (Maison- neuve), and tied first; but afterwards, since bleeding did not cease, the ver- tebral also was ligatured. The situation of the wound helps but little in the diagnosis; in most cases this has been near the skull, and about an inch behind the mastoid process; hence the surgeon is very likely to attribute the bleeding or the aneurism to the occipital artery, or, if the injury be lower, to the ascending cervical. In certain other cases, the penetrating wound has passed through quite different parts, namely, “mouth” (twice), “cheek,” at “the angle of the jaw,” “under the ear,” etc., where certainly a branch of the carotid would appear to be more exposed to injury than the vertebral. Since, then, situation of the wound gives no certain indication, the only method is to observe whether 1 Medico-Chirurgical Transactions, vol. lxiv. p. 1. 2 Sixteen have been gathered by Barbieri, of Milan ; four are mentioned by Pilz : and the other two are the cases of Liicke (Langenbeck’s Archiv, Bd. viii. S. 78) and of Kocher (Ibid., Bd. xii. S. 867). ANEURISM OF THE VERTEBRAL ARTERY. 953 "pulsation ceases—or, in cases of wound, whether hemorrhage is arrested—by pressing on the carotid; but it is just this pressure, exercised in the usual way, but with insufficient consideration of its effect, that has so completely misled diagnosis in the large number of cases above referred to. The place usually chosen for compression of the carotid artery is the trans- verse process of the sixth cervical vertebra, or perhaps, since the skin and fascia tend to bear the huger upward, a little below this point. Row this pressure, properly carried out, will certainly check all pulsation in the carotid and its branches, or in their aneurisms; but surgeons, founding upon this fact a diagnosis of carotid aneurism, have been led into grievous error, because they have not remembered that such compression must infallibly affect the verte- bral also. Even if the carotid be compressed against a transverse process higher up, there yet will remain a source of error in the irregularity of the vertebral, which occasionally does not pass into the chain of foramina until it reaches the axis. Hence the only means of secure diagnosis is by pinching the vessel, after Rouge’s method (p. 947), with the finger and thumb behind the relaxed sterno-mastoid, while the soft parts are drawn a little for- ward—away, therefore, from the spine, and not pressed against it. By this means, doubtless, an accurate diagnosis may be arrived at. Treatment of Vertebral Aneurism.—The treatment of these cases has not been fortunate; indeed, only two—those of Mobus1 and Koeher—have ended favorably. This infelicitous result is doubtless in part owing to mistakes of diagnosis, but also to inherent difficulties in the anatomical arrangement of the parts, which is such as to preclude the use of many of the means usually at our command. Pressure on the lower end of the vertebral could certainly not be borne without an anaesthetic long enough to have any effect on a traumatic aneurism; nor do I think, seeing how free is the intercommunica- tion of vessels at the base of the brain, that the prospects of a good result would be sufficient to warrant an attempt to cure by proximal pressure after the rapid method. The injection into the sac of perchloride of iron could not be effected under the principles necessary for success, namely, occlusion of the vessel, at least on one side of the aneurismal sac; while the danger of the clots and the solution being carried into the brain, is very evident.2 The same may be said of galvano-puncture, though that might be more safely used, since the clots formed by the current are less persistent. The 'parenchymatous injection of ergotin,unless the rapidly growing sac demanded the immediate use of more potent measures, might certainly be tried. Probably, however, in most cases, carefully applied direct pressure and the application of cold will be found the most efficacious of all the non-operative measures. As already said, only two cases have ended well, the first being that of Mobus—a traumatic aneurism which was judged to be formed on a branch of the carotid; the vessel was exposed, and the aneurism needle passed round it, -when pressure on the curve of the instrument being found not to restrain pulsation, the wound was closed. The patient refused to submit to further operation, and under the application of cold the aneurism consolidated. The successful case of Koeher was one of stab on a level with the interval between the fifth and sixth cervical vertebra. The wound had been received three weeks previously, giving rise almost dailj' to hemorrhages, which had been treated with pressure and the application of pads steeped in the liquor ferri perchlondi. Koeher introduced his finger, enlarging the wound pretty freely, and removing laminated, discolored, and loose, dark clots. He then 1 Grafe and Walther’s Journal, Bd. xiv. 2 The only ease thus treated (Liicke) died with brain troubles, repeated injections having probably much to do with the result. 954 aneurism. found that by pressing from above on the sixth, or from below on the fifth,, transverse process, hemorrhage was arrested. lie could even seize the bleed- ing point with long forceps, but it was impossible to tie any vessel, “ as the ligature had nothing to grip.” lie therefore introduced a pad, the size of a pea, steeped in porchloride of iron, upon the bleeding spot and well between the transverse processes. Most fortunately this device succeeded, and the patient recovered without further trouble. The case is thus shortly related to show what difficulties the surgeon who should attack such a case by the old (Antyllian) operation might have to encounter, for the aneurism is partly situate between the bones, and nothing would be found that could be tied.1 A firm plug of lint, as in the above case, might prove successful, but the inference to be drawn is rather to avoid operation, unless it be actually forced upon the surgeon. The device proposed by Gherini to lay bare the transverse processes above and below, sufficiently to permit the passage of an armed needle inside the- course of the vessel, over and below its wound, is fraught with difficulty and some uncertainty, but in case the plug did not fulfil its object, the method might be tried in spite of the danger of wounding a nerve trunk as it passed from the spine. Were all these methods to prove ineffectual, a last resource,, one almost of despair, would be to tie the vertebral both below the sixth and below the first vertebra.2 Aneurisms at the Root of the Heck. In tracing the carotid vessel lower down, we come to the root of the neck,. a region in which several forms of aneurismal tumor may show themselves. It appears to me, therefore, advisable to class all these aneurisms together under one general title, as thereby we shall avoid unnecessary repetition or wearisome reference. Under this head are included low carotid, subclavian, and innominate aneurisms, as also those aortic aneurisms which, springing from the first or second part of the arch, make their appearance above the sternum or clavicles, and always affect the upper two or three intercostal- spaces of the chest. By this arrangement it is not intended to lump or con- fuse together these different forms of disease, but rather by comparing them to draw distinctions, more closely contrasted. We have, then, many forms of the disease to study here: two involving the subclavian (1st and 3d parts); one, the lower part of the carotid; two, the innominate (high and low); and several forms of aortic aneurism,3 all liable to make their appearance within a very limited space. Aneurism of the Third Part of the Subclavian Artery.—This fre- quently manifests itself by very severe, neuralgia-like pains, running from above the collar bone down the arm, and to the back of the shoulder, before any distinct swelling is noticed; indeed, I have seen two cases in which such distressing pains, lasting for two months, had almost worn out the patient before aneurism was detected.4 When enlargement becomes perceptible, it 1 An authority on aneurism, writing in the Lancet, proposes this operation in vertebral aneu- rism ; but as is seen from the result of treatment when the disease is about the tarsus (p.903), the method is hardly applicable when the sac and its vessel are inclosed in bones. 2 In the dead subject it is quite possible to tie the vessel as it makes its turn between the axis and the atlas. 8 I shall presently have occasion to point out the essential differences between aneurism of the ascending aorta and of the proximal and distal portions of the transverse aorta. 4 Nevertheless, this symptom is by no means conclusive. In 1878, a gentleman avoided a fall, at a fence by hanging forcibly to a hurdle stake ; pains, such as described in the text, super- ANEURISM OF FIRST PART OF SUBCLAVIAN ARTERY. 955 first shows itself above the middle, or rather a little outside the middle, of the clavicle; frequently that bone is very early in the case pushed forward, and soon beats with a communicated pulsation ; especially is this the case in feeble persons and in women. When the shoulder begins to rise, one may see the throb in the little triangle bounded above by the clavicle, at the sides by the deltoid and greater pectoral. In all cases, the pulsation is strong, while the radial pulse on the diseased side is weakened. The aneurism, unless it encroaches on the proximal part of the vessel, never pulsates in the episternal notch; venous congestion of the arm only comes on when the tumor is large; congestion of the face and neck is absent. The disease is peculiarly liable to begin about the lower margin of the first rib, and to spread thence either downward, when it becomes high axillary aneurism, or upward, when it comes under the category of pure subclavian aneurism; not infrequently it spreads in both directions; it is then subclavio- axillary. The extension upwards is, as a rule, checked by the scaleni, which, supporting the vessel on all sides, prevent dilatation; but in some cases, those, namely, in which atheroma extensively affects the whole arterial sys- tem, the second part may be involved with the first, or with the third; or, indeed, the whole vessel, from beginning to end, may be affected generally by dilatation (fusiform aneurism). In such cases, the tumor is very generally constricted where it passes between the scaleni, so as to assume an hour-glass form. Aneurism never, I believe, begins in the second part of the vessel. The pressure symptoms vary somewhat according to the size of the tumor, its exact place on the vessel, and the direction of its growth; thus, while pressure merely implicates the nerves of the arm and shoulder, with slight enlargement of veins—chiefly those about the acromion and the external jugular—we have to do with an aneurism of only the third part, or encroach- ing but slightly on the second ; but more marked venous congestion, espe- cially if it implicate only the arm and hand, points to extension of disease towards the axilla. If, on the contrary, the face and neck—the whole jugular venous system—becomes engorged, the disease is intruding inwards towards the first part of the artery; and this diagnosis is greatly strengthened if some loss or diminished resonance of voice, and a certain teasing, irregular, laryngeal cough, be observed. The third part of the subclavian artery is aneurismal about six times as often as the first part,1 and is three and a half times more common on the right side than on the left, and about ten times more frequent among men than among women. In about one-eleventh of all the cases of subclavian aneurism, the first part alone of the vessel (on the right side) is involved, and even of this proportion the immunity of the rest of the artery is in a certain fraction doubtful. The first part of the left subclavian artery develops aneurism (unless merely as forming part of aortic disease) very exceptionally. Aneurism of First Part of Subclavian Artery.—An aneurism of the first part of the right subclavian shows itself by a tumor, which generally appears under the clavicular part of the sterno-mastoid muscle ; it lies, there- fore, a little outside the place where carotid aneurism first appears. The shape vened, and gradually increased, for four months ; after that time he came to me, and, on exami- nation, I found the subclavian artery, which lay high, heating violently. The space, however, was putfy, and swollen beyond the limit of pulsation ; the artery appeared to me flattened rather than dilated ; but in a case of such difficulty and importance I conceived it my duty to ask for a consultation. Sir J. Paget, examining the case with me, confirmed my view of its non-aneu- rismal nature, and expressed the opinion that neuritis of the brachial plexus produced the pains- and pressed the artery forward. Under treatment founded on this diagnosis, and on the gouty habit of the patient, he slowly recovered. 1 I include subclavio-axillary aneurism in this computation. 956 ANEURISM. of the swelling is a rather elongated oval, the long axis oblique, the lower part of the tumor being covered by the clavicle; it may, indeed, protrude and pulsate also just below that bone. If the shoulder be raised, this bone glides over the tumor until the whole of a moderately small, or only part of a larger aneurism, is thereby concealed. If large, an aneurism in this situation may press the clavicle forward until subluxated. Certain pressure-symptoms are well marked. The first is usually a teasing cough, with altered voice, from slight stretching of the recurrent laryngeal nerve; then the internal jugular vein becomes distended, and may be seen engorged at the lower part of the neck. The tributary veins are also full; this is especially the case with the external jugular, which, assuming part of the deeper vessel’s office, becomes often exceedingly large. At a somewhat later period the veins of the hand and arm swell, and then those of the front wall of the axilla. As the tumor increases in size, so are these symptoms aggravated. Irrita- tion of the larynx yields to paralysis of the vocal cords; the veins of the neck, arm, and side become fuller, and these parts may even become varicose; the radial pulse is weaker than on the other side, and, indeed, is sometimes barely or even not at all perceptible. There is frequently some difficulty in distinguishing low-carotid, subclavian (of tirst part), innominate, and even, strange as it may seem, certain aortic aneurisms, from each other. Diagnostic signs are chiefly derivable from com- parison of the radial and carotid pulses on the same side. If the innominate be unaffected, the beat of the carotid is not altered ; hence a pulsating tumor above the clavicle which greatly affects the radial, but not at all the carotid pulse, is purely subclavian; the innominate is involved if the impulse of both vessels be modified. Moreover, a purely subclavian aneurism is hardly ever to be felt in the episternal notch ; while innominate and proximal aneurisms of the aortic arch can very nearly always be detected in that situation. Carotid and subclavian (first part) aneurisms of the left side are more easily differentiated, the absence of an innominate rendering them independent of each other. The first part of the carotid—namely, that between its origin and the sterno-clavicular joint—is only the subject of aneurism as forming part of aortic disease. The same may be said of the intra-thoracic portion of the subclavian. It need hardly be said that in subclavian aneurism of the left side, laryngeal symptoms are absent. Low Carotid Aneurism.—The tumor, while yet small, is felt to beat in the angle between the sternal and clavicular portions of the sterno-mastoid muscle; and when that muscle is relaxed, so that the linger can he passed behind its inner portion, the rounded margin of the pulsating swelling can there he distinctly made out. As the size of the aneurism increases, its inner edge comes to lie inside this muscle, and may be felt in the right1 portion of the episternal notch. The tumor, if ovoid in shape, has its long axis directed upward and downward. The impulse is upward. I do not, of course, mean that the blood-stream can actually be felt, but that the expansile wave is in that direction. The pulse of the carotid above the aneurism, about on a level with the thyroid cartilage (where it is most easily felt), is decidedly weaker than on the left side, as is also the beat of the arterial branches—the facial on the lower jaw, and the temporal; I rely rather upon the extremely facile •compressibility of the arteries than on their mere weak beat. This peculiarity is carried even into very small branches, for if the patient’s ears be nipped simultaneously and with equal pressure for a few seconds, between the finger 1 Tlie aneurism is supposed to be of the right carotid. INNOMINATE ANEURISM. 957 and thumb of each hand, and then suddenly released, the white mark thus produced will regain its color more slowly on the diseased than on the normal side. These signs show that the carotid artery is aneurismal.1 We now must discover if it alone be involved. The “exclusion signs,” as they may be called, are these:—- There is no sign of pressure on any vein, nor, unless the tumor be very large, on any nerve; larynx, trachea, and oesophagus are all unaffected. Until the sac is large enough to press on those tubes, the radial pulses are alike and unaltered; percussion-sounds of the parts below the sterno-clavicular joint are normal; unless of course the lung happen to be diseased, there is no dul- ness over the first rib and intercostal space. It is assumed in the above paragraphs that the aneurismal nature of the tumor has been distinctly verified ; nevertheless, I would point out that it is well to give the patient a little water, and while he is swallowing to watch the behavior of the tumor—if it rise with the trachea or remain stationary. It is well to point out that the lower, like the upper, part of the common carotid, is in women occasionally the subject of a peculiar condition, which although anatomically abnormal, is yet not the result of disease. I have never had the opportunity of investigating this peculiarity after death, but, from study during life, the condition appears to be the result of the mode in which the innominate divides, incorrectly represented in anatomical works. The received idea of this bifurcation is, that the two vessels arise side by side from the end of the parent stem—in reality they spring one posterior to the other, the subclavian behind. How, in most persons, the carotid runs straight from this point to its bifurcation, leaving a little space, the thickness of the clavicle, between itself and the sterno-mastoid, just above that bone; but in other persons the vessel bends forward over the upper border of the clavicle, touches—even flattens itself a little—against the fascia between the two parts of the muscle, and then swerves back again. The most prominent part of this curve pulsates visibly, sometimes strongly. The sense of touch will, how- ever, distinguish this beat of a perhaps slightly dilated artery, from that of aneurism. Innominate Aneurism, pure and simple, is not a common disease, the trunk being so short that either one or both of its branches, or its root on the aorta, are involved, either at first or soon after the commencement of the disease. Indeed, clinical experience convinces me that many cases of innominate aneurism begin at one or other end of the vessel. Thus, as with carotid aneurism, we encounter a high and a low form of the disease, the symptoms of which are different. Hay, more, the high form, which term indicates participation, perhaps commencement, of the disease in one or other deriva- tive, exhibits different symptoms, according as it begins on the carotid or on the subclavian aspect of the vessel. These differences chiefly regard the re- sults of pressure. Some ambiguity may, however, be produced by a form of aneurism, purely aortic, which, springing from the front of the arch, near the root of the brachio-cephalic trunk, expands in front and in the direction of the latter vessel, occupying anatomically very much the same place as the disease under consideration. The tumor of an innominate aneurism generally occupies the episternal notch, but chiefly on the right side, and, even though it may not rise high, takes up the whole breadth of this space. On gently pressing the finger backward and downward, the rounded margin of the sac can be felt. After 1 It is true that some other forms of aneurism may compress the lower end of the carotid, and obscure the symptoms ; these forms are detected by the signs now to be specified. 958 ANEURISM. a little time, the sternal end of the clavicle protrudes abnormally and partakes in the pulsation (communicated), while the sternal and afterwards the clavi- cular portion of the sterno-mastoid is also pushed forward. Not unfrequently the tirst costal cartilage, outside where it joins the sternum, is also abnormally prominent, and throbs with the beat of the tumor. These parts are dull on percussion ; there is a peculiarity in the dulness of aneurism, which should be observed, namely, that in the centre it is complete, but at the circumference, on each side, incomplete or relative, gradually, as we go outwards, merging into the clear percussion note. Downward, the want of resonance usually mingles with the normal, aortic, and further downward and to the left, with the cardiac dulness. But occasionally, especially if some dyspnoea exist, a significant, resonant space lies over the sternum, between the second costal cartilages, dividing the cardiac from the tumor dulness. Its appreciation depends on the mode of percussion; gentle taps elicit hyper-resonance; heavier blows the deeper dulness. This condition is produced by an emphysematous lung-margin, overlying the commencement of the aorta. The pulsation is most marked where dulness is most complete, but extends even into the limits of relative dulness. Occasionally, a pretty evident throb may be felt beyond the dull region. The area of pulsation, until the tumor is large, may be taken as in the annexed dia- gram. The stethoscope detects over all this space the heart- sounds, with exaggerated dis- tinctness ; but they are altered in a way that has been insuffi- ciently, if at all, pointed out, viz., while both are heard as plainly as, perhaps even more plainly than, over the cardiac space itself, it is the second sound which is more especially exaggerated, and this is often louder than the first; the thin- ner the wall of the aneurism, and the freer from any lining of blood-clot, the more predomi- nant is this second heart-sound. The pulses of the right radial, and of the carotid and its branches, are altered, weak, and compressible. These signs are such as we meet with in the form of disease which affects the upper .part of the trunk, and either commences in or tends to carotid complication. But cases occur in which the tumor lies more outward in the episternal notch, and in which it may be felt along a certain distance of the clavicle, the symptoms being those of innominate and subclavian aneurism combined. The pressure symptoms of innominate aneurism are very variable: some- times slight, sometimes remarkably severe. If the high form of the disease be on the inner aspect of the artery, there is at first a constant, teasing cough ; this afterwards gives place, as the tumor grows, to dyspnoea, with paroxysms of coughing and breathlessness that seem about to prove fatal, until relieved by discharge of mucus or muco-pus. No venous pressure is demonstrable until the disease has attained considerable dimensions. When the tumor lies Fig. 547. Area of pulsation in early innominate aneurism. TREATMENT OF ANEURISMS AT ROOT OF NECK. 959 outside the episternal notch, there is at first an abnormal voice, tending to break into falsetto, afterwards want of tone, and then aphonia, with a ten- dency to “ swallow the wrong wayand about this time congestion of the left arm and of the left side of the head and neck. There is no dyspnoea until the tumor has become large. The low form of innominate aneurism, as it is usually combined with aortic disease, must be considered with that subject hereafter; but it will be well to point out here some remarkable peculiarities in the pressure symptoms. There are respiratory complications—paroxysmal metallic cough without aphonia, and marked dyspnoea. But the point to be especially remarked is this: the pulsation, dulness, abnormally loud heart-sound, etc., are on and to the right of the middle line ; the venous congestions are on the left side of the body, nor does the right participate till late in the disease. The very free communication between the cephalic vessels renders this less evident in the head ; but the veins of the forearm and upper arm look in such cases almost varicose, and a meshwork of blue vessels overlying the left pectoral region is especially striking. A peculiar, soft tumor, sometimes described as spongy, but giving a sense of being made of worms, smaller than those felt in varicocele, forms over the left clavicle—a very characteristic symptom. When the right side is also involved, the aneurism will have become large; the amount of dyspnoea and of exclusion of air from the lungs must decide whether this parti- cipation results from pulmonary congestion, or from pressure on the descending cava or right innominate vein. Treatment of Aneurisms at the Boot of the Neck.—Before going on to study the surgical treatment of innominate aneurism, which I shall take up with that of the aortic arch, it will be well first to consider the measures available for the other forms just described, assuming that no one would proceed to operative measures until rest, diet, one or other form of pressure, and perhaps some other of the methods already mentioned, had been fairly tried, and had failed to produce any lasting benefit. The word “ lasting” is used here because there are few cases, subject to rigid* rest and unirritating diet, which fail to exhibit signs that simulate improvement. The heart and the vessels being in repose, it is only natural that the aneurism should pulsate with less force; and, unless its coats be very thin, that it should, by the mere elastic contrac- tion of its walls on a less potent blood-stream, diminish in size. No doubt, in a certain number of cases, this immediate result is followed by material im- provement, or even by cure. Other patients, having simply reached that point, progress no further. Week by week, or oftener, a full examination shows the disease in the same state; at last the exigencies of life require resumption of occupation f when movement and employment immediately bring back the old rate of growth. Another and the larger series of patients experience some immediate benefit from the rest and restrictions, for the first few days; after which, and even while treatment is going on, the disease resumes its rapid progress. Under either of the two latter conditions, surgical measures should be resorted to. Best and Diet.—I find, of aneurisms of the subclavian, 31 treated by rest and regulation of diet, and 13 subjected to the stricter regimen and the vene- sections of Valsalva. Of those in the former category,2 4 were cured, but 2 of them so rapidly, or rather suddenly, that the event was evidently due to some 1 These are the cases which, in Hospital Reports, are noted as “relieved.” 2 Poland gives 22 cases ; the additional 9 are from my own sources, chiefly from Hospital Re- ports. There is no doubt that many more have occurred in different parts of the world ; but a case of aneurism treated by means so little noticeable, increasing and killing the patient, would hardly find its way into print. 960 ANEURISM. fortuitous impaction of clot. Cure can only be ascribed to the influenceof treat- ment in the 2 cases which recovered slowly, that is, by gradual consolidation. Of 13 patients subjected to Valsalva’s method, 7 are reported as cured, or in process of cure; but on examination this number shrinks considerably; 2 cases (Guerin) are very likely one and the same; 2 are doubtful as to the nature of the tumor; 1 patient was not cured, passing from observation almost immediately after treatment had been begun, and with little benefit; in 1 spontaneous cure fortuitously began with or before the treatment; 1 got well during acute enteritis; 1 recovered under the influence of a poisonous dose of aconite (Pancoast).1 Compression.—Proximal compression was rendered facile in a case under the care of Mr. Poland, by an arterial abnormity combined probably with the development of a cervical rib. The aneurism was cured. Another successful case recorded by Dutoit, is referred to in the sequel. Of the results of direct compression, it is hardly possible to acquire any ac- curate numerical knowledge; probably nearly every quickly increasing an- eurism has, at some part of its course, been restrained, or attempted to be restrained, by some bandage or pad; and a few of these cases have got well, as in Yeatman’s case, without any clear sequence between treatment and cure ;2 or an accidental detachment of clot, as in Corner’s case, has occurred under a protecting leather cap ;3 or an accident rupturing the aneurism has caused, by the blood-pressure, obliteration of the artery and afterwards sup- puration ;4 or, as in another case5 recorded by the same surgeon, the ten days’ very moderate pressure may have set up the first increment towards gradual consolidation; or the cure may have been fortuitous and spontaneous. In- deed, the only clear case of cure by direct pressure is that of Mr. Holmes.* The tumor was the size of a chestnut, and lay on the third part of the vessel; the index finger was gangrenous. The arm was enveloped in cotton-wool, and an India-rubber ball was bandaged upon the swelling with gradually increas- ing pressure, for about six weeks, and after five days’ intermission was again employed for ten days; after this, an instrument was adapted. Gradual con- solidation took place; and the man was'seen a year afterwards with barely a trace of the disease—a most gratifying result, which should encourage a trial of this method, but a result which we cannot expect frequently to follow, unless, as in this instance must have been the case, there exist a great ten- dency to spontaneous cure.7 Manipulation is a mode of treatment suggested by events which occur spontaneously with such frequency that we should not exclude it from, our resources, especially in dealing with a disease which offers to the sur- geon so few points of vantage. It should be very cautiously resorted to in subclavian aneurism; the danger of embolism in the brain, through the ver- tebrals, and on the right side through the carotid also, must be duly weighed. 1 111 my table I have marked one of the Guerin cases as doubtful, put two others in the same- category, and relegated the one not cured to its proper place, as also those influenced by poison and disease ; this leaves one case as cured by Valsalva’s method. 2 Med. and Pliys. Journ., vol. xxxiii. 3 Medico-Chirurgical Transactions, vol. lii. p. 303. Mr. Corner entitles his case one of Right Subclavian Aneurism cured by Direct Compression ; and Mr. Poland has accepted this nomen- clature. The first treatment, rest, diet, and ice, resulted in “ no benefit;” then “ a leather cap was moulded to the swelling and fixed on by straps.” The patient resumed his occupation, and there is no note of improvement. A year afterwards “ he felt himself suddenly bad, experiencing sickness and vertigo, so that he was obliged to hold on to something to prevent his falling ; and on feeling the swelling afterwards no pulsation was found in it.” No clearer evidence of acci- dental clot-impaction is possible. 4 Warren, Surgical Observations, p. 425. 5 Ibid., p. 427. « Lancet, Feb. 12, 1876. 7 A case by Dutoit, in which pressure aided other means, will be mentioned immediately. TREATMENT OF ANEURISMS AT ROOT OF NECK. 961 1 find this mode of treatment noted five times in the Hospital Reports of the last ten years, and each time as unsuccessful; while of the five cases quoted by Poland, in only one was it of avail.1 Parenchymatous injections of ergotin appeared to he of decided benefit in the case of Dutoit, the cure being confirmed by distal pressure.2 The case, as I read it, was one of fusiform dilatation of the left subclavian, just before it passes between the scaleni. Dutoit used large doses, beginning with half a grain, and rapidly increasing to three grains. After the fourth injection, the tumor began to diminish, while the surrounding tissues became exceedingly hard. After about three weeks, distal digital pressure became possible, and was used during six days—in all twenty-one hours. The aneurism became solid. But three more injections, and then an India-rubber pad and bandage, were em- ployed. The treatment occupied five months. This case gives the most potent evidence on record that such injections may be valuable. In Langenbeck’s case, that which laid the foundation of this treatment, the ultimate benefit was doubtful. I find no other instance of advantage derived from this plan; but it has very frequently been used without any good result. Injection into the sac of perchloride of iron has not proved beneficial, and its dangers are very great, since it is impossible to obviate the flow of solid or semi-solid blood-clots along the vertebrals. Temporary ligature and acupressure have proved even more surely productive of secondary hemorrhage than has permanent deligation. These plans were tried by Porter and Bickersteth, and will be referred to in the sequel. Amputation at the shoulder joint was suggested and practised by Mr. Spence,3 and the method has since been adopted by Holden,4 Heath (who, after ampu- tating, also thrust needles into the sac),5 II. Smith, Rose, and Bellamy.6 Mr. Spence’s patient seems never to have quite lost pulsation in the aneurism, though he survived four years. Rose also tied the carotid, and thus succeeded in curing his patient. In the other cases the procedure was unat- tended by any benefit.7 The results of these methods may thus be tabulated:— Treatment. No. of cases. Cure by treatment. Coincident cure. Death or no benefit. Doubtful cases. Rest and diet . . 31 2 2 27 Valsalva’s method . . 13 1 2 7 3 Proximal pressure8 . 1 1 Direct pressure . r 1 Manipulation . . . 8 1 6 i Coagulating injection . 2 .. 2 Injection of ergot8 . . 6 1 4 i Galvano-puncture 3 1 2 Temporary ligature . 2 • • 2 Amputation at shoulder-joint 7 28 5 1 Fergnsson’s second case cannot be regarded as cured by tbe manipulation. 2 Langenbeck’s Archiv, Bd. xii. S. 1070. 8 Spence, Med.-Chir. Trans, vol. lii. p. 306. 4 St. Bartholomew’s Hospital Reports, vol. xiii. 5 Med.-Chir. Trans., vol. lxiii. p. 65. 6 Unpublished. A case of ruptured artery after dislocation reduced by another surgeon. In the engorged condition the artery could not readily be found. 1 In Morton’s case (Pennsylvania Hospital Reports, 1868), amputation of the arm and subse- quent removal of the caput humeri, were undertaken for secondary hemorrhage after deligation of the second part of the artery, rather than for subclavion aneurism ; the man recovered. • I have placed the case of Dutoit among the successes by injection of ergot, and also by proxi- mal pressure ; he insists upon this latter, but I do not understand how it was applied. 9 One of these cases (Morton’s), referred to a few lines ago, was hardly an amputation for aneurism. Spence’s patient lived, but the aneurism was not cured. 962 ANEURISM. Ligature of the subclavian artery in its terminal division, for aneurism of the same tract of the vessel, would, at once, strike the surgical pathologist as a very hopeless procedure, (see p. 940), and we find that in the five cases in which this has been attempted, death resulted in three,1 a mortality of sixty per cent. But if the aneurism be subclavio-axillary, and do not reach as high as the border of the scaleni, a better prospect is afforded.2 Thus, for such disease, the vessel has been tied over the first rib twenty-eight times, with sixteen recoveries and twelve deaths; hemorrhage was the fatal complication in five cases. The small number of cases in which the second part of the subclavian •artery has been tied for aneurism, is probably due to an exaggerated idea of the difficulties of the operation. I cannot but think that this deligation might, with advantage, be substituted for that of the third part in a large number of cases, since, as already pointed out, the vessel is less often diseased at the spot w'liere it is supported by the muscles, than elsewdiere, and usually only one branch is given oft* from that part. I can find only nine cases of this procedure, with but four recoveries and five deaths. In analyzing the causes •of death find that only one patient died of secondary hemorrhage (Liston), mid one of cerebral complications, the cause being obscure; two cases of 'diffused traumatic aneurism3 terminated fatally by pyaemia, and one patient died of drunkenness when nearly recovered (Gay). Thus four deaths out of the five may be considered as not intimately connected with the operation, and we may, therefore, regard them as almost fortuitous. We have still to record seven cases in which the aneurismal sac so covered the artery that it could not be reached without exposing the patient to un- justifiable danger. Of these cases of commenced, but abandoned, operation, five ended in death ; one was followed by cure (probably the result of manipu- lation) ; of one, the result is unknown. Deligation of the first part of the subclavian artery, or of the termination of the innominate, is an operation which the surgeon would only undertake under very pressing circumstances; indeed, high authorities have pronounced it unjustifiable. But that judgment was given, and the experience whereon it was founded was acquired, before the modern improvements in the material of ligatures had been introduced. I should not, in a suitable case, decline to tie either of these vessels, although the statistics of the past (had we still to rely on silk or hemp), would, undoubtedly, deter me from any such under- taking.4 These statistics are as follows: eleven patients have been subjected to this operation, of whom every one died—one from pericarditis, pleurisy, and pyaemia, and nine from hemorrhage, the cause of death in the eleventh {Arendt’s) case being unknown. In a twelfth case (McGill’s), in wdiieh the artery was compressed with torsion forceps, death resulted from a wound of the pleura. The bleeding in the nine cases referred to took place from the •distal part of the vessel, that is to say, from beyond the ligature. Thus it appears that free collateral circulation keeps the part of the vessel on the further side of the heart open, so that when the artery is ulcerated through, blood passing along the branches, enters the trunk, and makes its exit from the peripheral end of the severed vessel. For this reason Liston and Cuvillier 1 One of Mr. Poland’s cases was in reality a deligation of the second part, and I find, since the date •of his papers, another case similarly incorrectly classified. 2 The difficulty of determining, before exposing the artery, the exact height at which such •disease may stop, is undoubted ; after laying the vessel bare, however, the surgeon has the •choice of placing his ligature behind the scalenus. 8 In reality a wound of the artery; it is the comparative absence of hemorrhage, that very fatal result of more central operations, on which I would especially rely as supporting the re- commendation given in the text. 4 The method of performance is given at p. 963. TREATMENT OF ANEURISMS AT ROOT OF NECK. 963 tied also the carotid, while Parker ligatured both that vessel and the verte- bral. The results, however, disappointed the expectations of the operators, and bleeding occurred in the same way. In nine cases, in which the first part of the subclavian only was tied, the operation was undertaken for the cure of subclavian aneurism, and in one case for that of axillary aneurism; these, with Arendt’s and McGill’s cases, and the three in which other vessels also were ligatured, make up the number to fifteen, of which all, save three, are known to have terminated fatally from hemorrhage. A sixteenth case (Hobart’s) belongs to and will be found in another category (aortic aneurism), while three cases (tabulated by Wyeth), in two of which the vessel was secured for gunshot wound, and in the third for vascular tumor of the scalp, do not belong to our subject; all four patients died of hemorrhage. An alternative lies between this operation and deligation of the innominate, but in this choice statistics guide us very little. There have been 25 examples of this procedure,1 and death has resulted in at least 23. In one successful case, secondary hemorrhage occurred; Dr. Smyth, of New Orleans, had tied, at the same time, both the innominate and the carotid; fourteen days afterwards, hemorrhage occurred, and was repeated, but less copiously, at intervals. At last, fifty-four days after the first operation, the vertebral was tied; the patient after this did well, and survived ten years, ultimately dying, however, of hemorrhage from the sac. When we consider the results of these forty-four cases of subclavian and innominate deligation, we are first struck by the frightful death-rate, and, going further, by the fact that the hemorrhage has invariably come from the distal part of the vessel. This is accounted for by the very free anastomoses in the neck, but principally by those of the vessels at the base of the brain. If the •subclavian (first part) be alone tied, blood finds its way down the thyroid axis, but more especially, down the vertebral into the vessel beyond the liga- ture, while tying also the common carotid helps but little, since blood readily passes down that artery into its branches, and so to the subclavian, as well as by way of the vertebral artery. The same thing occurs as in the last case, if the innominate alone be ligatured. Thus a question naturally arises, namely, if a certain sort of ligature could be trusted to effectually prevent secondary bleeding (the vascular coats being undivided), would deligation of the vessel cure the aneurism, unless other arteries—carotid and vertebral— were also tied ? This question can only be answered by experience, such as we have as had little or no opportunity of acquiring. It must be remem- bered that a certain current through the aneurismal sac is advantageous, but we do not as yet know whether the collateral flow would not, in a large proportion of cases, be so rapid as to prevent consolidation. The condition of the aneurism is described in a few only of the recorded cases; but in most of these the sac is said to have been contracted, much thickened, and filled with clot or with laminated fibrin. Deligation of the right subclavian artery in its first 'part.—The operations of tying the first part of the right subclavian and the innominate are very simi- lar. About six slightly different modes of making the first incisions have been practised. Two only need be mentioned, viz., the method by a single transverse or oblique incision, and that by two incisions meeting at an angle: this last is the one which I should recommend. Begin about 2| inches above the sterno-clavicular joint, and over the round belly of the sterno-cleido-mastoid muscle. Make an incision ending on the clavicle a little outside the articulation ; from this, carry outward another in- 1 Including the cases recently recorded by Thomson, Banks, and Durante. The result of the last case is unknown. In Banks’s case the subclavian was afterwards tied. 964 ANEUlilSM. eision over the bone to a little beyond the limit of the muscle; turn the triangular flap upward and outward, tying and cutting, if necessary, the ex- ternal jugular vein ; then the outer edge of the sterno-mastoid being found, a director may he passed behind it1 as far as its sternal origin, and all the clavicular portion divided. This being pushed on one side, exposes the fascia over-lying the sterno-hyoid ; the director, after a little opening in the aponeu- rosis has been made, can be insinuated behind that muscle, which also must be severed. It is well now to look and feel for the carotid artery before going on to divide the sterno-tliyroid, whose outer edge covers that vessel, and never, as far as my experience of the dead subject goes, conceals the subclavian.2 The finger of the operator, after division of the sterno-hyoid, readily detects the longitudinal course and pulsation of the carotid, and may with ease push the edge of the sterno-tliyroid from off its sheath, inward, in which position the muscle should beheld with a blunt hook. When thus the sheath of the vessel is brought into view, the operator should look for the large veins that always, but more especially if there have been dyspnoea, overlie it. Choosing a vacant spot, he merely nicks the loose structure in which they lie, and then pushes them up and down, tearing the cellular tissue a little, till the dense fibrous sheath is bared sufficiently—first, to have a small opening made in it, and then to be slit up. This should be done on the front, inner aspect. Now, at this part the vein diverges a little from the artery, so as to leave a triangular interval through which the vagus nerve runs. A blunt hook is placed over this, and it is to be drawn with the jugular vein gently outward. The next point is to find the subclavian. To do this the operator must remember that the usual description and delineation of the innominate bifurcation is incorrect. It is generally depicted as though the two branches arose side by side and almost at right angles to each other. In reality, the subclavian springs behind the carotid, and the angle between the two vessels is very acute; therefore, to detect the subclavian, the operator must place his finger at the back, outer aspect of the carotid, when, passing it down, he comes generally, a few lines above the clavicle, to the slightly divergent pulsating line of the subclavian, which lies deeper than the carotid by the whole diameter of that vessel.3 In selecting the spot for placing the ligature, it is well not to put it quite close to the bifurcation, but also not too near the border of the scaleni, lest the recurrent laryngeal or the phrenic nerve should be injured. The pneumogastric nerve and the jugular vein should be kept not too forcibly outward, and the needle should be passed from below, while with his left forefinger the surgeon gently presses the pleura downward and outward. Some obstruction behind the artery will very likely be encountered, but it is better patiently and gently to overcome this, and never on any account to attempt to pass the needle the other way; for if this be attempted, the point of the instrument is certain to penetrate the pleura. Having now passed and tied the ligature, the surgeon should consider the advisability of also securing the vertebral artery. It lies in the groove between the longus colli and the scalenus, so that the jugular vein must now be held 1 It may, by an operator sure of his hand, be cut freely. , 2 The mere division of the muscle is in itself unimportant, but there lies behind it a plexus of large veins, passing from the thyroid body to the internal jugular, generally distended by the dyspnoea accompanying aneurism at the root of the neck. Their division causes profuse bleed- ing, and subsequent difficulty in recognizing the deeper parts. This happened in both of Auvert’s cases, while the fortunate knife of Colles missed a large vein just behind the muscle. Hayden, too, encountered severe bleeding when dividing the sterno-tliyroid. 3 In one case, owing to the depth of the vessel, Liston thought it might arise from the aorta to the left of the right carotid, and pass to the right scaleni behind the oesophagus. This, of course, may have been the condition of things, but, also, he may have been mistaken. TREATMENT OF ANEURISMS AT ROOT OF NECK. 965 inward; the dissection already made will have so nearly exposed the artery, that a few touches with a director will lay it sufficiently bare to allow the passage of the needle. The position of the phrenic nerve on the anterior scalene muscle, outside and a good deal in front of the vessel, guards it against much risk of injury, but still it must be carefully avoided. The operator must not mistake the inferior thyroid branch (which is, however, much smaller, and usually at this part external) for the vertebral artery itself.1 Deligation of the Innominate Artery.—If it be intended to tie, not the sub- clavian, but the innominate, or if the former artery be found so diseased as to render deligation hazardous, the same incisions and dissection will suffice for passing a needle round the brachio-cephalic trunk. In most cases, how- ever, it may be necessary to divide the round, sternal origin of the sterno-mas- toid muscle, and in some the outer tibres of the sterno-thyroid. The sur- geon’s finger, passed down the carotid as above described, impinges on the innominate at its bifurcation, the only part which, without removal of bone, is attainable.3 Unless, as sometimes happens, the innominate be shorter, that is, divide lower, than usual, its extreme end can be drawn up into the neck by throwing the head well back. If the respiratory difficulties of the patient prevent this, or a low bifurcation render it ineffectual, a device which I have had more than one occasion to use on the dead subject may be resorted to, unless the carotid is aneurismal or much diseased, namely, to gently grip that vessel in a pair of smooth jawed (11011-serrated) forceps, and, by drawing it upward, lift the end of the artery from behind the sterno-clavicular joint. The fascia on each side of the vessel, that is, just below the subclavian, and inside and below the carotid, should be incised or torn to facilitate the passage of the needle. After tying the artery it will probably be safer, not merely as obviating distal hemorrhage, but for the future course of the aneurism, to tie the carotid also. The vertebral will probably lie behind the aneurismal sac ; if not, that vessel also may be secured without enlarging the incision, or indeed adding to the danger of cerebral complication. These operations are in all cases sufficiently arduous to demand from the surgeon all his coolness and skill; but when the aneurism lies over or very close to the part to be ligatured, when the disease displaces the vessel and changes its relations, when anatomical irregularity exists, all the difficulties become enormously enhanced.3 Deligation of the innominate artery, first performed by Valentine Mott, of Yew York, presents us with a ghastly list of deaths, every operation except one (Smyth, of Yew Orleans) having proved fatal, and by hemorrhage. Yev- ertheless, if we examine the events of each case, it is evident that this opera- tion would not be necessarily fatal if a ligature were employed which, by leav- ing all the coats of the vessel entire, could not be followed by bleeding at the site of deligation. Mott’s and Hall’s patients walked about (most imprudently), one on the twenty-third, the other on the third day. If we except Bicker- steth’s case (temporary ligature), and Hutin’s(not aneurismal, butacase of punc- tured wound), we find the patients living not a few' hours only, but days, until, namely, that dangerous moment for silk and hemp, the time of separation of 1 In certain cases, the aneurismal sac overlying the vertebral artery renders it inaccessible. * Cooper (San Francisco), in a case of large aneurism, removed the upper part of the sternum and a portion of the clavicle ; but when it is considered how frequently in thoracic aneurism part of the sac is formed by these bones, the danger of such a procedure will be evident; Cooper’s patient lived thirty-four days. 3 We find: pleura wounded, one case (Colies) ; severe bleeding from veins under sterno-thyroid, three cases ; abnormal arteries divided, two cases ; abandonment of operation on account of position of sac, four cases ; while in one case (Liston) great difficulty was found in reaching the subclavian, which was supposed to arise from the aorta and to come into the right side of the neck behind the oesophagus. 966 ANEURISM. the ligature, arrives. Sixty-seven and sixty-five days are the longest periods of life, but whether long or short, the mechanical action of insoluble liga- tures—the severance of arterial coats—is the immediate cause of death. To the record of completed cases, we must add four of abandoned opera- tion. One surgeon finding the innominate too diseased, tied the carotid -,1 two other surgeons simply desisted ; in one case (Key) complete, in another (Porter) partial solidification resulted from the manipulation, or from an inflammatory condition set up in the coats of the sac. As regards hemorrhage and the insoluble ligature, the same remarks apply•, all the recorded cases (except Smyth’s) have proved fatal, but the necessity of such a mortality with a different form of ligature is very doubtful, and is at all events not proven.2 Deligation of the Left Subclavian Artery in its First Part.—If the operation of tying the first part of the right subclavian artery be difficult, the deligation of the left vessel is hazardous in the extreme ; the artery on this side lies more deeply, passing into the neck out of the thorax from behind the lung, nor does it rise as high above the first rib: it is almost longitudinal in direc- tion—the internal jugular vein and the vagus nerve are dangerously near and parallel to the vessel—while in front and on the inner side, and somewhat outside, is the pleura. Thus the deep incision, in which the work must be done, offers hardly any space, and when we add the possibility, even proba- bility, that even this narrow area may be still further diminished by encroach- ment of the aneurismal sac, it will at once be understood that the operator must be bold and confident who would undertake such a task ; nevertheless, the deligation has been effected once, by Dr. Kearney Rodgers, of New York,® whose description of the operation, as both instructive and monitory, may here be abridged.4 The external incision was the same as that above described for tying the right sub- clavian ; the inner three-fourths of the sterno-mastoid muscle was divided.6 On turn- ing up the muscle, a portion of the aneurismal sac, strongly pulsating, was brought into view overlapping half the width of the scalenus. The fascia being torn, the deeper work had to be carried on between the aneurism on the outer, and the jugular vein on the inner side, aiming at the inner edge of the scalenus, half an inch above its origin, so as to avoid the thoracic duct ; when this point was reached, the vessel was found without difficulty by pressing the finger downward. The needle with removable point was used to pass the ligature, “great care being necessary to detach the artery and to avoid danger to the pleura and thoracic duct.” Very little immediate shock followed the operation. On the tenth day, a cough commenced ; on the thirteenth, secondary hemorrhage set in, and the case terminated fatally on the sixteenth. At the autopsy, “a large, irregular, lacerated opening was found in the pleura,” and the cavity was filled with coagulated blood. “ The artery had been completely divided by the ligature, which was found loose in the wound. The stump of the sub- clavian, between the aorta and ligature, presented the appearance of a round, solid cord, about one and a quarter inches long, impervious to water and air.” Beyond the liga- ture, no plug other than a soft, quite recent clot, occupied the lumen of the artery; the vertebral was given off immediately at the point of ligature, and contained a like clot, evidently formed only just before death ; the internal mammary, also, was patulous and healthy. 1 Afterwards the subclavian was ligatured by A. B. Mott; see table of cases of consecutive double distal ligature. 2 See Appendix to this Article, containing account of Mr. Thompson’s case of innominate liga- tion with the ox-aorta ligature. 3 Sir Astley Cooper tried to tie this vessel, but abandoned the attempt, believing that be bad wounded the thoracic duct. 4 The case is given at length in the New York Med. Journal, 1846. 6 It is not stated wliat was done with the sterno-hyoid and sterno-tliyroid muscles ; they are simply mentioned as seen, covered by the fascia. TREATMENT OF ANEURISMS AT ROOT OF NECK. 967 The complete division of the artery by the ligature, and the open state of the distal part of the vessel, require no further commentary than a reference to what is said at p. 893. The opening observed in the pleura shows that this membrane was probably wounded in spite of the surgeon’s great care. Temporary compression or ligature of the innominate has been resorted to by Mr. Porter, of Dublin,1 and by Mr. Bickersteth, of Liverpool.2 The for- mer used his artery compressor—an instrument like two aneurism needles sliding one within the other, or like a minute lithotrite; the latter employed a somewhat complicated appliance, whereby he hoped to compress the artery by an elastic force connected by lead wires to the pressure-bar passed beneath the vessel. The former instrument failed by causing a slough of the artery ; the latter by the giving way of one of the wires. Mr. Bickersteth then tied the vessel on each side of the part that had been compressed, with the usual result, secondary hemorrhage, beginning on the seventh day, recurring, and destroying the patient in twenty-four hours.3 Deligation of the axillary artery for subclavian aneurism has, as a distal operation, every possible defect, many vessels being given off by the diseased part of the artery, or between the sac and the ligature. The procedure has been employed five times, and in each instance certainly did no good, but probably hastened the fatal termination. The next aneurismal tumor at the root of the neck, of which the treatment is to be considered in the order we are pursuing, is low carotid aneurism., by which words it is intended to indicate a tumor placed so low in the neck that a portion of it is situated below, on a level with, or just above the clavicle. This position offers the surgeon no opportunity to apply a ligature anywhere between the tumor and the heart, unless he have recourse to tying the innominate. Hence the treatment is restricted to a tract of vessel beyond the sac, to what are called distal methods. Distal pressure on the carotid is. unpromising, because it has to be applied higher than Chassaignac’s tubercle, at a point where the patient cannot possibly bear it for a sufficient length of time, if it be directed backwards. The only feasible method, therefore, is that practised by Rouge,4 which has already been described (p. 947), as have also- the possible advantages and very certain dangers of the rapid mode of employ- ing compression. If rest and pressure fail, we have no recourse but to place a ligature round the carotid on the distal side of the aneurism.5 This opera- tion was first formulated and practised by Wardrop, who especially pointed out its applicability to the carotid, since no vessel is there given off between the ligature and the origin of the artery. A distal deligation of the carotid should be practised above the omo-hyoid muscle, and not far from the bifurcation. The method of performance has already been described, but I would point out that an aneurism may con- siderably displace the vessel, and that care in studying the part and its vicinity should therefore in every case be used. In this operation the pulsation of the aneurism does not cease, as in the proximal deligation. When the ligature is tightened, indeed, it may for a few seconds increase, but the tumor should not increase in size. Such an event would be of bad augury, as indicating danger of future rupture. Shortly after, a noticeable but not very great decrease in size can be verified, 1 Dublin Quart. Journ. of Med. Science, Nov. 1867. 4 Medico-Chirurg. Trans., vol. lvi. p. 129. 3 I am not aware that the instrument of Dr. Fleet Speir has been used on this vessel. For remarks on temporary ligature, see p. 889. 4 Rouge’s case was cured in 136 hours—viz., 8 hours daily during 17 days. 5 Neither electrolysis nor injection of coagulants is applicable, since cerebral embolism would almost certainly follow. 968 ANEURISM. and slowly the pulsation diminishes. We have not sufficient experience to fix any date for its cessation; indeed, in certain cases, as when the aneurism is placed very low, pulsation may be communicated to the solidified tumor from the innominate on which it rests. I find hut a few cases on record of this operation, for carotid aneurism pure and simple, and at least three of these terminated fatally.1 This paucity arises from the fact that low carotid disease, even though commencing simply in that vessel, has a great tendency to spread downward, and to encroach upon the end of the innominate; but chiefly because it is pro- bable that most of the aneurisms developed in this place begin, as so many aneurisms do, at the point of bifurcation of the latter vessel. Of course an aneurism commencing at that part may spread upward on the carotid, laterally to the subclavian, or in both directions. They remain, however, high innomi- nate aneurisms, although they are frequently called carotid or subclavian aneu- risms, involving the innominate. Innominate aneurism, when diet, rest, and medicine have failed, is hardly amenable to other form of surgical treatment than operative. The surgeon may, indeed, try galvano-puncture, the statistics of success and failure of which have already been given. Pressure, if used at all, can only be distal; nor can it be expected, as a rule, to yield any good result; yet the fact must not be overlooked, that one case of innominate aneurism is reported to have been cured, or greatly benefited, by this method.2 The instrument used was a modification of Bourgery’s compressor for subclavian aneurism, namely, a broad leather belt round the chest, bearing an oblique strap, which, fastening to the left side of the belt, back and front, passed over the right shoulder, and kept a pad firmly pressed on the subclavian. The corset carried behind a steel plate, bearing an upright rod, terminating above in an adjustable lever, with screws, pads, etc., whereby compression could be made on the carotid. The laryngeal symptoms and occasional faintings, previously distressing, dis- appeared in a week; at the end of three months the instrument was laid aside, and the patient returned to her usual household duties. The report was written ten months after treatment had been abandoned, the patient, if not cured, yet living her usual life. The means appear very inadequate to the end in view and to the success obtained; no doubt there must have been in the patient a great tendency to spontaneous cure. Still, the case is, as far as it goes, important, as showing the possibility, however remote, of aiding recovery by distal pressure. The operative treatment of innominate aneurism has, of late years, greatly interested the surgical profession, many having attempted to realize Ward- rop’s views regarding distal ligature. It is unfortunate that that surgeon, in his well-known case (Mrs. Denmark’s), should have erroneously supposed his patient’s right carotid to be obliterated, so that he tied only the subcla- vian, in its third part. Even with this inadequate operation the patient was greatly benefited, but died two years after, a large aneurism of the innominate still persisting. The method thus inaugurated, was repeated from time to time by other surgeons, with certain variations to be immediately described, but without 1 My figures differ from those of both Dr. Wyeth and Mr. Holmes. The names of the opera- tors are as follows : Wardrop, Bush, Lambert, Wood, Montgomery, Lane, and Colson (de Noyon). [Additional cases, raising the number to ten (with four deaths), are recorded by Demmd, Delens, and De Mello Ferrari ; an eleventh case is attributed to Barbosa.] Like Mr. Holmes, I count but one case to Wardrop; the vessel in his other case bore on post-mortem examination no sign of having been tied. I add to each list certain other cases. Several cases diagnosed as examples of pure carotid aneurism have been afterwards proved to belong to a different category. 2 A. M Edwards, Lancet, Jan. 9, 1858. The case appears to have been overlooked by most, if not all, writers on this subject. At least I do not find it quoted in any work that I have searched. TREATMENT OF ANEURISMS AT ROOT OF NECK. 969 much success, until 1865, when Mr. Heath tied simultaneously the right carotid and subclavian for a woman supposed to be suffering from innominate aneurism,1 who survived four years in spite of the most wretched, drunken habits. In 1872, an excellent study and resume of the subject, by Mr. Holmes, kept up an interest which had never greatly flagged.2 Nevertheless, no suc- cessful instance of this mode of treating innominate aneurism had occurred until August, 1877, when I tied simultaneously the right carotid and sub- clavian in the case of Robert Watson, illustrations of whose case, before and after the operation, I subjoin.3 Fig. 548. Fig. 549. Case of Robert Watson ; innominate aneurism. Case of Robert Watson, seven weeKs after operation. In thus dealing with an aneurism of the innominate by attacking its branches, it is evident that a certain choice lies open to the surgeon. He may either elect to tie, at the same operation, the common carotid and the subclavian, third or first part, or he may ligature one of these vessels as a first step, reserving the other to some favorable opportunity. These pro- cedures are called “double distal ligations,” the former being qualified as “simultaneous,” the latter as “consecutive.” Or he may content himself with tying only one of the vessels in question, the one selected being usually the carotid, though in a few instances the subclavian only has been tied. Having then this wide choice, the surgeon requires certain grounds upon which to base his decision: first, as to the propriety of adopting any operative mea- sure ; and secondly, as to what that measure should be. The former consideration is at the present day of very vast importance, because the method of double distal ligature has, of late years, received a great impetus; it is also one in which I am personally interested, as much of that impetus has been imparted by my own successes and writings. By the results of surgery in this department, during the next few years, posterity will judge the justifiable or unjustifiable nature of the procedure. Now suc- cess in great measure depends upon a judicious selection of cases; while want 1 After death, the aneurism was found to have been aortic. The case is reported in the Lancet, Jan. 5, 1867 ; the preparation is in the College of Surgeons’ Museum, Pathological Series, 1596 A. 2 Lectures on ftie Surgical Treatment of Aneurism, delivered at the CollegG of Surgeons, and published in the Lancet, 1871, 1872, 1873. 3 By kind permission of the Council of the Medico-Chirurgical Society, in whose Transactions, vol. lxi. p. 32, the case is published. The aneurism was cured, but the man exposed himself, insufficiently clad, to most inclement weather, and died of bronchitis, quite independent of the •original disease, six months afterwards. 970 ANEURISM. of judgment or insufficient care in examination will most certainly bring a valuable operation into disrepute. For the guidance of the surgeon, I would submit the following aphorisms:— I. An aneurism commencing suddenly, especially if traceable to some trau- matism or over-exertion, is more likely to be benefited by operation than one arising gradually and without assignable, mechanical cause. II. Distinct sacculation is a most desirable condition; fusiform dilatation of the innominate indicates almost certainly a similar condition of the aorta, and widespread arterial disease. III. If symptoms show the aortic arch to be also affected, the disease should be limited, that is, should not extend along the transverse portion; it should be of the sacculated variety, not a general dilatation of the whole calibre. Absence of any other aneurism, especially of the rest of the aorta, must be ascertained. IV. Absence of rasp-sound along the aorta, or any other indication of ex- tensive atheroma, should be verified. Y. Aortic incompetence (obstruction, regurgitation, or both), unless very slight, is a decided objection, as is also mitral disease or considerable hyper- trophy of the heart. VI. Patency of the vessels leading to the brain should be investigated by making a few seconds’ pressure on the carotids alternately, and then simul- taneously. VII. Absence of visceral disease must be ascertained.1 The choice of tying both vessels at the same time, or of at first securing one only, must depend in part on certain peculiarities of the aneurism, in part on other matters concerning the circulatory organs. In regard to this question I would offer the following rules:— I. If the aneurism occupy the distal end of the innominate, with the root either of the carotid or of the subclavian, but not of both, then we may tie the one or the other respectively. II. If there be only a moderate degree of aortic incompetence, such as might, however, be dangerous for simultaneous deligation, the surgeon must carefully consider whether its amount wrould also preclude tying a single vessel. III. Aortic dilatation may be such in amount as would permit of tying one, but not both vessels, without danger. IV. Any strong suspicion that the left carotid, or either vertebral, was blocked, would negative deligation of the right carotid, but not of the sub- clavian in its third part. Y. In all these contingencies, except the last, the value of a subsequent deligation of the other vessel must be gathered from the manner in which the first operation has been borne, the amount of good effected, and the changes produced in the direction of aneurismal growth. YI. When none of the deterrent circumstances are present, and when the aneurism of the innominate does not markedly obtrude on one branch to the occlusion of the other, both vessels should be tied. Aneurism of Arch of Aorta. We now come to a subject, tlie surgical aspects of aortic-arch aneurism, which involves the latest developments of the surgery of vessels. In the 1 Many a case has been placed on the debit side of the account when the aneurism had been cured, or was in process of cure, the patient having died of some other disease, the symptoms of which had been disregarded or overlooked. Some of these aphorisms may appear superfluous,, but they are all justified by records. ANEURISM OF ARCH OF AORTA. 971 year 1869, Dr. Cockle called attention1 to several cases in which aneurism of the aorta had been cured, or greatly benefited, by obliteration of the left common carotid artery, whether by accidental impaction or by the surgeon’s- art, under the influence of a mistaken diagnosis f and he recommended that in certain eases (which he did not very clearly define) of aortic disease, the left carotid should be tied in the neck. Shortly after, a suitable case pre- sented itself, and under Dr. Cockle’s supervision, Mr. Heath performed the operation. The practice has since been followed by Mr. Holmes and by myself, with incontestable benefit, I was assiduously going through this whole subject, studying the results of operation and the causes of success or failure, when it appeared to me- that Dr. Cockle’s theory did not by any means exhaust the sub- ject ; and this idea was confirmed by considering cases of aortic aneurism, indubitably benefited, perhaps even cured, when the diagnosis had been incorrect, and when, under error, treatment had been directed to the innominate by tying vessels on the right side of the neck. This appeared to me connected with a curious fact in pathology. A concretion de- tached from an aortic valve al- most invariably finds its way into the left carotid, occasionally into the left subclavian; into the right carotid about once in twenty-live cases. Hence it has been assumed that the left vessel lies more fully than the right in the axis of the ascending aorta, The very re- verse is the fact, as may be proved by making a little punc- ture in each carotid just below its bifurcation, and passing long probes down both, as far as they will go, when, on removing the chest-wall and opening the aorta, the two probes will be seen crossing each other within the vessel. The right probe passes through the aortic opening not far from its left margin, and is well within the ventricle. The left probe strikes the tendinous ring of the aortic orifice on the right aspect of the vessel. In some bodies the end of the instrument will be just within the heart; in Fig. 550. Axes of heart, aorta, and carotids. 1 Lancet, 1869, vol. i. pp. 422 and 489. 2 See hereafter the cases of Montgomery, Tilanns, and Rigen; when error has been committed, the aneurism has been diagnosed as of the left carotid itself. 972 ANEURISM. most it will be in the sinus of Valsalva. The probe is never in the axis of the aorta, but strikes the wall, be it of vessel or of ventricle, at a consider- able angle. There must, therefore, be a truer anatomical cause for this propensity of detached concreta. Solids within a stream, if not too heavy, go with the strongest current; hence we may infer that some subtle curve or slope of surfaces directs the most potent rush of the stream obliquely athwart the vessel, towards the orifice of the left carotid. Looking at the position of parts, it appears highly probable that this is really so. For the axis of the left ventricle is not in a line with that of the first part of the aorta, but, if prolonged from the apex through the centre of the orifice, falls upon and about the outer sinus of Valsalva, whose concavity appears well calculated to divert and reflect the blood-stream in the direction indicated. In this course the current would pass from the right aspect of the aortic, obliquely towards the carotid orifice ; it would occupy that portion of the trunk which in the diagram lies to the left of the whole probe (Fig. 550). Possibly the potent flow of blood in this direction is associated with the preponderance of the left brain and the right half of the body. Another matter must be pointed out, namely, the anatomical arrangement whereby each vessel is enabled to divert and gather from the general cur- rent in the aorta, that portion of the stream necessary for the supply of its own channels and branches. First, we see the great brachio-cephalic trunk ; then, be it observed, there is no interval between that and the left carotid. There is not, as is usually figured and imagined, between these two vessels a bit of transverse aorta, convex upward, but a mere angle, a sort of V-shaped double septum ; a rather wider angle separates the left subclavian from the carotid. If the lower part of the ascending aorta be severed from the rest, and we look along the tube of the transverse part, we do not see the orifices of the carotid and subclavian foreshortened into ovals, or mere slits, as would be the case if these vessels were given off straight and plumb from the parent stem. On the contrary, these openings face us directly, so that we seem to see right into the lumen of each branch, and chiefly into that of the carotid.1 This results from the mode of origin of these vessels. They are not given off' straight and rectangularly from the transverse aorta, but their roots take a very oblique direction to the left, and then swerve more directly upwards; hence the distal margin of each vessel lies on a level considerably lower than the proximal. Each such margin has running from it, downward and to the right, on each side wall of the aorta, a rounded ridge, so arranged that the projection of the distal lip and twofold spur—in shape not unlike a half- funnel—catches the blood-stream as it courses along the main trunk, and directs each its own share into its special branch. The arrangement of these ridges is such that they divide all the upper aspect, and a considerable part of the side wall, of the aorta, into districts, one for each vessel. Hence an aneurism, unless it spring .from the inferior, or concave wall, of the arch, must almost of necessity belong to the district of either one branch or the other (Fig. 551). In some bodies, however, the left carotid springs from the angle, as it were, between the aorta and innominate. In such instances, 1 In my article in the Medico-Chirurgical Transactions, vol. lxii. p. 393 et seq., being anxious to accentuate the absence of foreshortening, I said, “ These openings look nearly round.” The expression was infelicitous. Every careful anatomist knows that the openings are not round ; their shape is different in different individuals. The general condition is that the inno- minate and subclavian openings are nearly semicircles, having their flat sides opposed at a con- siderable angle to each other, so that they are more widely separated in front than behind. In the wider part of this interval, and generally anterior to both the other orifices, is the opening of the left carotid, rhomboid in shape, and with its short end behind, so as pretty accurately to fit the above-described interval. a:\eurism of arch of aorta. 973 the ridge on the distal margin of the brachio-cephalic trunk is particularly strongly marked, and there is also a smaller ridge in the innominate itself, running from the proximal opening of the left carotid. In two dissections, I have found the left carotid arising altogether from the commencement of the Fig. 551. &rch of aorta and large branches, showing oblique roots of great vessels, and ridges running from orifices om aortic walls. innominate. An aneurism of that vessel, occurring in such a subject, would give rise to some considerable embarrassment of diagnosis, and many doubts as to which point should be chosen as that to which surgical treatment should be directed. For instance, this was evidently the original state of the vessel in the aneurism here depicted ; in the preparation, the peculiar anatomy of the left carotid can he more clearly made out than in the drawing (Fig. 552). Now if these conclusions be correct; if there be in the aorta varying rates of current, and if there be districts of that vessel appertaining to the dif- ferent branches, so that the blood which Hows over or near any particular portion of its wall must pass into a given vessel, it follows that an aneurism in one situation, if amenable to surgery at all, must be treated from the ves- sels of the right side, while in other situations it must be attacked from the left. Any special resume of cases is impossible: my views were carried out, first, in my own case, at)d have since been followed by Dr. Lediard and Dr. Wyeth ; these, as far as I know, are the only three cases in which double distal deligation has been know- ingly undertaken for aortic aneurism. My patient lived fifteen months in fair health and comfort. Dr. Lediard’s lived nearly ten months. Dr. Wyeth’s died one year- after the operation, from exhausting diarrhoea. That gentleman writes me : “ Both arteries were obliterated at the points of deligation ; they were not. divided, but were 974 ANEURISM. strong and fibrous, and the ligatures had disappeared. A gratifying and perfect success.” The cases operated on under mistaken diagnoses have also done well in those instances in which the sac arose from the portions of the aorta about to be described, but badly when from elsewhere. Fig. 552. Aneurism of innominate, involving aorta and left carotid; 1, aorta; 2, wall of sac thrown down; 3, laminated clot lining aneurism ; 4, right carotid ; 5, right subclavian ; 6, left carotid ; 7, left subclavian. We cannot then deny the possibility, and, if we could be certain of diag- nosis, the high probability, of being able to benefit by operation some aortic aneurisms developed from certain definite regions of the arch. But to make his efforts valuable, the surgeon should be able to effect this, not merely in a few felicitous and fortuitous cases, while the less fortunate patients suffer injury; there should be in no case any haphazard element, but a clearly formulated view of what is to be done and what is to be gained. To attain such prescience, many difficult and minute problems in diagnosis must be solved. The only forms of aortic aneurism with which surgery can cope, are the sacculated, and perhaps a few of such dilatations as occupy but a very limited and defined portion of the trunk. The former is more favorable than the latter form of disease. Fusiform enlargements, occupying a considerable length of the vessel, are not amenable to surgical treatment; nor indeed would I operate upon any case, whose symptoms did not permit of fairly clear and distinct definition of the place whence the aneurism arose. The method of doing this has not as yet been fully developed. Till of late years, when once an aortic aneurism had been detected, enough appeared to have been done; and even now many medical men do not think it needful to dis- criminate between tumors which spring from one, and those which arise from another part of the arch. But the value which modern views on this subject have placed on more accurate diagnosis, will insure greater precision; and therefore symptoms, and AXEURISM OF AllCH OF AORTA. 975 ■combinations of symptoms, which we may not as yet thoroughly understand, will prove to future investigators of much significance. Especially must this be the case in the early phases of the disease ; the later stages, unless a history of the commencing phenomena furnish a clue, may still be undecipherable. These points being premised, we may go on to consider the symptoms produced by aneurism of the aortic arch generally, and at first without reference to the order of their appearance. (1) Tumor, pulsation, dulness, and certain sounds, depend upon the growth of an aneurismal sac from the artery, extending towards the surface, and dis- placing fesonant lung by non-resonant blood (fluid or solidified). When the aneurism comes within a certain distance of the surface, the chest-wall pro- trudes, at first by mere bulging, but afterwards by a conical tumor, which visibly and sensibly pulsates. Around the point of strongest pulsation, a space of gradually diminishing impulse is traceable ; so, too, dulness is in the middle of the space absolute, further out relative only, diminishing more and more until it merges into resonance; the dull area is usually continuous at one of its margins with cardiac dulness. Over the pulsatile enlargement, the heart sounds are heard with abnormal loudness, but the second sound is much more accentuated than the first; it is sometimes a dull, heavy thud, and in other cases a sharp, metallic ring, but it is always loud in proportion to the first sound, and even louder than over the heart itself. Bruits have hardly been mentioned hitherto, because their presence or absence is so variable; they are of different qualities and degrees, from a mere “ coo” to a harsh, saw-like noise. Many cases run their whole course without any such abnormal sound; others are accompanied throughout by bruits; while in still a third series, the murmur—blowing or rasping—may be heard, either at the beginning or end of the case, while the intermediate portion of its course is marked by silence. These sounds, then, when present, are valuable symptoms, but their absence does not negative the existence of aneurism. We may group this whole range of phenomena under the term “tumor symptoms.” (2) Changes of the pulse are important, and are of different sorts. An artery may be partially obstructed by an aneurism springing from another vessel, curling over and pressing on its trunk ; or, indeed, by a non-aneurismal tumor. The ambiguity which would arise from such a condition must be cleared away by examination of other symptoms. The direct influence of an aneurism on the pulse of the vessel from which it springs, is a reduction of the beat of the vessel below the tumor; it does not necessarily follow, though it is usually the case, that less blood finds its way along the tube, but it does so in a more even manner. A familiar, though not perfectly accurate, simile may be taken from the mechanism of a fire-engine (the heart), which delivers water along the hose (artery) in an even stream, al- though its force is imparted by alternate strokes of the pump. This is effected by letting the water first pass into a cavity—kettle I believe it is called—from which the hose issues. Now, the kettle contains at the top a little air, whose elasticity, acting as a spring, diminishes, if it does not quite eliminate the intermittent or pulsatile quality of the current. The aneurism has in it no air, but the widening of the channel at a point between the heart and the artery examined [together with the elasticity of the sac-wall] is sufficient to moderate, though it does not altogether suppress, the pulsatile character of the stream. Thus, the sphygmographic trace shows a sloping and low upstroke, and an absence of tidal and dicrotic waves, so that, for instance, in an aneurism of the innominate, or of either subclavian, the line may represent a mere succession of even and shallow undulations. This is represented to the finger by a weak, full, soft pulse—indicating an artery which throbs slightly, never empties 976 ANEURISM. itself, and, not having the stimulus of the expansile throb, does not con- tract fully. An aneurism situated less directly on the course of the artery examined, causes changes less easily described, because more varied—a less sloping upstroke, and all beyond represented by a zigzag line running down to the bottom of the next upstroke—and to the linger gives the sensation of a weak pulse, with a thrill or vibration. (3) Dyspnoea and other respiratory troubles are among the most distressing symptoms of aneurism at the upper part of the chest and root of the neck; indeed, many cases of the disease prove fatal merely by obstruction of the air- passages. These troubles are of two kinds, produced, the one by direct pres- sure on the trachea, bronchi, or both, the other by interference with the recur- rent. laryngeal nerve. jSTor are these forms difficult to distinguish from each other. The first produces dyspnoea from obstruction, and on applying a stetho- scope to the chest, a peculiar, harsh, loud, bellows or organ-pipe sound, is heard, at first only on inspiration; afterwards, when the obstruction is more marked, the expiratory murmur is altered in a like manner. If the pressure be on the trachea, this sound is equal in both lungs; if it be on a bronchus, it will be very much more marked on one side than on the other. It is always heard on both sides, unless the point of partial occlusion be very low down, since the irregularities in the current of air affect the stream much above the actual seat of obstruction, though more slightly. Subsequently, if the bronchus be- come altogether closed, no sound—not even the respiratory murmur—is heard. These symptoms are continuous, but every now and then there arise severe paroxysms of violent efforts for breath ; the chest heaves, the veins of the head and neck swell, the face becomes livid, a little air wheezes in and out, and severe, brassy cough adds to the distress until a little thick mucus is ex- pectorated. The quieter phase is then restored until another mass of secreted material obstructs the already too narrow channel. With all this, the voice,, unless in the exacerbation, is not particularly weakened; nay, sometimes it is. rather loud and metallic. The other form commences with changes in the voice, first of all in the tone, which is high, squeaky, and false—or whispering, with muffled falsetto. If dyspnoea occur at all, it does so early in the case, the symptoms resembling those of laryngismus strict,ulus.1 It is under such circumstances also paroxys- mal, but less frequent and more periodical than in the previously described variety. After an interval, aphonia, sometimes complete, sets in, and there may be considerable tendency to choking at meals, that is, to the food pass- ing into the wind-pipe. Examination with the laryngoscope will show that the former condition depends upon tightness (spasm) of one vocal cord, rarely of both ; the latter on paralysis.2 In some cases the dyspnoea and violent cough (tracheal or bronchial symptoms) coexist with the laryngeal troubles. (4) Dysphagia from pressure on the oesophagus is nearly always a later sign than tracheal or bronchial dyspnoea. The patient finds a difficulty in swallowing, at first solids, and afterwards even liquids. By listening a little on the left side of the last cervical or upper dorsal vertebrae, while the patient is swallowing a teaspoonful of water, a prolonged, reduplicated effort at de- glutition will generally reveal, even before the patient is himself aware of it, obstruction in the gullet. 1 Tracheotomy has been more than once performed. 3 Dr. Baumler and Dr. George Johnson showed specimens, in 1871 and 1872 respectively, in which, by the .pressure of an aneurism, both vocal cords were paralyzed (Pathological Trans- actions, vol. xxiii. p. 66, and vol. xxiv. p. 42). In both cases, however, there must have been considerable pressure on the trachea itself (in the former only is it distinctly mentioned), and to this I would attribute the partial paralysis of the right laryngeal muscles, the nerves of which were not directly compressed by the sac. The fact that such tracheal obstruction can take place, must inculcate caution in the interpretation of this symptom. 977 ANEURISM OF ARCH OF AORTA. (5) Another symptom is irregularity of the pupils, either dilatation or con- traction, from irritation, and afterwards impeded function, of the sympathetic, and perhaps also of the vagus. (6) Displacement of the heart downward and to the left, and certain pains in the depths and at the back of the chest, afford valuable though somewhat negative data for diagnosis. (7) One of the most important symptoms is produced by pressure on the veins, causing congestion of different parts, often a doughy lump over one or both clavicles, and oedema about the face or arms. The significance of the localities of congestion depends in great measure upon their relation to other pressure symptoms. Certain combinations furnish remarkably positive evi- dence. For instance: pressure wholly and entirely on the right bronchus; congestion of both arms and both sides of the head and chest; tumor symp- toms, chiefly about the second space and rib, considerably to the right of the sternum; heart displacement, if any, directly outward; the pulses equal, with very slight sphygmograpliic change—perhaps a rather sloping upstroke, usually a flat, blunt apex, absence partial or total of dicrotic wave, but undu- latory character of whole down-line—indicate disease of the ascending aorta. Congestion of the left arm, supraclavicular region, and side of the head; aneurismal character of right pulse (radial and carotid); tumor symptoms a little to the right of the sternum, and probably some tracheal dyspnoea, are symptomatic of aorto-innominate aneurism. Modification of left radial pulse; atfection of left vocal cord; left venous congestion ; tracheal dyspnoea and obstruction of air to both lungs, with tumor symptoms on and to the left ot the median line, mark disease of the transverse aorta. Obstruction to the entrance of air to the left lung alone, with pains at the back and along the intercostals, is indicative of disease of the third part of the arch. It is unnecessary to multiply these examples, which must be taken as indicating simply the broader lines of diagnosis. T/ratment'of Aneurisms of the Aortic Arch.—A certain number of patients suf- fering from aortic-arch aneurism have undoubtedly got well under treatment by rest and medicines. These cases, however, are but few; the great majority of these patients either receive no benefit or quickly relapse. Hence every such case should be sedulously watched, that failure of treatment may at once be recognized. Especially should the commencement of pressure on the air- tubes be carefully observed, because increasing dyspnoea is not only a sign that the aneurism is becoming larger, but shows that the rest treatment is no longer possible. There can be no repose for one who is now and again convulsed with violent cough, and whose every breath is labor. Moreover, as my late lamented friend, Dr. Pearson Irvine, conclusively showed, partial occlusion of the windpipe brings on a certain form of pulmonary disease, chiefly due to obstruction in the exit of air.1 This disease of itself would destroy life, even if the aneurism could be cured. Therefore any considerable difficulty of breathing should be a strong inducement to operation, unless the circum- stances be unfavorable. We should, however, have clear rules for guidance as to which cases will, and which will not, benefit by such treatment. Furthermore, we have to discriminate between the suitability of two operations, namely, that on the left, and that on the right side of the neck. In order, therefore, to save space and time, I will put in the form of a summary the conditions which should guide us in our choice. It must, of course, be understood that only the principal, not the minuter points, can be thus summarized, and that in 1 Pathological Transactions, vol. xxviii. p. 67. 978 ANEURISM. their combination certain of the symptoms may, especially if early in the case, he wanting. (1) For Deligation of Left Carotid.—Tumor symptoms upon and somewhat, but not far, to the left of middle line, and rising into episternal notch, or beneath left sterno-mastoid. Left venous congestion; alteration of left carotid, and to a much less degree of left radial pulse. Paralysis of left vocal cord ; obstruction to entrance of air, equal on both sides of chest; sometimes altera- tion of left pupil.1 (2) For Deligation of Fight Carotid and, Subclavian.—Tumor symptoms on right of median line. Marked changes in right radial and carotid pulse. Venous congestion on right side, affecting first and chiefly head and neck. Afterwards, with increase of tumor, right arm and chest, and right vocal •cord, may be paralyzed. Tumor symptoms on right of and upon mesial line, running up to sterno- clavicular joint and episternal notch; venous congestion on leftside; altera- tion of right pulse (radial and carotid); tracheal dyspnoea. Tumor further to the right, and lower (second space); congestion equal on both sides; no marked difference between the two pulses; heart displacement, ■chiefly outward. Pressure on right bronchus; left lung perfectly free; with puerile respiration, and perhaps emphysema. With any of these conditions, changes of the right pupil may be com- bined. (3) Doubtful Signs, only to be Read by the Light of other Symptoms.—Venous congestion on the left side ; tracheal dyspnoea; dysphagia. (4) Operation should be Avoided.—When tumor symptoms reach widely on both sides of mesial line. When, with paralysis of left vocal cord, there is obstruction of right bronchus. When “locomotive” pulse, thrill, and double murmur, show considerable aortic incompetence. When there is mitral dis- ease or considerable cardiac hypertrophy.2 When there is, in the course of the aorta, the rasping sound of calcification or advanced atheroma, more par- ticularly if the superficial vessels are felt to be rough and rigid. When there is pain about the spine and intercostal nerves; when there is obstruc- tion of the left bronchus only ; when there is pressure on the left apex, and expectoration of frothy blood. To these positive signs, I would add a nega- tive one, viz., the symptoms being so indefinite as to render any diagnosis as to the site of the aneurism doubtful. Results of Simultaneous Double Distal I/igature.—I have been restrained by considerations of space from giving, for the more usual deligations, the lists of operations, since tables of names, dates, results, etc., would in a work like this be inadmissible ; but here, partly because the cases are comparatively few, partly to show the importance of the views which I have expressed con- cerning the conditions of the heart and aorta, the whole list, twenty-seven in number, shall be given in full. The first twenty-four cases were all of aneurism supposed to be innominate. 1 I would carefully exclude sucli aneurisms as spring from the aorta beyond the orifice of the left carotid, as more likely to be injured than benefited by tying that vessel; whether any such eases could gain by deligation of the left subclavian, is doubtful, or has at all events not yet been proved. 2 Aneurism of the aortic arch offers a certain resistance to the blood-stream, and thereby is rapidly productive of a certain cardiac hypertrophy. Unless this be severe, it need not negative •operation if the valves be sound ; a much smaller hypertrophy is deterrent if there be also ■aortic incompetence. Perhaps it will be well also to point out a circumstance which should induce us to insist strongly on operation, with as little delay as possible. Aneurisms of the ascending and cardiac part of the transverse aorta cause the mass of blood a little above the valves to be large in amount; hence it falls with undue force on the valves, which can be heard fo close with violence—the door is slammed rather than shut. If this be allowed to go on, incompetence will soon be produced. 979 ANEURISM OF ARCH OF AORTA. Simultaneous Double Distal Ligature. No. Surgeon. Date. Duration of life. Termination. Post-mortem appearances, and remarks. 1 Hobart,’ 1839 For Inno 16 days ninate Aneurism (as dio Killed herself by throwing gnosed). 2 Rossi,2 1839 6th day pillow at nurse. Left carotid artery was closed; 3 Heath, 1865 4 yrs. 17 Aneurism practically patient’s brain nourished by one vertebral. It was of the ascending aorta. 4 Maunder, 1867 days 5 days cured*. Aneurism filled with soft Tumor to left of innominate ; left 5 Sands, 1868 13 mos. black clot. Aneurism nearly full of carotid should have been tied. 6 Hodges, 1868 12 days laminated clot. Merely an aortic dilatation. 7 Holmes, 1871 55 days No benefit. Aorta much dilated. 8 Lane, 1871 52 days No benefit. No post-mortem examination. 9 McCarthy, 1872 15 days Hemorrhage from proxi- 10 Durham, 1872 6th day mal end of subclavian. Death from shock. Probably in this case cardiac 11 Green, 1874 3 mos. Rupture of sac. hypertrophy. 12 Ensor, 1875 65 days Aorta much dilated. 13 King, 1876 111 days Suppuration of sac. Aorta much dilated. 14 Weir, 1876 15 days Sac nearly full of lamin- Aorta much dilated, atheromat- 15 Eliot, 1876 26 days ated clot. Sac occluded by laminated ous. Aorta very atheromatous. 16 Barwell, 1877 103 days clot. Aneurism cured (patient Bronchitis unconnected with 17 Barwell, 1877 19 mos. killed himself by ex- posure). Aneurism cured. aneurism. Bronchitis, no connection with 18 Barwell, 1877 30 hours aneurism. Aorta dilated; heart hypertro- 19 Little, 1877 40 mos. Aneurism cured. phied. Died from pleurisy, unconnected 20 Ransohoff, 1879 7 days Aneurism lined by lamin- with aneurism. Fusiform dilatation, arch of aorta 21 Stimson, 1879 Still lives ated clot. atheromatous,with calcification. 22 Palmer, 1879 125 days Aneurism consolidated. Pressure of solidified aneurism 23 King, 1880 14 mos. Aneurism cured. caused ulcer of innominate vein. Died from bronchitis; some aortic 24 Pollock, 1880 10 days Aneurism lined with lam- dilatation. Aorta dilated, and with large 25 Barwell, 1879 For Ao 15 mos. mated clot. rtic Aneurism (as diagr Aneurism cured (ox aorta patches of atheroma. osed). Died from slow exhaustion and 26 Lediard, 1880 8£ mos. ligature). Aneurism solid (ox aorta debility following dissipation. 27 Wyeth, 1880 1 year. ligature). Died from diarrhoea (ox Aneurism partly filled with clot aorta ligature). death not due to aneurism. [The editor has, in his chapter on aneurism,3 tabulated or referred to 48 cases of simultaneous, double, distal ligature, the aneurism in 34 cases having 1 This is set down as a deligation of the first part of the subclavian. Mr. Holmes, who had an opportunity of examining the preparation, doirbts if that vessel were tied. 2 Some writers report Rossi’s case as a deligation of the first, others as one of the third part of the subclavian. 3 Principles and Practice of Surgery, 4th ed., pp. 592 et seq. Six cases added sinc'e. 980 ANEURISM. involved the innominate, and in 13 the aorta, while in 4 the aorta was dilated though not aneurismal; of the whole 48 cases, 21, or less than half, termi- nated fatally, while in 22 decided benefit, of greater or less duration, was experienced. A successful case operated on by the editor, and reported by Dr. Wharton, may be found in the Transactions of the College of Physicians of Philadelphia, 3rd Series, Vol. IX.] It will be observed that in nearly all the cases of the above table which were followed by rapid death, the autopsy revealed disease of the heart, of the aorta, or of both. Therefore, the state of these parts should always be carefully investigated. In the present state of our knowledge, we may not always be able to diagnose atheroma of the aorta, or even a certain degree of dilatation ; but it may often be inferred, though not absolutely made out. At all events, it is well to point out what conditions injuriously affect the death-rate of the operation, which should never be lightly undertaken with- out due knowledge of what to seek, and what circumstances should deter. Consecutive double deligation has usually been employed in consequence of a hope that tying one of its branches would cure an innominate aneurism, the other branch being secured when, after a certain interval, improvement only, and not cure, has resulted. The operation may also, however, be under- taken because the surgeon, intending to tie both vessels, has reason, from the condition of the heart and aorta, to dread doing so simultaneously. Consecutive Double Distal Ligature. For Innominate Aneurism (as diagnosed). Surgeon. Carotid tied. Subclavian tied. Termination and post-mortem appearances. Fearn, Aug. 22, 1836 Aug. 30, 1836 Died of drunkenness, Nov. 27, 1838. Wickham, Sept. 25, 1839 Dec. 3, 1839 Died of rupture of sac, Dec. 15, 1839. Malgaigne, July, 1845 Oct. 17, 1845 Rupture of sac ; erysipelas, Nov. 7, 1845. Bickersteth, Fleet Speir, May 11, 1864 Constricted, May 4, 1874 June 17, 1864 Tied, Aug. 6, 1874 No benefit; died of progressive disease, Sept. 1864. Doughty and A. B. Mott, 1875 June, 1876 Phthisis. Aneurism apparently cured, 1879. Kuster,' May 30, 1879 Aug. 15, 1879 Mitral incompetence; dilated aorta, Aug. 30, 1879. Hemorrhage from site of deligation. Adams and Treves, June 30, 1880 July 2, 1880 The result of tying the right carotid alone for innominate aneurism is not to be considered satisfactory, and more especially is it unsuccessful if the disease involve the aorta. The vessel has been ligatured for innominate, or supposed aorto-innominate, disease, thirty times, with twenty deaths. But in cases of aortic, or aorto-innominate disease, the operation has been performed seven times, and in only one instance has it proved beneficial—the case of Mr. Annandale.2 With this exception, the longest survival was forty-one hours; the next, nineteen hours; the others, ten hours and under. The conclusion to he drawn, is, that for low innominate aneurism, which almost always involves the aorta, it is safer to tie both vessels than the carotid alone. Distal ligature of the right subclavian in its third part, for innominate aneu- rism, would not appear a hopeful procedure, since the carotid and so many 1 The patient was greatly relieved of pain, and asked, if it returned, whether the surgeon could not tie some other artery ; there were, however, other aneurisms, one of which seems to have burst. [Another successful case has been recorded by Mr. Beaney.] 2 The patient survived two years ; the cause of death is unknown, and there was no post-mor- tem examination. (Letter from Mr. Annandale.) I cannot persuade myself that the aneurism was aortic ; the immediate effect of the ligature—stoppage of pulsation—must surely negative such an idea. ARTERIO-VENOUS ANEURISM. 981 subclavian branches must allow a large stream through the artery. It has been done twice under the mistaken idea that the carotid was already oblit- erated (Wardrop, Broca), and once purposely (Bryant). All the patients survived some time, and appear to have been to a certain extent benefited. [Blackman’s and Laugier’s cases (the latter a deligation of the axillary) both proved fatal.] For aneurism of the aortic arch, the left carotid has been tied eleven times; in the first few cases, the disease was supposed to be of the carotid,1 but the operation has since been performed by others,2 with the direct intention of benefiting an aortic aneurism. The four cases of mistaken diagnosis, and the first three of the intentional operations, did well. Pirogoff thus operated on a woman with aorto-innominate aneurism—not the procedure to be selected; Kuster, on a man who had fusiform aneurism of the aorta and extreme car- diac hypertrophy.3 I have thus operated twice. My first patient was greatly improved, but died four months after of visceral disease; The next opera- tion was undertaken at the desire of a physician, somewhat against my convictions; both carotid and subclavian were tied, as the aneurism extended far to the left. The man was rapidly approaching death when the vessels were tied, and I do not think that the end was either hastened or postponed.4 Mr. Heath has also operated twice; his second case was unfortunate, the patient dying very quickly from syncope. Thus of the eleven cases, seven did remarkably well; four badly; proba- bly all four—certainly two of them—were ill chosen. [The editor has tabulated5 eighteen cases, including one of his own, of carotid ligation for aortic aneurism, more or less relief having been obtained in eight.] Arterio-Venous Aneurism.® A few words must be said concerning a form of disease involving not only the arterial trunk, but also the neighboring vein, or an adjacent venous cavity, which indeed essentially consists of an interparietal communication between the area of the one and of the other. In former times, when venesection was so frequently practised as often to be entrusted to unskilful hands, this disease was very common at the bend of the elbow, and indeed, since other external aneurisms were treated after one method, that of Antyllus, the ingenuity of the older surgeons was chiefly exercised upon this condition. Anel himself, whose name is still attached to one form of arterial deligation, first practised his method on an aneurism of this sort at the bend of the elbow (see p. 883). But as we shall see, the disease may be spontaneous, and is by no means confined to this situation, but may occur in any part of the body where an artery and a vein are in juxtaposition.7 The disease assumes two forms, viz., aneurismal varix, when the artery opens directly into the vein, the edges of the two holes being in contact, and adherent; and varicose aneurism when between the two vessels is interposed a distinct sac, into which they both open. 1 Montgomery, O’Shauglinessy, Rigen, Tilanus. It was these cases that prompted Dr. Cockle’s paper and suggestion ; Heath was the first to carry it into effect. 2 Heath, Holmes, Barwell, Pirogpff, and Kuster. 3 Das Herz war ungemein gross. 4 Med.-Chir. Trans., vol. lxiv. 5 Op. cit., p. 591. 6 That form of arterio-venous disease which consists in an enlargement of the arterioles and venules—viz., aneurism by anastomosis or cirsoid aneurism—has been described in the preceding article. i Usually, the communication is formed between vessels that are normally in contact; but even this is not essential. 982 ANEURISM. Aneurismal Varix.—The former of these maladies, nearly always trau- matic, may probably best be described by taking as our type the formerly common arterio-venous puncture in venesection. “ When this happens,” says W. Hunter,1 the first who correctly described this condition, “ the injury done to the artery is commonly known by the jerking impetuosity of the stream which Hows from the vein, and by the difficulty of stopping it when a suffi- cient quantity has been drawnalso, if what I saw long ago in a single case be usual, by the appearance of two colors in the blood. When, however, the hemorrhage has been checked by pressure, and the wound has healed, the op- posed openings adhere to each other, and the vessels intercommunicate. The disease is then marked by dilatation of the punctured vein and its affluents, for two inches or rather less, above, and for rather more than that distance below, the cicatrix left by the puncture. The enlargement is well marked ; its limits are somewhat abrupt; it pulsates rather less forcibly than an artery dilated to an equal size would do; and added to this, there is a continuous, vibratile thrill, best felt when the finger touches the part but very lightly. To an ear applied gently on the tumor, this thrill is translated into a rasping or snarling sound, which William Hunter2 compares to “what is produced in the mouth by continuing the sound of the letter R in a whisper.” I would call it “ thrill-murmur.” This vibration is, if the hole of communi- cation be large, apparent even to sight; especially at a point opposite the arterial opening. The venous tumor can be readily emptied by pressure, but immediately fills again, not by afflux of blood from the veins below, but from the artery above, as may be proved by tying a fillet tightly round the arm just under the seat of disease. When the limb is raised vertically, the tumor diminishes, and if, while that posture is maintained, pressure be made on the artery above, all thrill and bruit cease, while the swelling almost entirely disappears. In some cases the point of the finger, by following as a clue the line of most marked vibration, may be made to impinge directly on the arterial opening, when vibration is checked, and the enlargement almost entirely subsides. Occasionally the artery above is dilated and convoluted, pulsating more largely and strongly than natural, while nevertheless the artery below, and the radial pulse on that side, are smaller than on the other. The veins, for a little way above, and throughout the limb below, are enlarged, tortuous, and varicose, and for a certain distance may be seen, or by a very light touch may be felt, to pulsate very distinctly. Also, in most cases, the integuments of the forearm and their appendices, hair and nails, are hypertrophied, and some- times the part, especially in the course of the veins, is peculiarly hirsute. Varicose Aneurism.—Varicose aneurism differs from the above-described condition by tlie interposition of a blood-containing cavity between the arte- rial and venous woundtlie intercommunication of tlie vessels is, therefore, less direct, and lienee a certain difference exists in the relative intensity of some of the symptoms above described, according to the indirectness of the obstruction, and the mode in which the two opposing streams meet within the aneurismal pouch. The veins, varicose both above and below, are not, as a rule, as largely distended immediately opposite the puncture, nor do they pulsate as distinctly and clearly, as in the other form of the disease. The aneurismal tumor is easily distinguishable; it pulsates and makes a peculiar noise, more or less loud and harsh according to the size, shape, and relative position of the openings. It is sometimes hissing or rasping, sometimes like the murmur of a spiral shell, the boiling of a kettle, or, as 111 a case which I 1 Med. Observations and Inquiries, 1761, p. 34. 2 Op. cit., p. 37. ARTERIO-VENOUS ANEURISM. 983 saw in 1872, is like the noise of a gas-burner turned too high. It is some- times loud enough to keep the patient awake, or even to waken him if he happen to raise up the affected arm near to his ear. The same mechanism which produces the sound causes a vibration of the tumor, which is exactly like the sensation communicated to a hand placed on the back of a growling dog, or a purring cat. This thrill is continuous, and may be felt through and with the pulsation, but neither increases nor decreases with the beat of the heart. The same condition of tegumentary hypertrophy exists as was described in speaking of aneurismal varix, and to this is not unfrequently added a general, soft thickening of the sort sometimes called solid oedema; ordinary oedema, also, is not unusual. Other places where traumatism occasionally produces arterio-venous an- eurism of the varix variety, are some parts of the scalp, mostly over the tem- poral, large auricular, and occipital arteries; but in those places, because the vessels are smaller, the anastomoses freer, and the surrounding tissues denser, a somewhat different result is produced, namely dilatation of the arterial and venous branches, their offsets and minute twigs, into a mesh of enlarged, convoluted, and' pulsating vessels, closely resembling—indeed, generally in- distinguishable from—cirsoid aneurism ; a subject which has been considered in a previous article. Also, the disease has been known to follow fractures through the sella turcica or orbit, the preternatural communication being either between the carotid artery and cavernous sinus, or between the ophthalmic artery and vein, whence, as already described, originates one form of the disease termed pulsating tumor of the orbit.1 It must not, however, be supposed that arterio-venous aneurism is always the result of wound. Varicose aneurism has often occurred without such causation, and in deep parts of the body; even aneurismal varix may thus arise without direct wound. I believe Mr. Syme2 to have been the first surgeon who published a case of varicose aneurism of the aorta. Six years subsequently, viz., in 1837, Mr. G. H. Perry3 noted a case of this disease occurring between the popliteal artery and vein, and Mr. Porter4 recorded a similar example. In 1840, Mr. Tliurnam5 read his excellent memoir on the subject; since which time, although additional cases have been published by Rokitansky,6 Mayn,7 Beaumont,8 Pemberton,9 Wade,10 and many others, little light has remained to be thrown upon the matter. This light chiefly touches certain points regarding the relative frequency of the disease at differ- ent parts, and the mode of its occurrence. Mr. Thurnam’s paper first called attention to the fact that these preter- natural communications may take place between the largest vessels of the body—as between the first or second part of the thoracic aorta and any large vein or venous chamber of the heart. Thus there is distinct anatomical evidence of the existence of arterio-venous aneurisms of most of the larger vessels of the body. Thurnam’s cases, indeed, show that of 18 aortic aneurisms, 1 Delens, Thfese ; De la communication de la Carotide interne et du Sinus caverneux. Paris, 1870. 2 Edinburgh Medical and Surgical Journal, July, 1831, p. 114. 3 Medico-Chirurgical Transactions, vol. xx. p. 31. 4 Cyclopaedia of Anatomy and vol. i. p. 242. 6 On Aneurisms, especially Spontaneous Varicose Aneurisms of the Ascending Aorta. Medico- Chirurgical Transactions, vol. xxiii. p. 323. 6 Ueber einige der wichtigsten Krankheiten der Arterien. i Dublin Medical Journal, July, 1854. 8 Medical Times and Gazette, 1867, vol. ii. The preparation is in the College of Surgeonsr Museum. 9 Medico-Chirurgical Transactions, vol. xliv. p. 189. The disease followed pressure-treatment for popliteal aneurism. » Ibid., p. 211. 984 ANEURISM. 11 had formed communication with the pulmonary vein, 4 with a cavity of the heart, and 3 with one of the vense cavse. Thus, on examining these records and collating them with others gathered by Sibson and by myself, we may construct the following table,1 showing the relative frequency of these various conditions:— No. of Cases. Aneurismal Artery. Communicating with 17 Ascending aorta. Pulmonary artery. 6 “ “ Right auricle. 3 “ “ Right ventricle. 4 “ “ Descending vena cava. 3 “ “ Left ventricle. 2 Transverse aorta. Descending vena cava. 7 Descending aorta. Ascending vena cava. 5 Common carotid artery. Internal jugular vein. 1 External “ “ “ “ “ 4 Internal carotid “ Cavernous sinus. 2 External iliac artery. External iliac vein. 3 Femoral artery. Femoral vein. 2 Popliteal artery. • Popliteal vein. 1 Posterior tibial artery. Posterior tibial vein. In five of these sixty eases, the form of intercommunication was that of aneurismal varix; in the rest, that of varicose aneurism. The mode in which the disease is produced in the large internal vessels, and frequently in external parts, is as follows: First the artery develops an aneurism which, in the course of its growth, presses upon and ultimately opens into a vein or venous cavity, just as it might, if otherwise placed, have opened into a bronchus or the pharynx. Sometimes such a rupture is followed by rapid or immediate death. Of the patients whose cases are above tabulated, though one lived for only a very few hours after the event, the larger number survived for weeks or months, and one even for more than three and a half years.2 That life could be thus com- patible with so grave a lesion, would be, unless supported by ample evidence, incredible; yet, not only does clinical observation indicate this fact, but the smooth and rounded margin of the arterio-venous opening attests the long duration of patency. Indeed, in one case the condition diagnosed during life caused so little trouble that the man “ declared he was quite well, except that his breathing was a little short; he could not be induced to remain longer in hospital, as he was determined to resume his employment."3 The mode in which these openings form is the same as of any ruptures of aneurismal sacs into other adjacent cavities. The tumor in its increase presses on the walls of the venous space, causing adhesion, and then gradual thinning and absorption of the walls, until the sac bulges into the vein or cavity, and at this part—since an empty cavity or one with fluid contents offers less resist- ance than solid tissue—the wall is apt to further dilate and become thinner. The actual rupture may be aided by some sudden effort, or may be quite spontaneous ; in the latter case it is more likely to be slower than in the former, but may be as sudden ; and although one would suppose that sudden rupture must of necessity be more constantly and rapidly fatal than the more gradual breach, yet I do not find, as far as clinical symptoms permit the moment of the event to be fixed, that such difference really exists. 1 I am, of course, aware that more cases are scattered, and especially of late years, in surgical journals, but it seemes to me sufficient to take those which I have found recorded between 1840 and 1870 1 Case VIII. of Thurnam. The communication was with the pulmonary artery. 3 Wade, loc. cit. The communication was at that time only with the pulmonary artery, the opening into which was, after death, found to be round, regular, and smooth ; a further opening, ragged and thin-edged, was recent, and the immediate cause of death. ARTERIO-VENOUS ANEURISM. 985 External arterio-venous aneurisms may form in the same way, Qr from an •abscess opening into both vessels ; but this mode of origin is undoubtedly less frequent than some form of traumatism,1 and especially common are, first, venesection wounds, and then gunshot injuries. Bardeleben collected from published sources 91 cases of traumatic anterio-venous aneurism. Of these 49 were from venesection, 14 from gunshot wound, and the rest from various forms of injury ; therefore, as might be supposed, the greater number of cases depend upon preternatural communication between the brachial artery and the median basilic vein. The next most frequent seat of the disease is between the femoral artery and its vein (13 cases), the next in the temporal artery (9 cases),2 etc. Nor are we to suppose that the disease follows, of necessity, immediately or rapidly after infliction of the injury. In Rokitansky’s case,3 the disease first made its presence known in the axilla thirty years after the receipt of a gunshot wound. Beaumont’s (Toronto) patient had received a wound in the groin ; for more than ten years a loud and constant thrill-murmur, audible at some distance, was the only symptom ; at the end of that time an aneurism formed while riding on horseback.4 In Dr. Cotter’s case, a wound of the thigh occurred eight and a half years previous to the formation in the scar of an aneurismal varix.6 That comparatively small vessels may be thus affected, is shown by the relatively not infrequent occurrence of a communication between the tem- poral artery and its companion vein ; this has been generally due to arterio- tomy practised for therapeutic purposes, but it has also followed an accidental wound. But perhaps the most interesting example of such disease in a very small vessel is the case reported by Mr. Moore.6 The disease was developed on a branch of the sciatic artery within the substance of the popliteal nerve ; therefore, though the tumor was not large, and communicated with very small vessels, it gave great pain, and caused considerable embarrassment in diagnosis. It is not mentioned, whether or no, in this case, auscultation was employed. The case is described as one of arterio-venous cyst. Diagnosis of Arterio-Venous Aneurism.—The diagnosis of this disease, in those parts of the body which interest us as surgeons, depends upon the points of symptomatology and history already described. A direct wound in the course of an artery, followed by pulsation of enlarged and varicose veins; a tumor at or near the site of injury ; and a murmur more or less loud and harsh, present the problem in its simplest and easiest form. When the vessel is superficial, as at the bend of the elbow, or near the groin, the distinctive differences between aneurismal varix and varicose aneurism can be readily made out. Certain symptoms may, it is true, either by their presence or absence, cause some doubts ; but the peculiar purring, or thrill-murmur, is, when pre- sent, so characteristic, that, even if there be no tumor, the existence of arterio- venous communication may be taken as established. More deeply seated disease, especially if it be surrounded and compressed by firm, strong muscles, occasionally, though rarely, omits the most significant symptom—murmur7—or, at least, that phenomenon may be but slightly marked. 1 Pressure, as in Pemberton’s case already mentioned, may be classed as a traumatic cause, although the mechanical injury be slow (chronic) in its mode of action. 2 Bardeleben, Diss. Inaug., Berlin. Ueber das traumatische Aneurysma arterio-venosum. * Ueber einige der wichtigsten Krankheiten der Arterien. * Med. Times and Gazette, July 27, 1867. 5 American Journal of the Medical Sciences, vol. xlviii. p. 36. 6 Med.-Chir. Transactions, vol. xlix. p. 29. 7 See a case by Mr. Annandale, Lancet, April 24, 1875. The disease was in the posterior tibial artery and companion vein, and was, until operated on, mistaken for a common aneurism. 986 ANEURISM. On the other hand, if the vessel be one of the smaller branches of the scalp, dilatation of its offsets and of all inosculating twigs may cause the disease to assume the characters of cirsoid aneurism rather than that of direct com- munication, though in nearly all such cases the thrill-murmur is quantita- tively different from the slight, rustling bruit of ordinary, large angeiomata. Again, from the cases already quoted, it is evident that murmur may, for a time, be the only symptom of the disease, which must surely have been present, though inactive, during the ten and the eight and a half years of abeyance of Beaumont’s and Cotter’s cases. Treatment of Arterio-Venous Aneurism.—The treatment of this condition must be on the lines, slightly modified, of that of common, sacculated aneu- rism, but certain of the methods applicable to that affection are, as a rule, useless in this complicated form of the disease. Moreover, certain differences exist as to the management of the varicose and varix varieties. In varicose aneurism, treatment is always necessary, while many cases of aneurismal varix, especially of the upper extremity, producing no pain, and not leading to rupture and hemorrhage, may be left untreated, or be simply met with palliative measures. Fortunately, also, varicose aneurism is some- what more amenable than the other form to non-operative measures, namely, to the various forms of pressure. The presence of a sac in these cases is the point of vantage accorded to that form of treatment, and, indeed, it is pro- bable that Reid’s method—the elastic bandage being applied both below and above, but not over, the tumor—would be that most adapted to the exigen- cies of the case.1 In the event of that mode of treatment failing, direct and indirect pressure should be given a full and fair trial, and in most cases it will be better to alternate these methods, according to the pain produced and the susceptibility of the patient. Even if the aneurism itself be not cured by these means, it may, perhaps, be converted into a simple aneurism by closure of the venous opening. aSTelaton2 records four cases in which this transformation took place, hut it is somewhat singular that no such change has occurred in the practice of any other surgeon ; Kelaton’s patients were, it appears, afterwards cured, some by indirect pressure, some by the Hun- terian ligature. Injection of perchloride of iron has been employed, and in two cases with success—once, namely, by coagulation, and once by suppuration of the sac.3 When, however, the precautions which must be taken during the treatment of simple aneurism by this method are considered, it certainly seems to me that the double communication of the sac of a varicose aneurism must render still more pressing the danger of embolism, unless, indeed, the blood in the whole limb be entirely immobilized for an unusually long time. The same remark may apply to galvano-puncture ; yet three cases, two quoted by Cini- selli and one recorded by Debout, are said to have been thus cured. The ligature for varicose aneurism is not to be lightly employed, hut is most certainly justifiable when the tumor is increasing quickly enough to render rupture a mere question of time, or when pressure on other veins, besides that immediately implicated, renders gangrene a more probable re- sult of delay than of interference.. Cases, moreover, in which expectant or temporizing treatment can be adopted, are rare, though less so in the upper than in the lower limb. The Hunterian deligation must be rejected ; it almost 1 I have not myself had, since the introduction of this method, any opportunity of treating a varicose aneurism, nor can I find any record of a case so treated; the above opinion must, therefore, he taken as formed on a priori grounds only. 2 Journal de Medecine et de Chirurgie pratiques, 2e s., t. xxxiii. p. 155. 3 Jobert (de Lamballe), Bulletin de l’Academie de Medecine, 1854; Yallette, ibid., 1859. ARTERIO-VENOUS ANEURISM. 987 always fails to cure, though a few cases are on record in which it produced a certain benefit1 by delaying the progress of the malady. The form of deliga- tion should be after the method of Antyllus, that is, immediately above and below the site of disease. Generally, in such cases, it will be necessary to open the sac and turn out any clots, little in quantity and loose in texture as they are in this form of aneurism; or, when feasible, greater safety may be insured by tying the vessel above and below, while leaving the sac intact. But certain difficulties attend this operation ; if the vessel be not very deep, the upper part of the artery is reached with ease; but that part which lies below the tumor—contracted and often very small, surrounded also by swollen and tortuous veins—can with difficulty be found, and perhaps can only be taken up by tearing or cutting through many of those vessels. Herein lies one, per- haps the chief, danger of ligature for varicose aneurism, namely, the inter- ference with and probable ligature of the main veins, which, in a limb already weakened and predisposed to sphacelus by the varicose condition of those vessels, may lead to rapid gangrene, especially if the disease be of the lower extremity. Hence in some cases, more particularly in old or enfeebled persons, the safer and more prudent course will be to amputate, rather than to incur the risk of producing an inevitable and perhaps irrestrainable gan- grene. The treatment of aneurismal varix should also be commenced by pressure, but direct pressure, not merely on the tumor, but also upon the foramen of communication, is that which is most likely to prove successful. Moreover, the finger has proved of all compressing instruments the most efficacious; yet it is only right to observe that in a large number of cases the treatment ends in disappointment. i!76r does it seem desirable to continue it for any lengthened period unless palpable improvement gives encouragement to fur- ther effort. The Esmarch bandage and cord, if care be taken to keep the vessels at the site of disease full, also seem likely to be of avail. If this simpler treatment fail, the circumstances of the case must be well considered before recommending any more severe measures. Frequently, and more especially in the upper limb, an aneurismal varix, having culminated in a certain enlargement of the vein about the site of disease, and in a certain varicose condition of the veins lower down, together with some weakness or facile fatigue of the part, proceeds no further, and remains stationary for years. In such circumstances, prudence would counsel both surgeon and pa- tient not to employ, for a malady which involves so little inconvenience, any treatment that might endanger either life or limb. When, however, the troubles become, or in other cases are ab initio, more severe, and especially if they are increasing, surgical interference becomes not merely justifiable but imperative. Galvano-puncture and the injection of coagulants are not likely to prove of any avail.2 There is no sac to the aneurism, but merely two tubes, one being more or less dilated; hence blood loosely coagulated by either method would probably be washed onward and cause embolism, as soon as the restraining pressure was removed. Both methods are probably more dangerous than in sacculated aneurism. More safe is deligation with a properly selected ligature. The vessel should 1 See case by Czerny (Archiv fur pathologische Anatomie und Physiologie, Bd. 62, S. 464) ; the disease was femoral; the Hunterian ligature produced a certain temporary benefit. Also one by Ambrogio Gfherini, who tied with slight transitory benefit the brachial artery at the junction of its middle and lower thirds, for varicose aneurism following venesection at the bend of the elbow (Annali Univers. di Med., Novembre, 1873). 8 The latter mode of treatment has been recommended by a high authority as likely to be use- ful ; but the opinion is not founded on any practical experience. (Holmes’s System of Surgeryr vol. iii. p. 531.) 988 ANEURISM. be tied above and below the place of opening. The vein—especially if an important one, as the femoral at the groin—ought to be spared, though some- times it is so adherent to the artery as to be barely separable yet to tie it would be very likely to induce gangrene. I would strongly advise very careful and patient attempts at separation to be made. It is below rather than above the opening that the difficulty occurs, and at the same time the artery is here so diminished in size that it is not easily found. Under these cir- cumstances, and unless the diseased spot be immediately above a large branch, it may be well to relinquish the attempt to tie the artery below the mouth of intercommunication, and to elevate the limb. Blood from the vein could not, under such circumstances, flow along the artery, and in the absence of any arterial branch very near to the spot, return blood from the artery could hardly get into the vein. The Hunterian mode of deligation, whenever it has been tried under these circumstances, has, as far as I can find, invariably failed. Appendix. Although this article was finished some time ago, it appears to me de- sirable to render it complete by inserting a case of deligation of the innomi- nate artery, recently performed by Mr. William Thomson, of Dublin. I do this with the more pleasure since the case, although terminating fatally, proves that my views concerning the action and importance of a fiat ligature are correct. It also illustrates the value of the needle depicted at p. 926, which was devised by me for facilitating the passage of a ligature under the subclavian and innominate. As will be seen on perusal of the case, the operation could hardly have been completed without its aid. In March of the present year (1882) Mr. Thomson wrote to me, describing a case of right subclavian aneurism which was under his care, and saying that he proposed tying either the subclavian in its first part, or the innominate. He asked me for a piece of my ox-aorta ligature. 1 replied immediately by sending what he had requested, and my needle. As the patient dallied a good deal, sometimes accepting, sometimes declining Mr. Thomson’s proposal, that gentleman returned the instrument, believing that the patient would not sub- mit to an operation. However, at the beginning of June, I again heard from Mr. Thomson, and in pursuance of his request once more sent him the needle. He had preserved the ox-aorta ligature forwarded to him in March. The patient having finally determined to undergo the necessary treatment, I am able, by the great courtesy of Mr. Thomson, to give the details of the case in that eminent surgeon’s own words:— John Murphy, aged 49, a locksmith, was admitted to the Richmond Surgical Hos- pital, Dublin, on the 7th of February, 1882, suffering from aneurism of the right subclavian artery. He was a man of medium development, healthy looking, and of dark complexion. His hair was grizzled. He had never had syphilis, had lived a fairly temperate life, and had been for eighteen months in America, where, in the war with the Confederate States, he had received a bayonet wound over the right scapula. For two years and a half he had been suffering from pains in the right arm, which he thought were due to rheumatism ;* but ten months before his admission he first noticed a small tumor, “ about as large as a marble,” in the posterior inferior triangle of the 1 When treating of deligation of the femoral artery, I pointed out that occasionally the femoral vein, or a vein close to it, had in this operation been wounded, and yet that when the artery had been tied, bleeding had ceased. If in endeavoring to isolate the artery venous bleeding from the enlarged vein should occur, I would recommend that this should not be immediately ligatured. When the artery has been secured, the effect of thus checking the flow of blood to the part, and of raising the limb above the level of the pelvis, should be tried. APPENDIX. 989 neck. He had sought advice at another dispensary, and at our own, but he had re- fused to come into hospital until he found that the tumor Avas steadily progressing, and that in addition to increase of pain he was now unable to work. The tumor, as it now presented itself, Avas globular and about tAvo and a half inches in diameter, pulsating violently, with evidently very thin walls. It occupied the posterior inferior triangle, its inner margin being close against the outer edge of the sterno-mastoid muscle. The linger, passed behind the muscle, received a very strong impulse, and the vessel, as far as it could thus be traced towards its second part, appeared to be enlarged. The pulse varied from 130 to 140, and was very full. No pulse could, as a rule, be felt in the right radial artery, but occasionally it could be made out as a faint dicker. The arm could not be raised from the side ; the pain in the shoulder Avas unbearable, and the patient lay in bed with his left hand grasping that part tightly, as he said that doing so gave him some relief. The heart sounds were healthy ; the pupils were regular; there was no cough and no laryngeal irritation. The other functions of the body were natural. The patient was kept under observation for a week, being at the same time treated with tincture of digitalis, but without any impression being made upon the rapidity of the pulse. I then had a consultation with my colleagues, Mr. Stokes, Mr. Thornley Stoker, and Mr. Corley, and I also had the advantage of the assistance of Dr. Robert Mc- Donnell and Dr. Bennet, Professor of Surgery in the University of Dublin. The ma- jority of opinion was in favor of attempting an operation upon the drst part of the sub- clavian, and, in the event of that proving diseased, upon the innominate. I put the case before the patient, who consented to the proposal; but after an interview with his son, he declined it. He remained, hoAvever, in hospital, and I then tried for some time the iodide of potassium treatment, but without any appreciable result. The pulse still continued high, and the tumor increased in size, while the pain in the arm Avas combated by frequent hypodermic injections of morphia. The patient suddenly took his discharge on the 30th of March, as he said he had “ private business” to transact. He once visited me at my house some Aveeks afterwards. The tumor had then grown to a considerable size, passing upAvards in the neck ; the pain kept him from sleeping, for he now had no hypodermic injections. There Avas no pulsation to be felt in the radial or brachial arteries. He promised to come into hospital next day, but he did not return until the 22d of May. He now stated that during the preceding night the tumor had ceased to pulsate for over an hour. When I saw him, pulsation was as violent as ever; all the local symptoms were aggra- vated, but the pulse had fallen to 100. Measured by the callipers, the tumor now marked three and one-fourth inches in diameter in all directions. A further consulta- tion was held, and ligature was again determined upon ; but on the 29th, the day but one fixed for operation, I Avas sent for to see the patient. All pulsation had stopped in the aneurism, which was now hard and tense. I resolved therefore to postpone any operative interference. The pulsation returned after about ten hours, and next morning was as bad as before. He had now three minim doses of tincture of aconite every three hours, but the pulse was not affected. On the 31st, pulsation stopped for fifteen minutes, but then recurred, accompanied with great pain. He was now ordered three minim doses of tincture of aconite every hour for twelve hours, the effect to be Avatched. The pulse-rate, which had been 116, fell to 96 ; but next morning the pulse was full and bounding at 100. On the 4th of June, the patient said that the tumor had ceased to beat several times, but this was not verified by the resident pupil; the pul- sation was, however, feeble. During all this time, in which I had the benefit of daily conference with my colleagues, the tumor continued to grow in size until it reached three and a half inches in diameter at the base. The movement of pulsation was observed over a large area. When the patient sat up, the shoulder and the Avhole scapular region rose and fell with each pulsation of the aneurism. The hope which Ave had entertained of spontaneous cure did not appear likely to be fulfilled, and, in face of the fact that the disease Avas progressing, we unanimously agreed that operation should no longer be delayed. Accordingly, on June 9, when I was favored by the presence of many eminent surgeons, the patient was brought into the operating theatre, and placed in the usual position on his back, with the head thrown well towards the left side, and deeply anaesthetized. I 990 ANEURISM. made a free incision along his clavicle, from the anterior margin of the sterno-mastoid outwards, and joined its inner extremity by an incision along the anterior border of the same muscle. The clavicular attachment of the muscle was divided and turned up, and then the sterno-mastoid and sterno-thyroid were cut, to uncover the carotid, care- fully avoiding the branches of the omo-hyoidean plexus, which could be seen. The vessel was of very large size, so much so indeed that some of those present thought I had arrived at the innominate. This belief was encouraged by the fact that at first, pres- sure upon it with the finger stopped pulsation in the carotid higher up, and also in the tumor; but this did not always occur, and was evidently the result of pressure on the subclavian communicated from a distance. I now went further down in search of the bifurcation ; but this was an extremely tedious and anxious proceeding, and I was com- pelled to divide nearly the whole of the sternal attachment of the sterno-mastoid. Coming at last upon the origins of the subclavian and the carotid, at what appeared to be an alarming depth, the difficulty of reaching the innominate beyond was increased by the sky becoming obscured by a heavy thunder-cloud, which seemed to shut out all the top light. A mirror was then used to throw light into the wound, but without much good result, and I was here much delayed. The sheath of the innominate was at last slowly scraped through, and using an ordinary aneurism needle for this purpose, I succeeded in passing it under the vessel, which appeared to be healthy. I then determined to thread it with ordinary silk, and to use this to draw back the tape ligature which Mr. Barwell had been good enough to send me. But failing in this, as the opening between the sheath and the vessel was too small, I withdrew all, and threading a special needle, invented by Mr. Barwell, with the curved portion movable by a lever, I introduced this with comparative ease. I then, before tying, tested the effect of pressure upon the vessel, between my finger and the tape; lifting the vessel freely from its bed, and finding that all movement ceased in the aneurism, and in the carotid, I secured the ligature with three knots, drawing the ends with moderate firmness. The edges of the wound were brought together, and a drainage tube having been introduced into the lower part, an antiseptic dressing was applied, and -fixed by means of an elastic roller. The arm and shoulder were also swathed in sheets of wadding which had been pre- viously heated. The patient was at once carried to bed, and I saw him again in half an hour. The right side of the face was cold, but the pupils were equal. He had not fully recovered from the effects of the ether, but I noticed that when he attempted to ask me some questions, he always broke down in the middle of the sentence, and then seemed to be trying to recollect what he wished to say. This was the only symptom of brain disturbance that ever presented itself, and in the evening he seemed to have his mental faculties perfectly unimpaired. He was ordered ice, milk and soda-water, and beef tea. Two hours after the operation, the patient complained of pain in the shoulder, and had one-third of a grain of morphia hypodermically, repeated in two hours. Slept for three hours during the evening. Evening temperature 100.6° Fahr. right side, 99.4° left; pulse 136. At 11 o’clock, 99.6° right side, 99° left; pulse 120. No pain. 10th (2d day). At 3 o’clock this morning the patient was seen by Mr. Kidd, house- sm-geon. Complained of pain over region of the stomach, and was given a hypodermic injection of morphia. Slept for several hours. In the morning I saw the patient; his stomach was much distended with flatus; ordered turpentine stupes and a carmina- tive. Temperature at 8.30, 99° on both sides; pulse 120. The abdominal symptoms were relieved. At 3.30 respirations were shallow and rapid—44. No pain. Finding t|iat the temperature was then only 99°, and believing that the dyspnoea was caused by compression, I loosened the elastic bandage and the dressings, which gave much relief. Evening temperature 99.8° on both sides; pulse 132. Diet as before. 11th. About midnight, severe pain in right shoulder; pulse 148. Relieved by mor- phia. Passed a very good night. Morning temperature 99.4°; pulse 128; respiration normal. Wound dressed under spray. Slight serous discharge. Edges uniting. Drainage tube cleansed. Much pain in arm after dressing. Hypodermic injection of one-third of a grain of morphia. Slept nearly all day. Evening temperature 100.4° ; pulse 128. 12th. Morning temperature 99° ; pulse 120. Passed a good night. Looking remark- ably well to day. No radial or temporal pulse. Carotid still. Tumor decidedly smaller, the wrinkles beginning to return in the hitherto tense skin. No pain until APPENDIX. 991 evening, when there was a slight recurrence of it in the right arm. Evening tempe- rature 98.8°; pulse 124. 13th. Morning temperature 99° ; pulse 120. During early part of night complained of difficulty of breathing, and pain on swallowing, but afterwards passed a good night, sleeping soundly. Wound healed save at the drainage opening. Tube cleansed and returned. Slight serous discharge. Evening temperature 98.6°; pulse 124. 15th. Morning temperature 98.6° ; pulse 108. Wound looking well and tirmly closed up to the drainage tube, which was removed and replaced by a few strands of catgut. Patient a good deal troubled with tenesmus ; enema did not give relief, and he was ordered a mild saline aperient, which was effective; bowels moved twice. Evening temperature 98.4°; pulse 116. 16th. Morning temperature 98.4° ; pulse 132. Mixture of tincture of digitalis in 5 minim doses, and sulphate of quinia in 2 grain doses, every fourth hour. Evening temperature 98.4° ; pulse 116. 17th. Morning temperature 98.4° ; pulse 120. Wound dressed. Some healthy pus escaped from sinus. Can feel when the right hand is pinched. Very quiet day. Evening temperature 98.6°; pulse 104. 18th. Morning temperature 98.4° ; pulse 100. Wound dressed with boracic lint. Patient only complains of being tired from keeping in one position. Expresses him- self as being otherwise well. Evening temperature 98.4°; pulse 108. 19th. Morning temperature 98.4° ; pulse 104. Wound syringed with carbolic lotion, 1 in 40. Only about a teaspoonful can be injected before it returns. The discharge seems to come from above the apex of flap. Evening temperature 98.8° ; pulse 108. 20th. Morning temperature 98.8° ; pulse 104. Pus small in quantity, quite healthy. Temperature, which has been normal for seven days, rose to 99.6° this evening. He had a good deal of stinging, burning pain in the hand this afternoon. Tumor measured in one diameter 2\ and in the other 2|- inches—showing an altered form, and giving a reduction of one inch in one direction, and of half an inch in the other. Evening tem- perature 99.6° ; pulse 108. 21st. Morning temperature 98.6° ; pulse 100. Passed a very quiet night. Sensa- tion good in the arm, but still very imperfect in forearm. Still no radial or temporal pulse. Temperature of arm very good. Swallowing again very painful. Evening temperature 99.6° ; pulse 100. 23d. Morning temperature 98.2° ; pulse 100. Pain in right eyeball, and occipital headache. Ordered 20 grains of bromide of potassium, which had the effect of relieving him. Pulse fell to 96 in an hour and a half. Pain in right hand, as before, for a short time. In the evening pulse rose to 116, and temperature to 101°. As there was no apparent cause for this, I was sent for, and saw the patient with Mr. Corley. The wound was examined, but nothing could be found there to account for the increased fever. Ordered 20 grains of bromide of potassium, and ice. Deglutition not as difficult as yesterday. 24th. Morning temperature 98.4° ; pulse 108. Passed a good night. Had a pur- gative. Pain in right hand and arm at intervals during thefday. Wound healthy. Ordered grains of quinia in pill, and a mixture containing 20 grains of bromide of potassium, and fluidrachms of infusion of digitalis three times a day. Pulse and temperature at night again increased. Pain in hand very severe. Had hypodermic in- jection of morphia. Evening temperature 101°; pulse 128. 25th. Morning temperature 98.8°; pulse 108. Pain in head and eye returned. Temperature almost normal during the day, but again increased at night to 101°, after a severe attack of pain in the hand. Pulse 116 in the evening. 26th. Morning temperature 98.4°; pulse 116. Patient rather depressed this morn- ing, for the first time since the operation. Sinus syringed out. with carbolic acid, 1 in 40. A piece of ligature, about two lines long by a line broad, with some shreddy substance, was washed out. This, on subsequent examination under the microscope by Mr. P. S. Abraham, proved to be yellow elastic tissue. Presumably it was one of the cut ends beyond the knot, as it was sharply defined, and under the microscope, at one part, the fibres were suddenly turned upon themselves, as if forming part of the knot. Evening temperature 99.8°; pulse 120. 27th. Morning temperature 98.8° ; pulse 100. Patient looks very well and passed 992 ANEURISM. a very good night. Sinus surrounded with granulations. No pain in hand until towards evening, when it became severe. Temperature taken on both sides, when it was found to be 101.4° in the right axilla, and 100.4° in the left. Complained of heat in the right arm. Had a hypodermic injection, after which he slept for two hours, and awoke free from pain. Temperature again taken—right axilla, 99.6°, left 98.8°. 28th. Morning temperature 98.4°; pulse 104. Passed a good night. Swallowing easy. About half a drachm of pus escaped front sinus. Some shreds of yellow elastic tissue washed out. Pain in the arm again, followed by rise in temperature—right 100°, left 99.4°. Had a purgative mixture as before. July 2 (24th day). Opening of sinus the size of a pin-hole. A few drops of pus escaped. Temp.: right 99.4°, left 99°. July 4 (26th day). Sinus closed ; pain in hand recurred as before. July 6 (28th day). Sinus opened, and half a drachm of pus pressed out. Tempera- ture rose to 100° in the evening. July 8 (30th day). Pulsation visible at apex of flap, coming from portion of the inno- minate. Passed a very good day. At 11.15 P. M., patient noticed that he was bleed- ing. Hemorrhage had stopped when he was seen by the house-surgeon. Mr. Stokes and Mr. Thornley Stoker saw the patient with me soon afterwards. Wound examined ; no bleeding. Dressing renewed with a shot-bag over all. Amount of blood lost about three ounces. Hypodermic injection of morphia. Ice. July 9 (31st day). Passed a good day. No bleeding. Ergot ordered. Morning temp. 98.6°, pulse 100 ; evening temp. 100.4°, pulse 104. July 10 (3‘2d day). Very quiet day. gr. of atropia every fourth hour. Small quantity of pus. July 11 (33d day). Some minute sloughs discharged on syringing. July 14 (36th day). Says he is very well. Morning temp. 98.6°, evening 100°. Sulphide of calcium gr. three times a day. July 16 (38th day). Patient says he has not felt so well since the operation. Morn- ing temp. 98.2°, pulse 96; evening temp. 100°, pulse 104. A few drops of pus. July 17 (39th day). At half-past three this morning a terrific hemorrhage took place. The clothes were saturated, and the blood ran in a large stream on the floor. The patient was greatly blanched and collapsed. Mr. Kidd gave a hypodermic injection of ether. Cold, clammy sweat, flickering pulse, voice a mere whisper. Patient dia not lose consciousness, but said he could not see. When I saw the patient, bleeding had stopped. The patient had then rallied somewhat, and complained of pains in his- head and limbs. Increased pressure was made with shot-bags, the dressings not being disturbed. Warm jars placed to feet and body. Further stimulation prohibited. Ice and beef-tea in small quantities. July 18 (40th day). No bleeding. Seen with me by my colleagues, and by Dr. R. McDonnell and Professor Bennett. Very weak. Treatment as before. Pain in limbs treated with morphia. July 19 (41st day). Has rallied considerably. His expression is much improved. Color has returned to liis face, and his pulse is stronger, but jerky. Pain in limbs. As patient’s bedding had not been disturbed since the hemorrhage, he was carefully lifted by seven persons, and a clean mattress, etc., substituted. July 20 (42d day). Complained of difficulty of breathing at 2 A. M.,and much pain. Had half a grain of morphia subcutaneously. Slept for some time, and died quietly at 8.15 A. M. There was no recurrence of bleeding. Post-mortem Examination.—An autopsy was held a fewr hours after death, but as any interference had been forbidden by the patient’s son, a partial examination only could be made. Only the parts actually involved in the disease and the operation could be removed. A small opening in the skin was the only part that appeared unhealed. The rest of the incisions were firmly cicatrized. The size of the tumor was by inches. When the skin was reflected, there was no trace of infiltration of parts, and no sign of blood. The opening in the skin led into a small cavity containing about a drachm of pus. When.this was removed, the cavity was found to be about three-quarters of an inch in depth, above and slightly behind the right sterno-clavicular articulation, point- APPENDIX. 993 ing downwards, backwards, and inwards. It received the end of the little finger, like a thimble. The tumor itself was covered by skin and platysma, and some outer fibres of the sterno-mastoid muscle; the omo-hyoid was stretched across it. The phrenic nerve passed along the inner side, borne otf by the anterior scalenus; the muscle was bulged forwards, but the nerve did not seem to be pressed upon. Across the whole surface of the tumor were, lightly stretched and flattened, large roots and branches of the brachial plexus. In the anterior inferior triangle the tissues overlying the great vessels were so matted together that they could only be dissected with difficulty, especially at the lower part of the carotid. The internal jugular was collapsed. The common carotid was full and firm to the touch as far as the bifurcation. The subclavian vein was empty, and was tightly stretched along the lower and anterior part of the tumor. Its coats were thin, and in two places, near the junction of the internal jugular, there were small translucent patches, apparently from thinning of the internal coat. A few drops of pus oozed out of the lower end of the carotid, into the ulcer which terminated the sinus. On turning forward the anterior scalenus, the aneurism was found to involve the second part of the artery. The tumor was found to rest upon the first rib, and to press against the clavicle in front. These bones were removed ; the rib with its attach- ment to the aneurism, and as much of the aorta as could be reached, were cut across; and the parts were taken out en masse. The tumor was found to spring from the posterior part of the second and third portions of the subclavian artery. It was flattened below, where it rested on the rib, and passed upwards for three inches, ending in a dome-like surface. Corresponding to the cla- vicle, it was constricted. Its clavicular portion measured two and one-eighth inches antero-posteriorly ; its basal portion, two and three-quarters. The artery was elsewhere normal in size. It formed a cord from which the tumor sprang. The axillary portion, as far as it could be removed, was firmly plugged. All the vessels of the first portion were traced, and were pervious. The ulceration, which was somewhat larger than a sixpence in area, was situated at the bifurcation of the innominate into the subclavian and carotid arteries. It involved the anterior portion of the walls, and, looking into it, the clot* blocking the three vessels could be seen. The surface was gray and shreddy ; there was no staining of blood visible; the vessels were partly slit, and a syringe was used to force water through them in the direction of the circulation, but although this was carefully tried with each vessel, not a drop passed through. The incisions were extended along the vessels towards the ulcer. The wall of the innominate was thickened almost from its origin, and this thickening increased gradually as the site of the ligature was approached, until the depth was about two lines. The clot was firmly adherent to the walls, and extended backwards through the greater extent of the vessel. At its cardiac side was a tongue of organized clot, rather loosely attached, and between it and the firmly adherent clot were some retiform bands of fibrous tissue deeply stained with blood. The subclavian was found to be empty, except at its cardiac end, which was well blocked with a firmly adherent clot. This projected towards the aneurism for about half an inch. No water could be forced through. The common carotid felt solid, but on opening it, it was found that the centre of the clot had degenerated, and was occupied by pulpy, purulent material. The walls of the vessel were thickened; the clot terminated near the bifurcation into the external and internal carotids. The aorta was thickened, atheromatous, and in patches calca- reous. The lung and pleura, as seen on the right side, were healthy. An incision was made into the aneurism from summit to base; it contained about half an ounce of dark, thick blood, and in the centre was some passive clot occupying a cavity about the size of a walnut. The process of cure was evidenced by fibrinous layers upon the walls to the extent of a third of an inch, and on the inner sides of this coating were masses of coagulum, less firm, but evidently undergoing consolidation. A prolonged and careful search was made for traces of the ligature, but none could be found. On the posterior surface of the innominate, opposite the ulceration, was some fatty tissue, intimately adherent to the wall, which could with difficulty be cleaned. A more minute examination of the parts was subsequently made. The vessels were all divided into the ulcer. This showed that the innominate had been constricted at 994 ANEURISM. about a quarter of an inch from the cardiac margin of the ulcer. The walls were not divided, and the ulcer had not taken origin at the site of the ligature. -The vessel was not occluded by adhesion of the inner surfaces, but a chink remained at the ligatured portion, through which the clot was continued, and had been united to the clots in the subclavian and the carotid. The clot in the subclavian was well formed. The ulcer had eaten into the innominate at its centre, and had in this way doubtless caused the hemorrhage. In order to search for the ligature, an inch of the posterior wall of the innominate was cut out, and several sections made by Mr. Abraham, but no trace of it could be found. The coats of the vessel were undivided. The result of this case, although much to be regretted, clearly shows that the ligature had entirely succeeded, but that an abscess, resulting from imper- fect healing of the wound, had opened into the innominate close to the bifur- cation. No blood, however, had passed the point of deligation, nor had any descended the common carotid; the hemorrhage must, therefore, have been supplied by the vertebral. The occurrence of an abscess, which, not having exit externally, burrowed deeply till the pus found its way into a vessel, is an accident hardly likely to recur. The fact that the vessels were closed on each side of the ligature by firm clot,1 that the aneurism was far advanced in the process of cure, and, above all, that the coats of the vessel were, at the point of deligation, unin- jured, vindicates, most completely, the principles which guided me in the choice of a flat ligature, viz., to leave the parietes of the vascular lumen intact and without breach of continuity. The fortuitous opening by an abscess into that lumen does not, in any way, aflect or detract from that position. The case, though ending in death, proves even more conclusively than if it had been successful, the value of the ox-aorta ligature. 1 That in the carotid had been subsequently softened by admixture with pus from without.